Week 8 Shift 3

Day two with Maycee. Somehow she survived her first shift and is back for more, and even looked a little energetic during shift change, which was downright irritating for me because I hadn’t had any coffee yet and felt like a lake of lukewarm shit. Fortunately our unit has free (terrible) coffee in a truck-stop-style machine in the supply rooms, so I was able to get my smack-and-wince dose of caffeine before my ability to feign personhood ran out.

I wasn’t always such a complete caffeine junkie. On nights I rarely ever drank coffee because it fucked up my sleep schedule so badly. Nowadays I can’t get through the morning without my usual half-cup mixed with a stolen mini carton of milk, and I drink the second half-cup cold and kind of stale-milk-tasting later in the afternoon. It’s not much caffeine, but I can’t do without it.

This disturbs me.

Maycee was drinking some sort of sentient green morass out of a Nalgene bottle. It smelled like algae and pineapple. It’s probably some healthy superfood thing I should be drinking instead of a paper cup of two percent and bean tar.

We took report from that one nurse again, the one with the propofol tubing fetish. He was still bitching about the damn tubing. I mean, I have been taken to task by some nurses for stupid things, but by this point I was a little embarrassed for him, especially since the pt we were taking back had been down to almost no levophed at all when we passed him off and now he was cranked up to a stupendous dose, his urine output had been trending downward for three hours with no MD notification, and he looked sweaty and shitty and filthy because apparently that bed bath he’d tried to trick Maycee into was the only bath he got all night.

Night shift nurses do the official bed baths, especially on vented pts. Whatever. I used to be a night nurse and I still have a Thing about my pts being clean. We opened up our shift with a stiff, polite nod to the departing nurse and then a proper bed bath for the pt.

We only had the one this time. Thank goodness—I planned to have Maycee assume all of his care today, and that would be completely impossible if we were running back and forth between pts all day. The neighbor, the humongous guy with diarrhea who was (also) wrongfully intubated, is still doing his thing and I still got to run in every twelve seconds and fix his IV so he could keep getting his sedatives, but we were able to focus mostly on the liver failure/sepsis pt and his increasing needs.

He was not getting at all better, but then again he wasn’t doing anything flashy either. He had high gastric volumes (amount of stomach juice that wasn't moving from stomach to intestine) so we couldn’t start tube feeds; he had lots of fluid in his abdomen so we ended up doing another paracentesis for another 6 liters. Since he weighed in at about 15 liters up this morning, in excess of his base weight, this was less impressive than I could have hoped… but there’s something deeply satisfying about watching all that gooey liquid pour into the suction canister, knowing that we’re cheating the body’s self-destructive excesses and recovering the balance.

A friend of mine observed this recently: a lot of what we do in the ICU is simply keeping your body from killing itself. Many of our natural processes are totally normal and productive at low levels: swelling is an important part of washing out infected or traumatized areas of the body, clotting keeps us from bleeding out, fevers fight infection… but at a critical level of acuity, those same processes become a potential death sentence. Inflammation crushes our bodies, deforms our tissues, drains the liquid from our blood; clots occlude our arteries and contribute to adhesions and use up our platelets where they aren’t needed; fevers cook our brains and organs like gently poached eggs.

Past that threshold, the body can’t heal itself effectively. It’s a last-ditch effort, a forlorn hope: maybe another half a degree will stop the bacteria, and we can rebuild the damage later, maybe, or live without the ruined parts. Maybe a little more swelling will give us the edge against the infection, and maybe we can catch up on blood volume later. Maybe this clot will be the one that heals the damage.

If this one doesn’t work, we die anyway.

But then here comes modern medicine with its antibiotics and other weapons of microbial mass destruction, ready to save the day, if only we can get the body to stand aside and let us do the work. Septicemia? Sure, we have an antibiotic for that—one bug, one drug. Maybe two or three, if we can’t figure out which thing we’re fighting.

But while the vancomycin and piperacillin and ceftriaxone are working perfectly well and the invaders are in fast retreat, the body is still fighting as if it’s alone on the field. So we give drug after drug to support the body through its berkserk phase: liters of fluid to replace losses, pressors to keep the fluid where it belongs, blood-thickening albumin to draw the swelling back in, diuretics to pee it off; steroids to interrupt the cascade of inflammation, blood to counter the dilution and make up for the body’s deficit while it focuses on white blood cells instead of red. Heparin to keep the immobile body from clotting. Bicarb to counteract the acid produced by stressed cells.  Mechanical ventilation to keep the swollen lungs functional and increase available oxygen. Proton pump inhibitors to prevent ulcers and acid reflux while the body is stressed and ventilated. Chlorhexadine mouthwash to keep other germs from crawling down the breathing tube.

It’s insane. If we can naturally produce the antibiotics we need as soon as the germs invade, antibodies with the right markers to identify their enemies immediately instead of mounting a full septic assault, we don’t need any of the other drugs. If we can interrupt the sepsis early, before the inflammation gets out of control and the body’s organs are dying from low blood pressure, we don’t need the ever-increasing volumes of supporting drugs to deal with the consequences of sepsis. And if our bodies can’t control the infection and our doctors can’t keep our bodies in check, we die.

Nothing in nature prepared us to survive things like this. When we save someone in deep sepsis, we are fighting more than germs, more than poisons: we are fighting human history, evolutionary pressure, nature itself.

I have no problem with this. Nature is a bitch. Tumors are natural; epidemics are natural. I am perfectly comfortable fighting nature, as long as we remember that the battle is fought on many fronts and that winning the battle with sepsis doesn’t always mean winning the battle against organ failure, old age, lingering infirmity, and pain. So yes, absolutely, I will fight nature bare-fisted and without shame—but I know better than to gloat over my victories.

All this makes it very hard, emotionally, to care for pts who are doomed. This poor guy never wanted to suffer like we’re making him suffer: he wanted four days, max, on the ventilator, and here we are punching holes in his belly so his weeping, failing liver can get some relief, days beyond his deadline. It’s fucked up and awful and out of my hands. It’s a very American way to die.

Fortunately the ethics committee is involved in this one, and we’re hoping for permission to withdraw pretty soon. Until then, you had better fucking believe I’m blasting him with fentanyl. If he’s got to stick around for this shit, he’s gonna be oped up to the eyelashes the whole time.

Maycee performed most of his care today. I helped with turns and assisted whenever asked, but I let her try things out, make mistakes, and zero out her pressure lines by herself. She did wonderfully, and between chores we exchanged war stories of hospital life.

Having worked on the telemetry unit until now, Maycee’s patient loads have been three and four pts to a nurse, and none of her pts are sedated or on titratable drips. She also worked nights, which means she got to see pts at their weirdest and most whacked-out—a thing I kinda miss, now that I’m days.

She described a group of three sundowning pts whose rooms were unfortunately close to one another, all of whom spent all night yelling at each other. One was a tiny old lady who constantly demanded: “Who’s there? Who’s there?” Another was a little old lady who cursed and screamed for “them” to leave her alone. The third was a developmentally delayed man in his forties who called out for help with almost every breath he took. Two could be redirected temporarily with a bit of soothing company, but the paranoid old lady got worse every time someone came into the room, and the other two responded to her bellowing with a litany of responses: Who’s there? Help! Who’s there? Help me!

All night they kept this up. If one of them fell asleep, the others would wake them back up. Closing the doors increased the screaming—a lot of delirious pts are terrified of being enclosed. Maycee related the charge nurse’s ongoing battle with Bed Control and the shift administrator, as all three pts needed to be close to a nurse station for observation, and breaking them up would involve transferring at least one of them to another floor. Finally the shift admin dropped by to have a face-to-face chat with the charge, observed the noise firsthand, and had transfer orders for two of the three within thirty minutes.

I laughed my ass off, naturally. We’ve all had nights like this, and we’ve all begged distant, uncomprehending administrators for mercy the way prisoners wish upon stars. Any story where someone doesn’t believe a nurse until they see for themselves is a relatable story; any story where the unbeliever is driven mad, splattered with body fluids, or chewed out for their disbelief is a great story. We are nothing if not predictable.

Well. Maybe we’re also bloodthirsty and petty. But we’re predictably bloodthirsty and petty.

I told her about a pt I had in Texas, a woman whose panniculus obscured her legs down to the knee, whose labia majora were distended with edema and obesity to the point that they looked like sagitally aligned panniculi on their own, and whose foley catheter placement was an effort of legend. We used a hammock-style bedsheet hoist to restrain her panniculus and lift it toward the top of the bed—a sheet folded lengthwise, tucked under the hanging gut, threaded through the bed rails on either side and pulled back to achieve a primitive pulley effect.

She had been an uncontrolled diabetic, as I recall, and had a raging raw yeast infection downstairs. I felt fucking terrible for her—she had not been taken care of at all, and was well past the point where she could take care of herself. As we struggled to hold her labia back, she sobbed and hissed with each pressure of a glove against her bleeding, excoriated skin. I had one coworker holding each labe, and I was wearing long gloves and squinting at the bloody, curdled mess of her vaginal vestibule, searching for her urethral meatus—

When one of the coworkers started to lose her grip. “Get out,” she barked, understandably not wanting to grapple with that incredibly painful stretch of skin for a better hold; I got my arm out of the way just in time, as did the other coworker, and the two labia slapped together the way you might clap dust out of a couple of rugs. It sounded like somebody had dropped a fresh brisket on the linoleum. Yeasty effluvium launched from between the folds like taffy thrown from a parade float. All three of us caught a little bit of the splash; I was spackled from my right elbow all the way up to my left ear.

And man, what do you do with something like that? I mean, you can’t really laugh that shit off until you’ve had a chlorhexidine shower and a glass of gin. You sure as fuck can’t freak out and gag and cry and curse, because your pt is right there and no matter how gnarly her vagina is you don’t want to be the dick humiliating a sick woman for being half-eaten by yeast. You can’t even really process it. You assess the damage—did any of it get on my mucus membranes? Do I need to control any secondary drippage? Will I need to get some fresh sterile gloves?—and if you’re not in immediate danger, you just take a deep breath and get back at it.

I do remember reassuring her that I would get her a topical treatment to help with the pain and itching, and that she was extremely relieved once the foley was in and she wasn’t trickling hot urine over her raw, infected skin.

She actually ended up doing pretty well, as I recall. She came back to the MICU three weeks later after a panniculectomy and double knee replacement, and was able to walk a few steps on her second post-op day. I hope that gave her a chance to turn her life around.

After our second-to-last turn, I was tapped to watch a pt down the hall while his sitter was on break. Fifteen minutes of watching a little old guy scratch his balls and ask whose garage he was sitting in? Sweet. We had a great conversation about carburetors, mostly consisting of me having no idea what the fuck a carburetor does and him explaining it to me four times without making much sense, and then he looked me in the eye, lifted his wrist to his mouth to cover a yawn, and pulled out his IV with his teeth. Blood went everywhere. I stanched the flood, paged IV team, and apologized to his nurse for my utter failure as a sitter.

Turned out this was his fourth IV that day. I hadn’t known, when I started sitting him, that his IVs were supposed to be wrapped in an obscuring bandage at all times, and apparently while the sitter was handing off to me he’d unwrapped his line and thrown the bandage on the floor all sneaky-like. Some pts are crafty lil fuckers, I don’t care how confused they are. It’s kind of impressive, really. I don’t know if I could come up with a plan that effective, and I’m not even tripping Haldol-pickled balls on the ICU.

Toward the end of the shift, the abd guy started having a lot of trouble. He had gone down for surgical placement of a tracheostomy and PEG, and I guess he’d been fine for most of the day. During the PEG placement, it seemed, they had insufflated his abdomen—pumped it full of air to allow free movement—and the leftover air was causing pressure issues. He ended up having what I can only describe as an abdominal needle decompression, the way you decompress a tension pneumothorax, and the catheter in his belly farted as they rolled him back and forth to work out all the air.

He nearly coded, apparently. I have never seen anybody react that harshly to insufflation. It’s not like they leave you all blown up. I guess he was just hoarding air—his abdomen is probably a maze of adhesions and scar-pockets by now. Once they decompressed him he was perfectly fine, and even came to enough to open his eyes and move his mouth in voiceless ba ba ba syllables, singing to the ceiling.

Today they started talking to rehab facilities to see if we can get him a bed with Kindred or one of the other long-term care places.

We wrapped up the shift without any more remarkable occurrences, and after running over the day’s events with Maycee, I signed off as her preceptor and gave her full marks for work well done. She will work with a couple other nurses before they start giving her pts of her own. I look forward to seeing how she grows as a nurse. She’s pretty cool.

Regarding the story I mentioned last time, the man and his mother and the cats: I honestly didn’t think this blog would be popular at all outside of the people who already read my forum posts, and they already know that story. I might post it here at some point this weekend, but I want to give a couple of disclaimers:

--It’s definitely the worst thing I’ve ever experienced as a nurse, and hopefully the worst thing I ever will. It’s not the kind of cool story you want to gross your friends out with; I still find it distressing and disturbing and almost sacred in its awfulness, like retelling it is some kind of violation. But I also know that it’s a real thing that happened, and that storytelling is one of the ways we give awful things meaning beyond tragedy, and that some of the things we should fear most are simply hidden from us because they’re too awful to discuss. So I might post it anyway.

--I will definitely have to figure out how to hide it behind a read-more link first.

Week 8 Shift 2

The new crop of ICU nurses is coming on this month. We’ve recruited our usual blend of experienced RNs from other facilities across the country, pre-trained travel RNs who’ve been seduced onto full-time jobs after finishing their contracts (I was one of these), and PCU/PACU/telemetry RNs who are excited to move to the ICU and learn the ropes. The latter group requires a hell of a lot of attention before they’re ready to be turned loose on patients.

When I entered the world of the ICU, I was a new grad, fresh off the NCLEX. I knew I wanted to work ICU, and I had done a lot of high-focus work in school to get there, but I was in absolutely no way prepared to actually provide critical care. I don’t know why they hired me—I probably smelled like amniotic fluid and fresh hay, sitting across the desk from the manager with my incisors clamped together and my lips peeled back.

As it turned out, they were desperate. A mass exodus of nurses from their MICU had made conditions very tight there, and I suppose everyone figured it would be easier to foist off the low-acuity pts on a clueless tottering foal of a nurse who probably wouldn’t kill them than it would be to suffer through another month of catastrophic short-staffing. And, I mean, I’m pretty good at making competent faces.

Fortunately, I had excellent preceptors. I sat through two weeks of class, then another week of computer training, then started two weeks of precepting—following an experienced nurse through the care of a single pt, slowly learning the ropes and getting used to all the drips and rhythms and schedules and reports. At this facility, new nurses are precepted for up to three months; at my initial facility, I had two weeks on days, one week on nights, and then a full pt load. I don’t know how I managed not to kill anybody.

I probably did kill some people. Not immediately, but by providing less-than-competent care that didn’t give them the foundation they needed to heal. I over-sedated my pts—to be fair, we all did this—and I often ended my shifts completely confused and with so many chores left to do that I was the terror of the day nurses who had to follow me. I was Not A Good Nurse.

So precepting is really important to me, and I came to work early because I knew I would be teaching someone how to ICU today.

Her name is Maycee*; she is tiny and energetic and has the cute kind of freckles that speckle the bridge of her nose (unlike my all-over sepia dapple that looks like an old-fashioned Instagram filter of a nasty crime scene under blacklight). She has only ever worked telemetry until now. She’s quite smart and used to hard work (tele/progressive care nurses are some of the hardest workers in the hospital), and so I didn’t feel too overwhelmed when they told me we’d be caring for two pts instead of the traditional precepting one.

This is actually an intense load. You can’t just do anything—you’re explaining all of it, the principles behind it, the rationales for your actions, the processes you used to arrive at your decisions, the whole time. You have to ask leading questions and see if your preceptee can follow those routes on their own, which means setting up a decision situation, prompting the preceptee with a question, and taking the time to gently prod and guide them until they answer the question on their own. It basically doubles the time anything takes, which means that taking two pts is an absolutely mind-blasting time-management gauntlet.

One pt was a desperately ill pt with liver failure and sepsis who had, before being intubated, said that he didn’t want to be intubated for more than four days, and who was now on his fifth day with no family members to follow up on his wishes. The other had chronic worsening respiratory issues and hadn’t wanted to be intubated at all, but had been found down by a neighbor who didn’t know his end-of-life wishes, so he’d been tubed and brought in by the EMTs and was now in full-code hell waiting for some family members to get back to us and let us put him on comfort-only care.

This has been somewhat of a theme on our ICU lately. It’s discouraging. I hate to imagine being chronically ill, having no chance of recovery, and being forced to stick around and suffer because nobody can speak for me.

By the way, DNR tattoos don’t count. DNR papers, signed by a physician, are good for something if they’re posted where the EMTs can see them before they get the tube in and start CPR… but they aren’t allowed to pull the tube out or, in many cases, stop the CPR once it’s started. If you really don’t want to get beat up before you die, it’s a good idea to get the signed papers and put them just inside the front door, and maybe to get a med-alert bracelet instructing any rescuers to look at your papers and/or call your POA (power of attorney) person.

Our pt was on levophed, which meant his pressure was okay, but his arms and legs were enormously swollen. He was up by nineteen liters of fluid from his admit weight. We diuresed him as much as possible, using albumin between rounds of lasix to suck the fluid back into his bloodstream from his tissues. An hour into the shift, we started a lasix drip. We also had to keep him on a continuous potassium drip, as lasix works by dumping potassium to force the kidneys to dump water as well (in simplified terms, anyway).

At max rate, the lasix got his kidneys up to a break-even point where he was peeing about as much as we gave him every hour, except hours where we gave him antibiotics or literally any other fluid above and beyond his continual IV drips.

Meanwhile, the guy next door required frequent bolus doses of sedatives to keep him comfortable, and was shitting more or less continuously. He weighed a fucking ton, so we were relieved to discover that his room was one of the two-thirds on our unit that has an overhead lift by which we could turn and haul and move him. It didn’t really help a lot with cleanups, since it lifts pts by hoisting the corner-straps of a mesh hammock the pt is lying on… so if you need to clean the pt’s butt, you have to move the hammock out of the way. But it made turns a thousand times easier.

Our liver failure/sepsis guy was really not doing well. His PEEP had to be cranked up; he was so fluid-overloaded his lungs were flooding, and the high doses of levophed provided even more systemic resistance that backed up into the left side of his heart. I’m not actually sure if this is true, as I haven’t fully researched it, but I’ve heard that levophed and phenylephrine in particular contribute to pulmonary hypertension by squeezing the lung capillaries, which causes the same swelling in the lungs that happens in the hands and feet with those drugs.

Either way, I can tell you that a pt on a high dose of levophed isn’t going to be breathing on their own for long.

(The hand and foot swelling comes from the way levophed closes up your peripheral blood vessels, resisting blood flow to those areas so that the blood is redirected to critical organ circulation… but also impeding the return flow of fluid that actually makes it out that far.)

So we had him on a whalloping fourteen of PEEP. I can’t remember if I’ve explained PEEP before, but I am the kind of person who precepts well because I can’t stop myself from ranting, so buckle the hell in.

PEEP stands for Post-End Expiratory Pressure. If you just breathe all the way out at the end of each breath, the little air sacs in your lungs—the alveoli—can collapse at the end of expiration. And because the inside of each alveolus has to be wet and gooey with lung-mucus to allow oxygen to diffuse across the membranes, the walls of those little sacs stick together when they close—especially if there’s lots and lots of goop, ie lung boogers or edematous flooding.. It takes a shit-ton of work to force those stuck-shut alveoli open again, and until they pop open again, they aren’t exchanging any air. It’s better to keep them open in the first place… but how?

As a bonus, if your alveoli are swollen up with too much water, they might stop working properly—in which case you gotta bring that swelling down. Diuretics might work if it’s a systemic overload problem, but if your lungs are just irritated and inflamed, you need to find another way to squeeze the fluid out. If you’ve ever had a sports injury, you know that compression helps a lot… but how are you going to squeeze your lung tissue?

The answer to both of these questions is PEEP. At the end of each breath, a sharp puff of air forced into the lung keeps the interior pressure of the lung juuuuuust high enough to prop open the alveoli, and maybe even force a few closed ones to reopen. And by maintaining pressure on the alveolar tissue, PEEP compresses the swelling, forcing fluid back into the bloodstream so your heart can pump it and your kidneys can dump it.

There’s a problem with PEEP though. And we ran into it almost immediately, as our pt suddenly bombed his pressures and had to be given albumin, then cranked up on his levophed even further. Why was this happening, I asked Maycee?

She pondered this for a while. It’s not an easy concept to grasp, and I was asking her to piece it together on her own. I hinted that it had to do with pressures and pressure imbalances in the thorax, and she worked on that until I could see her brain sweating. At last she ventured: is his heart not making enough pressure?

Yeah, I said. There are three reasons why the ratio of pressure involving the heart might be off. The heart itself might be having trouble generating pressure; the pressure beyond the heart (either in the body or in the lungs, the two areas the heart empties into) might have spiked, making the heart’s normal pressure insufficient compared to the new resistance; or the heart might not be getting enough pressure supplying blood to it. Or a blend of these things—it’s rarely just one.

Had we recently changed any pressures in his body?

Any post-end expiratory pressures?

At that point she got it, and it was amazing to watch the string of lights behind her eyes igniting a trail from one concept to the other. “More pressure in his lungs from PEEP,” she said. “More pressure for his his heart to push against; more pressure to resist the flow of blood back to his heart from his body. We changed the pressure! So can we fix that?”

The answer is complicated. More fluid in his bloodstream would increase the return pressure to his heart, but stood a good chance of never making it back to his veins after the pressure in his arteries petered out, and he was already desperately fluid-overloaded. He had run out of places to put extra fluid; his arms and legs were weeping and taut, his scrotum had inflated to the size of a basketball, and his belly was a distended, thumpable tank of fluid that had oozed from his liver into his abdominal cavity.

And honestly, you can only give someone so much levophed.

So we called the charge nurse and asked if we could hand off the other guy at 1500—the answer was yes—and then called the pulmonologist/intensivist, our brilliant and beloved Dr. Padma, and asked if she felt like tapping this guy’s abdomen.

She agreed with us: we needed to get some fluid off this guy, and a quick bedside ultrasound showed that he had too much fluid in his belly to measure easily just by looking at it. She said she would go finish her rounds, then come back after shift change.

I sent Maycee on an extended lunch break. It’s hard to absorb all the things you’ll see in an afternoon on the ICU if you’re not used to it, and I firmly believe that part of the learning process involves time spent staring at the wall, trying to piece all the memories and ideas together. By the time she got back, it was ten minutes after shift change, and I had the room more or less prepared for the paracentesis.

Dr. Padma set up a paracentesis kit at the bedside, and we watched as she used the ultrasound machine to guide a needle into a fluid-filled pocket of his abdomen, thread a hollow plastic catheter over it, then withdraw the needle and leave the catheter to drain.

The bag that came with the kit filled to its total—a liter—almost immediately. We emptied it, then drained some more, then realized that this was going to continue for some time. So we hooked the catheter up to a wall suction canister, turned it to low suck, and changed the canister every time it filled up.

The fluid was thick and gooey and wheat-colored with a pink tinge. It also foamed as it poured into the canister, forming a thick layer of bubbles at the top that forced us to empty the one-liter canisters whenever they hit 800mL. I explained to Maycee that the foaming came from protein dissolved in the fluid, a common finding in ascites runoff. Albumin—yes, the same protein that we give intravenously to thicken up the blood and draw in fluid from the third space—is essentially the same thing that you get in egg whites, albumen, which means it foams up nicely when agitated.

I pointed this out to Maycee, and added that you could probably make a decent meringue out of the stuff. She tripped over a gratifying dry-heave and then spat in the sink. “That’s fucking gross,” she said, the first time I’d heard any real language out of her, but her tone of voice was not one of censure.

I mean, you probably couldn’t make meringue out of it. Any decent cook can tell you that any kind of lipid or protein impurity in the albumen can keep the foam from locking; additionally, the acid-base balance of ascitic fluid is more likely to be alkaline than acidic, which means you’d need a lot of cream of tartar to make the foam stable.

Either way, the gates of gross stories had now been unlocked. As we removed liter after liter of fluid from his abdomen—we totaled at nine and a half liters—she told me about a pt she’d had once with severe osteomyelitis in a leg-bone exposed by rotten diabetic flesh, who refused amputation until the doctor reached into the wound and squished the bone audibly, pointing out that it felt like soggy Triscuits.

I told her that one story about the guy and his mother and all the cats, and she called bullshit, which is an appropriate reaction to a story that grim (I will probably never have another story to rival it), but I texted my coworker from that night: “Hey, remember that one guy and his mom?”

Thirty minutes later she responded: “FUCK YOU WHYD YOU BRING THAT SHIT UP AGAIN”

“But you remember it, right?”

“Uh I’m carrying that smell to my grave. How’s your week going, stinky oatmeal?”

The weird thing is that we actually do talk about this almost every time we hang out. We get a bloody mary each and order a thing of garlic cheese fries and sit there picking at the gooey stuff, talking about that guy intermittently between gossiping about coworkers and bitching about administration. I don’t know what we hope to unearth about it, or what draws us back, but in some ways our friendship is about that guy. We’re still working on it.

We finished the paracentesis and Dr. Padma retrieved the catheter. In its wake the insertion site continued to ooze copiously. His blood pressure gained by twenty points within thirty minutes, and we started titrating the levophed down. We administered intravenous albumin again, and shortly after that deep wrinkles appeared in his feet as the swelling started to recede.

A short-term fix. We’d just reclaimed his abdomen as a reservoir for extra fluid; he was still weeping internally. But it felt nice, and it gave Maycee some visible indicator of the pt’s improvement.

The charge nurse appeared in the hallway and beckoned to Maycee. “We’re putting in a trach and PEG down the hall,” she said. “You should come see this.” I waved her off and wrapped up the shift while she and the other preceptees crowded around my abd guy’s bed, watching the doctors attempt to open a hole in his neck and one in his belly for breathing and feeding on a long-term ventilator in a care facility.

He’s actually getting… not well, exactly, but better. His hemorrhagic necrotizing pancreatitis seems to have turned around, and while I’m sure he’ll never have full pancreatic function—or, at this point, full neurological function, as he barely responds to questions and commands—he doesn’t look like he’s going to die of this anymore.

At this point, it’ll probably be pneumonia that gets him. That’s what usually gets people on long-term vents.

They did not have much luck with the trach, although the PEG went in easily enough. He just has weird anatomy. It will need to be done surgically.

I barely recognized him when I poked my head in. His hair has grown a lot, and he’s grown a full beard and then had it shaved. The distribution of weight in his face is really different. You can tell, now that the swelling is down, that he’s not a tall man. As they cleaned him up after the trach attempt and let him come back around, his eyes opened and he looked around the room: a human expression of bewilderment, a hint of comprehension, a glimpse… I regret, now, that I hoped he would die. He didn’t seem to be in much pain, despite someone having just literally slit his throat. He looked uncomfortable, but who knows what discomfort and pain mean to him now?

I wonder what his life is going to be like from this point on. I wonder if he’ll ever really wake up. I wonder how much brain damage he sustained during his intense illness, and whether the dialysis and the tube feeding and the tracheostomy will give him some quality of life. It’s entirely possible. It’s also possible that I’ll never know.

When the night nurse came on, he flipped his shit because we had forgotten to change the propofol tubing at 1600. Because propofol is suspended in a lipid solution, we change the tubing every twelve hours to keep it from getting goopy; I had completely forgotten. I didn’t feel like the flipout was completely appropriate, though. He browbeat Maycee when I left the room and told her it was unacceptable to forget to change the tubing, which is a bit much considering that she didn’t know the rules on propofol tubing—it was entirely my fault—and that we were now three hours late on a non-critical task with a pt we’d spent all day struggling to keep alive. Then he cornered her into performing a full bed bath on the pt with him before she left.

Well, part of a bed bath. He’s notorious for this: you give report to him, and he’ll try to keep you until 2030 as his own private CNA, bitching at you the whole time. I hooked Maycee by the elbow, gave the night nurse a frosty look, and dragged my preceptee off to the break room to clock out.

She looked exhausted, excited, ready for a few hours of sleep and another shift tomorrow. She doesn’t even seem upset at the prospect of spending another day in my tutelage.

I think she’ll do well.

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 ???? Shift ???????????

Some things I forgot to mention last time:

At 1100, shortly after I received the abdomen pt, I called up the charge nurse and politely requested to have him made 1:1. I don't ask for this often, and pride myself on my ability to balance multiple high-acuity pts safely. But part of this ability involves my recognition of when the load is too heavy for safety-- anyone can pretend they have things under control right up until a pt codes-- and when I realized this pt had hourly insulin checks, constant potassium replacements from an electrolyte replacement protocol (the intensivist declined to start a potassium-containing IV fluid despite refractory K+ levels below 2.8, the cutoff point below which the heart starts to starve and freak out, on the grounds that his renal failure would cause his K+ to skyrocket eventually), q2h labs, and 200mL+ output every hour from his NG tube (thus the potassium loss: stomach juices contain a lot of K+)... I had also just started levophed to pull his blood pressure up, couldn't find peripheral pulses in his feet, and was calling the RT in frequently to handle his ventilator-bucking. Yeah, at this point I decided he wasn’t going to be compatible with the high-need lady next door on bipap, no matter how clean she was now.

I was pretty sure he’d code by mid-afternoon.

The charge nurse came in, looked around, and agreed with me. So after 1100 he was 1:1. This came in really handy when the GI surgeon took him down for that washout.

So for the next couple of days, he wore me out. His open abdomen wept constantly through the drains in the intestine-containment bag, and every thirty minutes he required a full dressing change just to control the flow. His insulin infusion had to be cranked up from one algorithm to the next, as higher and higher doses failed to control his wild hyperglycemia. Worse, as I finally caught up on his blood sugars the next morning, his anion gap stayed wide open—the acidosis continued, and although his potassium finally caught up and began to rise as his small bowel obstruction stopped backing four liters of stomach juices out of his NG tube every day, the problem was clearly not a sugar/insulin imbalance.

Anion gap acidosis has a number of possible sources, although insulin deficiency is probably the most common. A few of them were addressed in that nephrologist’s note I quoted the other day. Another occurred to me during my camping trip this weekend, as I was studying for the CCRN test I took today (AND FUCKING PASSED YESSSS I AM A CCRN NOW). This guy is an alcoholic, and had been sick for a little while, homebound. What if he got into some alcohol that wasn’t drinkable? Specifically, methanol? It would explain some other major things, like the encephalopathy and his eventual failure to maintain pupillary reflexes.

Man I got no idea. I haven’t actually taken care of a pt with methanol poisoning, so all my knowledge is book knowledge. Methanol, aka wood alcohol, is an alcohol much like ethanol (booze), except that it turns into formic acid in your body, destroys your eyesight permanently, causes brain swelling, and tends to result in horrible death. I’ll have to look that up when I get back to work on Saturday.

Anyway. He stayed very high-acuity for the next few days; I was 1:1 with him the next day, and the day after that I was first admit, but ended up not admitting because the only person who came up from the ER was a telemetry overflow. He was one of those pts who isn’t panic-level crazy, but whose workload nurses describe to each other as “steady.” Basically, there’s something to do at least once every ten minutes, some of these things taking as long as twenty or thirty minutes and requiring multiple RNs or the help of a CNA, and you spend very little time charting because you’re constantly scanning medications or taking blood sugars or turning or changing dressings or titrating drips.

In this case, about halfway through the second day, the intensivist ordered lactulose enemas to be given every four hours, in hopes of stimulating his bowel to move. I took extreme issue with this because I could SEE the guy’s intestines and they were obviously too swollen to twitch, let alone move stool effectively, but considering that his colon was relatively un-irritated per report of the GI surgeon and the enemas were only about 250mL volume (we often give 1L-2L enemas!), I figured it couldn’t hurt. And sure enough, after the second enema he dumped a decent handful of mucoid stool, although his small intestines were obviously still not moving.

How did we administer these enemas? The traditional way involves turning your pt on their left side, sticking a tube up their rectum, and draining a bag of fluid into their butt to get the shitslide cookin’. Turning this guy onto his left side would have been… tricky, so instead I pulled the rubber tube off the business end of a foley catheter, lubed it up a bit, jammed it up his butt via the “lift balls, grope for anus” method, and inflated the balloon with a syringe of saline. Then I mixed up the enema, drew it up into a giant Toomey syringe of the kind we use to instill fluids into a GI tube (it holds about 60mL at a time), and flushed it all through the rubber hose into his colon. Between flushes I clamped it off with a large hemostat, the kind we use to clamp chest tubes shut. An hour or two later he dumped the full enema, still clear, into the bed. Time to start over.

Turning was tricky. Any time we moved him, he would grimace and his blood pressure would skyrocket—even though he was heavily sedated and receiving a pain med drip, he was clearly having a lot of breakthrough pain. His blood pressure tended to run dangerously low whenever he wasn’t in pain, though. So I would dose him with a huge bolus of fentanyl, wait about two minutes for it to kick in, watch his blood pressure start to bomb (watching in real time through an arterial line), and then do all the turning and washing and dressing changing and whatnot.

Ventilated pts also get their teeth brushed or their mouths swabbed and suctioned once every two hours, usually right before we turn them so there isn’t a drool river when we’re moving them around every two hours. 

The whole time, we were hunting desperately for someone to make decisions on his behalf: a family member, a designated power of attorney, anybody. His kidneys weren’t pulling out of their tailspin, and the buildup of nitrogenous wastes in his body wasn’t doing him any favors. Before we made the huge step of initiating dialysis, though, knowing that this would be a long healing process with a huge amount of involved and intensive care, it would have been really nice to know if he’d have wanted it.

This being a weekend, and this fellow being a member of a specific healthcare group that has its own social workers and discharge nurses that aren’t available on weekends for whatever goddamn reason, I found myself doing most of the work of contact hunting. I called his job and, without being able to give them any details over the phone, asked if he had any next-of-kin numbers. None of them worked. I called his home phone, got his roommate, learned that he had a daughter he had only ever referred to as “my daughter;” received a phone call from a coworker of his who had heard he was out sick, and found out that he has a landlady who “might know somebody;” called the landlady and learned that he had family somewhere in a Middle Eastern country “who don’t speak any English and I don’t know their names;” and was finally suggested to contact a religious leader of his community, who might have access to lineage papers.

By the time I got to that point, it was Monday morning, and the social workers were back on the job. So I spent about an hour pushing them over the phone, giving them a full report of everything I’d done to seek contact, and signed off on his “call the family” duties.

Meanwhile, down the hallway, the drowned kid circled the drain for days. His lungs were torn to shreds by the lake water; his anoxic brain injury caused him to start seizing for hours at a time; his mother went completely insane before my eyes and descended from “horrified and grieving mother” to “crazy woman in filthy clothing laugh-sobbing in the end of the hallway all day and all night.” God, we all felt terrible for her. She threw a shoe at the palliative care people when they came by. 

He went into a rotoprone bed, as I think I said before, and coded in it. A rotoprone bed is no minor thing in ICU practice. It’s like a huge padded coffin/cradle into which a pt can be packed, then wrapped tightly in cushions and panels and straps, then rotated until their face is hanging downward so their lungs can drain. Once they’re proned, we open the back of the bed and let them lie there, gently swinging back and forth with their belly facing the floor, letting their lungs stretch and drain and slowly recover. It’s very effective when used early, and was originally marketed for H1N1 support, since young pts who survived the initial respiratory catastrophe of that strain would recover easily enough in a week or two.

Now we use it for ARDS, acute respiratory distress syndrome, which can happen for many reasons ranging from pneumonia to aspiration to pancreatitis. In ARDS, the lungs become so inflamed that their tissues turn thin and stiff, they can’t exchange gas well, fluids weep into the air sacs, and even the blood vessels lose their pliancy and become hard and resistant to blood flow. 

We use a lot of things to treat ARDS. Paralytics can help reduce the pt’s inclination to fight the ventilator, and minimize their oxygen usage; Flolan (epoprostenol) is a ruinously expensive inhaled medication that dilates the blood vessels of the lungs to allow improved blood flow; chest physiotherapy can sometimes be used to help break up secretions and move fluids around; and, of course, antibiotics and steroids and protective settings on the ventilator to prevent lung damage. And PEEP.

Remember how a bipap mask adds a kick of pressurized air at the end of the breathing cycle to keep the airways (large and small) open? PEEP (positive end-expiratory pressure) is similar to that. Cranking up the pressure helps force fluid back into the veins, keeps the air sacs open, and increases the pressure gradient of air vs blood so that air exchanges more effectively across the membranes. Usually ventilation (CO2 shedding) is harder than oxygenation, but in ARDS pts often have oxygenation just as bad as their ventilation. 

I’ve seen ARDS fought effectively. I cared for a pt once who was very young, got a nasty pneumonia, spent days and days in the rotoprone bed, and was eventually transferred to the local children’s hospital to receive ECMO—extracorporeal membranous oxygenation, in which blood is drained from the body, oxygenated through a membrane, and pumped back into the body constantly. She ended up doing well, and sent us a letter about a year later to let us know that she had not only survived, she had recovered enough to walk across the stage at her graduation.

The drowned kid will not be so lucky. Even if his lungs manage to recover from the lake water problem, his brain is completely fucked from the continued hypoxia. We are, essentially, buying the family time to say goodbye.

Which is a victory, sometimes. If we define death as failure and any kind of life as success, then pretty soon our successes are often hollow—we have quite a few pts who end up suffering for a very long time and being shipped back and forth between the hospital and a long-term acute care facility—and our failures are nearly constant.

You have to look for other definitions of success and failure, here. Sometimes our victories are good deaths. Sometimes we work our asses off day and night to make sure a pt is comfortable as they’re dying. Sometimes we finally manage to talk the family into letting go; sometimes we struggle to win them the few days they need to come to terms with their loss. Sometimes we squeeze enough time to let the plane land and the taxi speed from the airport, so that the kids can be there when their father dies. Sometimes we wash our hands of a code and catch our breaths, and the corpse cools in the room while we go back over the entire crisis and realize that we did everything right and they died anyway. But it’s still a victory, just as all these others are victories: we did everything right.

But they died anyway.

And sometimes we practice our skills on a pt who has made every possible bad choice and is dying of their bad choices, knowing that our care is futile and the resources we spend are wasted, but knowing that when the next pt comes in needing that unusual procedure, we will be that much fresher in our practice. That’s a victory, if you squint.

And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.

Which is to say: when the drowned kid died, my last day before I went on that huge long camping trip and didn’t post for a while, we were all devastated. His mother cried like an animal, gagging and groaning and clawing at her arms, and we all twisted our mouths and ground our teeth and remembered that we were people and wished we weren’t.

Rachel went home again. Her younger child’s birthday is coming up.

That same day, the last day before camping, I sent my open abd guy down to have his belly incision revised. They will slowly close it until at last his intestines are all contained, giving him time for the swelling to diminish between each revision. Then, because he wasn’t expected back up before my end of shift, I took two more pts: a comfort care pt in his thirties with Huntington’s, who was starting to lose his ability to swallow his secretions and was choosing to go home to die rather than move forward with a tracheostomy, and an older fellow with severe hearing loss who had come in for a very mild GI bleed from an ulcer in his stomach.

The comfort care pt’s case was relentlessly sad. His young wife is pregnant; he is not expected to live to see the child. He declined to make a video for the baby, saying that he didn’t want his son to see him like this. His family are rollicking good-ol-boy country folk, and they all sat in his room picking on him affectionately and watching Pawn Stars. They were delightful; they had faced this monster directly, and chosen not to be destroyed by its inevitable rampage, and as a result they were wonderfully supportive and caring. They helped move his cramped arms and roll him gently when he needed to be repositioned; they joked that his stubble “looked like wanderin’ pubes.” They ate five boxes of Fruit Roll-Ups in the room (making me crave Fruit Roll-Ups), and tirelessly suctioned his mouth with a soft plastic tube so he wouldn’t choke.

We tried out atropine drops to dry up his mouth, and they worked fairly well, although he still needed some suctioning from time to time. He was just waiting for the hospice group to pick him up in the morning and bring him home, where he can spend the rest of his life in comfort, surrounded by family. He got the shittest deal on the table, but I think he’s choosing the best possible option with it.

The GI bleed old guy told me about gladiator diets (beans and porridge, with burned plants to provide magnesium?) and house paint (never just use flat white, it looks too bare!) and nail storage (lots of yogurt containers!). He was advanced from a clear liquid diet to a full liquid diet, and delighted in his tray of four different kinds of soup instead of “all that sweet stuff they’ve been trying to trick me into eating.” He called me darlin’ and ma’am and Nurse Elise. He was an absolute doll and I wish all my pts were like him. Plan was to send him home the next day.

The next day I left for my camping trip, and haven’t been back to work yet. The trip was wonderful—I moved into a hammock by Lake Crescent, out on the peninsula, one of the prettiest places I’ve ever camped—and then I came home, finished my studying, took my CCRN exam, slept for a full day, and went to Cardiology Summer School today (first of three Fridays spread throughout the summer, lectures by a popular nurse educator in the area). Tomorrow, I go back to work.

I did stop by and check on my open abd guy. He is still alive and seems to be doing well, though the dialysis nurse was in his room setting up shop when I poked my head in. I didn’t see his abdomen, though. Maybe it’s closed by now. I will check his chart tomorrow and see what all has been going on while I was eating hot dogs and smores at the lake.

And I had my ninety-day review at this facility (I worked there for three months as a traveler before hiring on full time). My manager said there have been absolutely no complaints about me, which makes me pretty giddy, but added that the charge nurses were surprised by how easily I fell asleep on my nap breaks and how often I spend my breaks napping.

I really don’t know what to say to that. I’m fucking exhausted all the time at work and I sleep like a dead rock every chance I get. I just kind of stammered something about being ex-night-shift and wandered away. I thought break naps were one of the crucial characteristics of the nursing profession in general? Maybe I’m just lazy. That is a very real possibility.

I wonder if I’ll get my abd guy back tomorrow. I guess I should head to bed soon, since I have to be up in six hours. Shit, I think I figured out why I nap on all my breaks.