Whitney the Muslim

I apologize for the brevity of this post. For those of you that follow my scrawlings on Something Awful, I’ve been doing an AMA for the last twenty-four hours on the BYOB forum, which has diverted just a little of my writing powers.

I did manage to rant with embarrassing fervor about fruit that I like.

Anyway.

Sometimes the ICU runs like you expect it to: occasional periods of panic, lots of gross chores, and a slump around 1600 when you can catch up on your charting. Sometimes it gets a little crazy, and if you have a really rowdy pt with a lot of things going wrong, you can easily spend a whole shift on your feet and do all your charting after you’ve passed your pt to the next shift. And sometimes, the whole ICU loses its goddamn mind at once, and all your pts are desperately high-acuity and breaks only happen if everyone works together, and staffing calls random people on their days off and begs them to come in—not to take pts, but to serve as an extra flex nurse, just to help people get all their chores done.

When this happens, you have to be a special kind of dumbass to actually answer your phone, let alone come in extra. Unfortunately for me, I am that exact kind of dumbass. That week, I worked a lot.

Week 7, Shift 1

Well, I definitely got the crazy little lady this morning, and no, my attempt at jinxing her didn’t work. But more on that in a bit.

My adorable pt with the screaming hearing aids had really bad sundowners last night, and spent all morning groggy and slow to communicate. Even after I put in her hearing aids, she mostly just lay in bed napping, drifting off mid-sentence every time I tried to have a conversation with her. Somebody had given her a bump of dilaudid last night for an episode of back pain, and she apparently processes opioids slower than I process an entire brick of cheddar cheese, so she was completely zorked most of the morning.

Her family came in and stood around the bed, morose, watching her mutter in her sleep. “She’s really gone downhill,” said her son. “Yesterday she was so bright and awake, and she was up in the chair for hours… Today she barely wakes up to say hello. What happened?”

I explained about the pain medicine and our plan to closely limit her opioid administration from here on out, and added that her labs were all improving and her vital signs were solid, and that I was recommending to the MD for her to be transferred to a unit with a lower level of acuity. The family was uneasy, and I don’t blame them—I was keeping a weather eye out for weirdness myself, because while I had a pretty good explanation for her behavior (or lack of behavior), any time family says their loved one is different, I pay attention. I can’t tell you how many times I’ve caught something that would have gone unrecognized—a heart attack, a stroke, a major status change—just because I pay attention when family is worried.

(Sometimes I have to completely ignore worried family, when their worry is pathological and they’re doing themselves and their families no favors… more on that later. And yet, if the family is worried, even if it’s just because they’re always worried, I stay at a higher level of worry all day. Not necessarily about the pt, especially if I can look at them and tell that they’re doing fine, but I have plenty of my own shit to worry about and if we’re having a party anyway, heeeey!)

In this case, I was definitely watching her closely, especially when family brought in some edible and drinkable treats to try and coax her into eating. I was concerned that, despite her passing her swallow eval earlier, she would (in her current groggy state) fall asleep while chewing and end up with a hamburger in her lung. I hovered by the bed while her daughter leaned over and bellowed in her ear: “MOM. DO YOU WANT SOME DIET DR. PEPPER.”

And man, her face lit up like Mardi Gras in Las Vegas. Her eyes popped wide open and she levered herself upright in bed like a vampire popping out of the coffin. “Do you have any?”

After that, she was still prone to drifting off, but now she had a vested interest in staying awake. Family? Pssshhh, you can see them anytime. Diet Dr. Pepper? Now that is worth feigning alertness.

Fortunately, she really wasn’t in need of a lot of care, and the doc agreed around 0900 to downgrade her acuity to telemetry. I say ‘fortunately’ because my other pt Martha*, the crazy lady from last night, demanded almost all of my time.

Her history of bipolar disorder has provided her with a history of lithium use, and last year she attempted suicide by taking all of her lithium pills at once. The ways in which people attempt to kill themselves just horrify me. Taking two bottles of Tylenol? Finishing off your Wellbutrin in a single go? Jesus, are you trying to make sure you suffer on your way out? I mean, I sincerely hate the idea that anyone has to deal with the utter bleakness of chronic depression and the spiral that leads down to suicide, and I wish to god nobody killed themselves at all, and I hate that our society makes mental illness such a hush-hush no-funding issue that people can reach that point of suffering without having the resources they need to escape… But the shit that people do to themselves trying to kill themselves, that shit is like an Eli Roth porno. Even handguns fail frequently enough; it’s not uncommon for a person to attempt suicide, fail, and have an entire lifetime of medical fallout to deal with… or six weeks of pure torture in the ICU before they finally manage to actually die.

And of those who succeed in slow motion… they all want to live by the time they die. It’s awful.

Please don’t fucking kill yourself. Entirely aside from the fact that you’ll miss all the movies of the next few decades, that you’ll miss the chance to fake your own death and escape to a South American country and become the mysterious foreigner who lives in the jungle, that you’ll leave behind a body that somebody has to clean up… you have a pretty significant chance of ending up in a nursing home, just conscious enough to feel pain and humiliation, for the rest of your life.

Give it another year. Do something different. Talk to somebody about it. Don’t end up on my unit with ARDS from inhaling your own vomit when the pills kick in. If the Huntington’s is closing in and you really gotta go before you turn into a slack-lipped veggie on a vent, plan that shit out and have your family by your bed. If you don’t think you could convince someone to sit by your bedside while you die, it’s not time for you to die yet.

Anyway, that’s a grim little side note. The point is, this lady took all her lithium pills, and after a major round of dialysis, she ended up with a seizure disorder, diabetes insipidus, and maybe about two-thirds of her original IQ. This time around, she’s in the hospital because a week ago she tripped and fell at home, broke most of her ribs on the left side, and ended up with a hemothorax—a big pool of blood in the space her left lung was trying to occupy—plus pneumonia from her immobility and from being unable to breathe deeply and cough without pain, plus dehydration from the DI, plus a UTI.

Diabetes insipidus is a totally different animal from what we usually refer to as ‘diabetes’. Diabetes mellitus—those of you with some base in languages may recognize the root of ‘mellitus’ to mean ‘honey’—is sugar diabetes, which I have ranted about at length here. Type 1 diabetes mellitus means all the insulin cells in your pancreas were devoured by your immune system in a bizarre childhood autocannibalistic orgy, and you probably need an insulin pump; Type 2 diabetes mellitus means your body is growing resistant to insulin and your pancreas is maybe not pumping out as much as you need, often because you have a genetic predisposition or (more likely) your fat cells are overstuffed and trying to tell you to lay off the cheesecake.

It’s called ‘mellitus’ because your kidneys are dumping sugar, and your piss turns sweet. Doctors used to have to taste their pts’ urine to see if they were diabetic. It’s never been a good career for the mentally well.

Diabetes insipidus, therefore, means that your urine is insipid instead of sweet—it’s bland and watery. Lucky doctor. The problem here is that, inside your braincase, your pituitary gland (yes, the gland responsible for dragging you through puberty) has become fucked up somehow. In addition to hairy-armpit hormones, your pituitary gland regulates your water balance, secreting a hormone called vasopressin to remind your body that it actually needs water to survive. (In higher doses, vasopressin also causes your vasculature, your blood vessels, to constrict and increase your blood pressure… thus the name ‘vasopressin’. We use a synthetic version of this regularly on the ICU to raise blood pressure in septic pts.) So if you have a pituitary tumor, or massive brain trauma, or certain types of toxicity like lithium… you will constantly gush gallons of dilute watery fifteenth-beer piss, even though you’re dehydrated and dying of thirst and could really, really use all that water you’re filling your Depends with.

So this woman was constantly in desperate need of a trip to the ladies’ room, which is hard to manage when you’re completely deranged from a urinary tract infection, your entire left chest is hamburger on the inside, and you aren’t firing on all cylinders to begin with. She couldn’t bring herself to use a bedpan, and initially she was too dizzy and sick to get up to a bedside commode, so she would try to hold it until she just couldn’t, then fill the bed with a liter of water-pee and start screaming. Nothing we said to her made any sense to her. She hit and kicked and screamed, and it took her daughter and a sitter to keep her in bed and safe and calm.

Her daughter looked familiar. I’d seen her last night in the hallway, but now that I was in the room with her, she looked really familiar. After the first ten minutes of introductions, I recognized her with a start—she’d been the caretaker for a pt I cared for at my last facility, and she’d been an absolute nightmare. A few delicate questions confirmed my suspicion, and she recognized me too.

She had been enormously controlling, extremely anxious, convinced that we were neglecting her ward even though her nurse could never even get out of the room. She would regularly decide that the pt needed something—a breathing treatment, a new medication, a very specific positioning, an aggressive round of nasotracheal suctioning—and she would insist on it until the doc either gave in or had a stern, invariably ugly talk with her about appropriate care. She was absolutely unable to manage her stress, and this led to her ward being absolutely punished with unnecessary and uncomfortable turns every time she got comfortable.

But this just meant I’d had time to establish a rapport and a set of boundaries with her, and thank living fuck, I was able to get those back into place pretty quickly. I promised to genuinely consider any request she made, but told her I wouldn’t sugarcoat anything or perform any kind of care that I felt endangered her mother, and that if she got stressed out I would stay in the room for fifteen minutes at a time while she went to the waiting room to collect herself.

It worked pretty well.

Then she fired the sitter. The new guy who’d come in for the morning shift is this super sweet CNA I’ve worked with several times, a tall black guy with a genuine smile and dimples to boot, who spent thirty minutes with me last time he floated to our floor while we scrubbed a massive Code Brown off the walls even though he could by rights have ducked out halfway through. He is a wonderful, compassionate human being whose bedside manner is gentle as a lamb and soothing as a fifth of whiskey, and within thirty minutes of his assuming sitter duty, the daughter fired him for being ‘intimidating’.

“My mom is kind of old-school,” she said, clutching her elbows and speaking in low tones, trying her damnedest not to sound racist as hell. “She gets really scared if there’s anyone… intimidating around.” Inside the room, my pt was holding the CNA’s hand and smiling at him while he asked her about her grandchildren.

I told her I would see what I could do, and dove into the chart. Turns out, this cute little old lady with the crazy thrashing etc had not received any pain medication during her stay besides her scheduled toradol, which seemed unrealistic to me considering that she had six broken ribs and regularly freaked out like somebody had filled her bed with bees. She had PRN dilaudid IV available, and I drew it up and headed into the room.

“Are you having pain,” I asked her.

“No,” she said. “I want to go home.”

“Are you hurting?” Sometimes it helps to ask again a different way. “Maybe just a little bit?”

“Yeeeeeah. But I want to go home. So I’m not hurting.”

“We’re gonna get you home as fast as I can,” I said, and pushed the dilaudid. Pts with dementia often have trouble recognizing and expressing pain, and sometimes they think that if they tell you they’re not hurting, they can go home faster. Sure enough, five minutes later she was sleeping like a baby, had peed another liter without freaking out, and had gone from shallow rapid breathing to deeper, regular breathing.

So I sent the CNA off to the charge nurse to be reassigned, and gave her round-the-clock dilaudid coverage. She woke up nicely between doses, no thrashing, coughed on command, and gradually improved to the point that she could get up to the bedside commode.

Pain control is a big deal. And it amazes me that, with all her WebMD recommendations for care, her daughter hadn’t seemed to pick up on her pain. She didn’t need a sitter for the rest of the day.

Her two other daughters dropped by that afternoon. One was even more anxious than the first, terrified of the hospital, terrified of her mother’s condition, not wanting to talk about any of it. The other was fairly laid-back, having worked for a nursing home for a long time, and was mostly stressed out because her sisters were stressed out.

The pt did have a seizure. It started with her eyes jerking to the left, which apparently is her characteristic onset symptom; her daughter called me in, and I gave her Ativan to break the seizure as it kicked in, so she ended up having a few seconds of genuine tonic-clonic seizing before lapsing into post-ictal grogginess.

About 1300, just after my hastily-shoveled lunch of microwave burrito and cottage cheese, the charge nurse cornered me. “I hate to do this,” she said, “but we have a new pt coming in and nobody to admit them. Can you give your tele lady to this other nurse, and admit?”

Charge just seems like a position where you have to constantly deliver bad news and ask people for huge favors. I will definitely want to train for charge someday, but I also dread the thought of having to tell someone that I’m screwing them over because their assignment is too easy and I need somebody to land a clusterfuck and you’re it.

So I gave report and handed off my cute little lady, who was chugging her fifth Diet Dr. Pepper, and took report from the emergency room on a frequent flier.

This poor guy has been in the hospital five times already this year, and god knows how many times last year. He has some kind of GI bleed, probably in his small intestine, which recurs regularly for no reason anybody can pin down—no history of alcohol, no NSAID use, no fucking idea. Last year he had what our GI docs call the “million-dollar workup,” a cascade of diagnostic tests culminating in a literal swallowed camera capsule that films your entire gut as it passes through. No results.

This time his hematocrit was really, really low. I gave him several blood products and wiped his ass a few times while he shit out the last of the blood, and his GI bleed was over—just a couple days of blood transfusion and crit checks, and he’d be back home with his mystery bleed, happy as you please. He’s been here so often that the docs ordered him a full meal plan as soon as his crit stabilized, recognizing his telltale signs of recovery. Usually GI bleeders have to wait a while to eat… we just know that this poor guy is done bleeding once he starts getting hungry, and there’s no use in keeping him ravenous all the way up to discharge.

We did an EGD though, because we kind of have to, because it would be shitty to miss a bleeding ulcer just because he’s never had one before, and have him perf his stomach and die. It was a five-minute affair and he was damn near awake for the whole thing—he said he was used to it by now. That is not a thing I can imagine getting used to. He had a beautiful pink happy stomach lining though. His breakfast of scrambled eggs was still intact and recognizable and made me extremely hungry. I really need to start bringing multiple freezer burritos per shift.

I got hiccups toward the end of shift. I used to get them all the time on nights, usually between three and four in the morning, big whooping hiccups that sounded like some kind of lost stork wandering the darkened hallways calling for its young. My coworkers used to make relentless fun of me. Well, guess what, these coworkers also make fun of me when I start yelling HOOP uncontrollably in the middle of shift.

I could close my mouth and kind of muffle them, but that hurts. So fuck you, I’m gonna contribute to noise pollution, and you can all suck it and/or wear earplugs.

I hope this doesn’t become a regular thing.

At 1500 shift change, the new charge nurse dropped by and poked her head into the room. The pt’s daughter gasped. “Oh my god, I didn’t know you worked here now!” Turns out, this particular charge nurse once directed the adult family care center where my pt’s mother spent her declining years, had known my pt since she was a teenager, and had held all three anxious daughters while they were all still in diapers.  There was a distinct change in the dynamic after that—they seemed to trust us more, now that their old friend was in charge, and I didn’t have to enforce boundaries quite so stringently.

It’s a small fucking world, my friends. I never met this charge nurse before I started working here, and now here I am, taking care of a pt she practically raised, whose daughter I knew from another facility as a pt caregiver. This isn’t a huge city/region (technically the two facilities are in different cities, part of the sprawl of the central metro), but I am always amazed at how often I run into nurses I know from other places, pts I took care of years ago, and people I have to pretend not to recognize lest I violate HIPAA or make shit awkward.

Been checking up on my abd guy. Yeah, he’s still alive. Why, how, I’m not sure. His hemorrhagic necrotizing pancreatitis and total kidney failure have reduced his quality of life to “constant torture when he’s not in a coma.” Lots of legal pushing later, and they’ve assigned him a guardian ad litem… who now has to jump through a million legal hoops and decide whether or not to let him just die.

It’s not an easy choice. He’s very far removed from anyone who could speak for him. His roommate, who only realized he was hospitalized because nobody was using the toilet paper for three days, says he has a daughter somewhere…. But he’s never said her name, just called her ‘my daughter’. He left no living will, no advance directive, nobody with a durable power of attorney.

His coworkers keep coming by to check on him. They’ve all shelled out to get a rental storage unit for his belongings; they show up in their work uniforms, still sweaty and obviously exhausted from their shifts, to stand by his bedside for a few moments and tell him what’s going on at work. We can’t tell if he understands any of it. He opens his eyes sometimes to painful stimuli.

They obviously care about him a lot, and to me this means something. Most people who suffer from major addictions don’t have a lot of people who care about them; they sever their ties, drive away their families, and are slowly devoured by whatever chemical owns them, alone. Even recovering addicts usually spend a little while with their only friends being fellow recovering addicts, if they’ve been addicted for some time. At least that’s what it feels like.

But it’s telling that this guy, despite being a profound alcoholic, separated from family and friends, struggling with addiction, is still someone that his coworkers care about. They’ve worked with him for a long time. Some of them know that he had big issues with alcohol, and have delicately made the awkward effort to inform his nurses so we can “make sure that gets taken care of too.” They really miss him, and that means something to me—even feeling isolated, even in the throes of addiction, even sweating on his deathbed… he (like many other addicts) is still loved. And they are so glad to see him get help that they’re holding out hope he’ll recover, even though he’s long past the point where his death can be more than delayed.

It breaks my heart. I wish he’d got help sooner. He would have been surrounded with love.

In the meantime, all I can really hope for him is that he dies soon, and quickly. Maybe somebody will show up for him that has some legal authority.

Fucking depressing, man. On a bright note, today one of the consulting MDs accidentally locked himself into the staff bathroom, jamming the doorknob somehow. While the environmental services guys scrambled to try and get him out, he kept up a steady litany of exhortations and pleas: “You guys have to hurry, I gotta get out of here. I took a power dump in here. You gotta get me out, guys. Take off the hinges…”

I’d laugh harder if I didn’t occasionally get locked in a room with a pt who’s shitting uncontrollably. The aftermath of a three-pounder is nothing you wanna breathe in a closed space.

Week 5 How Many Fucking Shifts Jesus

I didn't write the day of this shift because I was too busy sobbing like an open drain at a Sufjan Stevens concert that night, and then afterward my friend dragged me to her house and forced me to watch (okay, fall asleep trying to watch) Tinkerbelle and the Legend of the Neverbeast. (She has a two-and-a-half-year-old and might be going a little crazy.)

Opened the shift with a decent duo: a GI bleeder and a post-laminectomy. The latter was only under my care for a few hours, as her biggest issue was pain-- a lot of pain-- and she had come to the ICU because all the pain meds made her loopy on the medical floor and they wanted to watch her a little closer. We were concerned by how dramatically her neuro status had declined; she wasn't somnolent or respiratory-depressed at all, as you'd expect with someone having an opioid OD, but she was totally hallucinating and paranoid. We don't like to see major mental status changes in a pt who's fresh off a major back surgery and/or had an epidural (as is common with back surgeries), because there's always the chance of infection in the central nervous system.

She cleared up around 0845 and seemed totally fine. I interviewed her a little more closely about what she thought had happened, and she said: "Oh, I just have these episodes. Never really thought they were a big deal." Straight from there to a head CT, where the radiologist noted what could be a lesion-- possibly a tumor-- in her head. From that point the neuro team got involved, and because she wasn't really critical care status they moved her off the ICU.

That interview process, by the way, is one of the more ticklish and annoying aspects of nursing, but one of the most important if you want to catch things before they go south. Most people are hesitant to offer their own opinions about their medical issues to healthcare staff, which means that sometimes valuable bits of information get withheld because the patient doesn't want to look dumb in front of the doctor. Thing is, we aren't mind-readers, we rarely have a truly comprehensive health history, and we don't always connect the dots with the same one-on-one scrutiny that a person can perform on themselves. We might not be able to take a pt's diagnosis at face value, because we can't expect them to have a full medical education (I mean, shit, I can't diagnose anybody either), but we can definitely get a lot of crucial information from a person's opinions about their body.

It's like: you might not know exactly what's wrong, but by god, you know something's wrong. And we don't always know even that much, until your vital signs start to crash.

There's a saying that, when a pt tells you they're dying, you fucking listen. People don't just toss that phrasing around. They might not be able to tell you exactly why they're dying, but they know their body is about to lose its grip. 

That kinda came into play later in the shift. More on that later though.

My other pt, the GI bleeder, was a bit of a weird dude. He'd gone AMA the week before and returned vomiting blood, and in addition to a massive variceal banding, he also needed a TIPS procedure. 

If you need a refresher on liver failure and what it does to your guts, here's my patho lesson from last week.

So this guy, a chronic heavy drinker who regularly mixes Tylenol PM with his vodka (do not fucking do this, alcohol + tylenol/paracetamol = liver-ripping molecular knives), has a liver so blocked that all his esophageal vessels are bubbling up like a teenager's face. All the blood vessels around his liver and intestines are completely blown out and ready to explode. Medical treatment hasn't helped him at all, and eventually we'll run out of chances to catch his bleeds... so the next step is a TIPS.

A transjugular intrahepatic portosystemic shunt, TIPS, is a tube that connects the blood vessels on either side of the liver. Now the intestines can dump straight into the system, bypassing most of the liver. If you're guessing that this can have amazingly nasty side effects, you are absolutely correct-- jizz proteins and brain-pickling nitrogens and straight-up chunks of shit are free to wander. Your liver is still getting a little filtration done, and making what proteins it can, but if it's almost completely cardboarded sometimes blood doesn't even bother and just travels by shunt... which cuts off blood flow to the liver and can kill you. But hey, you won't bleed to death?

As is common with families that involve alcoholism, this guy's family-- him and his wife, his children being estranged-- was extremely enabling and secret-keeping and just weird, with bad ideas about boundaries. He and his wife insisted that his hospital bed be moved closer to the wall sofa, so that he and his wife could hold hands as he slept; his wife refused to leave the room at any time, and spent weird amounts of time in the room "changing" (ie naked for some reason????) so that any entry to the room had to be preceded by lots of knocking and calling out. Super codependent, super enmeshed, super inappropriate, and super terrified of "being caught." When I stumbled across the pt's wall charger plugged in by the sink, a totally normal thing that everyone does, the wife reacted as if I'd caught her slipping her husband booze. Families afflicted with alcoholism run on secret-keeping, and most family members have a hard time telling what's an actual secret and what's normal, because they're so used to keeping the world at bay. I felt really, really bad for them both, because things will never get better for them without help, and they'll never get help because they're so invested in the secret and so locked into the psychological addiction of enabling. 

But he went down for this TIPS at two, and did pretty well, so he's got maybe another year or two's worth of chances to break the secret and get their lives back.

While all this was going on, Rachel went home. She isn't even going to rehab-- she's been totally off vent for a while, even taking a few steps at a time, and she went home in a medicab to her children and her own home. I hope things go well for her.

The exploding poop guy was doing much better. A few days of nonstop diarrhea had loosened his belly up to the point that, when I poked my head in, I could see the droopy skin of his abdomen flopping as his nurse turned him to wipe his ass. 

A couple of people asked me how somebody can live without shitting for six months. (Hopefully tomorrow I can get caught up on replies?) The answer is: you can't live without shitting for six months. You can, however, be massively chronically constipated, and if it starts slowly and doesn't advance too quickly, your body gradually learns to compensate for the increasing blockage. You shit liquid around the blockage, mostly. But eventually even that deteriorates, and soon you're backed up to your neck. Literally. So this guy hadn't pooped in something like a week, but he'd been working on that week of constipation for so long that it damn near killed him.

The last pt I got for the day was an utter clusterfuck. She was an older woman, a marathon runner, who had developed a hiatal hernia and had it repaired via Nissen fundoplication (wrapping the stomach around the esophagus, which I can't describe any better than Wikipedia). Her wife is an RN and had been staying with her since the surgery a couple of days before, and yesterday had started expressing some concerns about the pt's status: requiring more oxygen, having increased pain, unable to advance her diet, and just "looking weird." Overnight the pt's oxygen needs had increased to the point that, when I finally got report, she had been on a non-rebreather mask at 15 liters, satting 89% O2 (you and I probably sit between 96% and 100%), for almost six hours without anybody insisting there was a problem.

Sometimes nurses make the worst pts. This nurse, however, impressed the hell out of me both with her insight and her grace in light of the medical floor staff's failure to recognize her wife's decompensation... though honestly I would have been a lot pushier than she was. I can't nitpick. She's trauma-ortho and I'm ICU and therefore she's a steady time-managing proceduralist while I'm a neurotic compulsive paranoid with control issues.

The transfer was awful. Charge told me I'd be getting a pt shortly, so I asked my break buddy to watch my TIPS guy while I took a fifteen-minute nap, and notified the charge and the unit secretary to call me on break if report came up. Instead, I enjoyed a nice snooze, checked on my TIPS, poured myself a cup of coffee, and walked down the hallway to find the new pt waiting for me-- no RN, no report, just a confused transport guy from CT and a pt who looked like she was about to crash on me.

As we moved her into the new bed, she grabbed my arm and gasped: "I think I'm dying." Then she was too short of breath to say anything else. I keep my hair back in a sloppy french braid, but I'm pretty sure half of it popped out and stuck up straight in the air. Remember what I said earlier? That's not a good thing to hear from any pt.

She had subcutaneous emphysema with crepitus-- crackling bubbles under her skin-- from her shoulders up to her temples. A quick chest x-ray showed that she had a massive pleural effusion, so I got her sitting up on the side of the bed, and the pulmonologist stuck a needle in her back and pulled out a liter of bloody-clear fluid, which improved her breathing but was extremely alarming. Her wife watched the whole procedure and looked increasingly apprehensive, especially when the pulm ordered the fluid checked for amylase-- one of the enzymes secreted by the pancreas, which belongs in the intestines breaking down your food, not in your lung cavities. 

Sure enough, the radiologist showed up twenty minutes later to tell us that her CT showed a giant rip in her esophagus, with communicating fluid and free air between abdomen, thorax, and mediastinum. This is SUPER BAD AND HORRIBLE and requires immediate surgery. Unfortunately, our cardiothoracic surgeon that day had started an open heart an hour before and wouldn't be available to operate for at least another four hours, and the nightmare in her gut was massive enough that she would need a GI surgeon and a thoracic surgeon to perform the surgery. We intubated her immediately to stabilize her, then transferred her to another hospital in the area, a thirty-minute drive at the end of which the op team was already preparing the OR. I hope she's okay, for her wife's sake. I can't imagine being a nurse, knowing what I know, and watching helplessly as my spouse suffered horrible pain and life-threatening health events. I don't know how she wasn't flipping tables and kicking doctors all night, watching her wife go from nasal cannula to mask to non-rebreather without being assessed for critical care status needs, watching her face blow up with subcutaneous air without somebody at least asking for a chest x-ray to rule out pneumothorax. 

This is why nurses make terrible pts. We get all freaked out and controlling about our care. It's just ridiculous. Any time my husband spends in the hospital is time I will spend gnawing my tongue off in the middle so I don't get thrown off the campus.

Let me tell you, though, getting that pt with no report and no prior warning was more of a wake-up than any amount of freshly-poured coffee that I promptly forgot about and left on the station until it got cold and the unit secretary threw it away. A pt with no report AND massive sub-q (uh, that's subcutaneous in nurse jargon) emphysema will give your sphincters a workout. I had to stay a little late just to write up the incident report. Still a little stressed out just thinking about it.

I only worked eight hours though, and after that I went home and washed up and put on something way too shabby and sloppy to wear to a concert, but I guess it didn't matter because I had a blast. Or possibly an emotional breakdown. It's kind of hard to tell. I will write about today's shift tomorrow, after the morning's meeting with my sister's social worker. 

My sister, btw, is doing really well, but she reminds myself a lot of me at that age-- questionable personal hygiene, terrible time management, serious lack of some basic social niceties. The usual rural-religious homeschooled stuff. But she's just as smart and articulate as I remember, and has charmed my friends and responded well to all our conversations about my expectations for her time in my home, and I'm really glad to have her with me as she starts her adult life.

Week 3 Shift 3

Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.

Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.

This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.

The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.

It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.

So down he goes for his cath.

My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.

(We typically refer to this procedure as an EGD, for obvious reasons.)

So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.

She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.

The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.

She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.

Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.

Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.

This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.

Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.

And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?

If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.

Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.

While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.

Well, maybe a few people. But judgement like that isn’t mine to make.

I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?

Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.

No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.

Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.

Favorite memories of the two departing nurses:

--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.

--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.

Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.

The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?

I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.

Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.

She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.

Hopefully I won’t die of anaphylactic shock.

Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.

If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.

There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).

My stories are short stories. My endings are reports at the end of shift.