Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

This is just a fact of life: we can’t save everybody. Bodies fall apart if enough bad things happen to them. Sometimes we can keep part of the body alive, but not the rest; sometimes we can support consciousness even when the body is doomed, although eventually even consciousness will fade. More often, we can keep the body running even while the brain is completely dead.

You’ll notice that, with other organ systems, we use different terms than with the brain. If your kidneys have some working tissue, but aren’t strong enough to get your blood really clean, you have renal failure. If your kidneys are so fucked up they shrivel into black raisins and you never pee again and you depend on a dialysis machine to clear out all your nitrogen waste products forever, we call it end stage renal failure, not renal death.

If your liver is a huge lumpy pile of scar tissue and blood can’t flow through it at all, you aren’t experiencing liver death (although you will soon die unless you get a new liver), you’re in end stage liver failure. If your lungs are full of gross shit and require mechanical assistance to get oxygen and carbon dioxide in and out of your blood, you are in respiratory failure; if your lungs are filled with scar tissue and nodules and all the cilia are burned out and every breath uses up more oxygen than it gains, you are in end stage respiratory failure. All of these things lead directly to death, although we’ve learned to cheat them a little better over time, but they are not death.

We also talk about heart failure, in which the heart can’t move blood well enough to maintain equilibrium without medical help. We even talk about end stage heart failure sometimes, although this mostly means this person is about to be dead. The true end stage of heart failure is cardiac death.

We call it death, because for a very long time, the lack of a pulse was death. There was no way to get it back. Once you crossed that line, you were gone.

But we’ve learned to cheat even that death, sometimes, if we’re lucky. We can, if we’re willing to break ribs and insert tubes and flood the body with toxins, restart the heart. We can even support a fatally wrecked heart for a while with ventricular assist devices. What was once death is now closer to failure.

So if we’ve blurred the line between life and death, what’s left? Is there anything that can be so damaged that we can’t compensate for it? Is there anything that truly goes beyond failure into death?

Week 7 Shift 3

This shift did not start well. I gave report the night before to a nurse who has, best I can tell, the most brutal ball-shriveling resting bitchface I have ever seen in my life. Alex* is extraordinarily pretty, always immaculately groomed, incredibly capable and conscientious, and has the amazing power to make me feel like a feeble, wriggling brine shrimp during report.

“What have his sugars been running?” No eye contact.

“Oh, uh…” /checks the lab sheet “Not too high. Uhhh… One-sixties. See.”

Her lips thin out. “Mmmm-hmm. Did you cover him?”

“I gave him… uh… one unit at noon. And uh…. I didn’t cover his last blood sugar.”

Flat stare. “You didn’t.”

“No, it was… his blood sugar was like… one point above the cut-off. I didn’t want to crash him.”

“Mmmm-hmmm. So I’ll cover that, then, and recheck in four hours. When I’m supposed to. Did you get all the tubing changed?” Her expression is somewhere between of course you didn’t and I can’t fucking believe this.

“Yeeeeeah.” Then I wither in my seat and stare at my report sheet for a while. She never says anything hurtful or really judgmental, she just has a tone. Also did I mention she’s beautiful? That makes it a thousand million times worse. I always tell myself after report with her that I didn’t fuck anything up, that I did a good job this shift, that the things I didn’t get done were things I had good reasons not to do.

So, having given report on the crazy lady to her, I came back in a little terrified in case I had missed anything.

Instead, she informed me that she’d got a sitter for the pt again once her daughters had left for the evening—our night CNA who always stays over, Rose*—and that she’d really gone nuts last night. Great. Alex also said that she’d had two seizures last night, both of them beginning with the characteristic left-eye jerk that she usually pulled, and ending with tonic-clonic seizing.

She’d also had something that Alex described as “really weird,” an apparent syncopal episode. She’d recovered afterward, although her mental status was not so great for the rest of the night, but she’d gone apneic (unbreathing) and unresponsive for almost a full minute, and her heart had raced. Her post-ictal period had been extremely short.

“I don’t think it was a seizure,” said Alex. “She didn’t jerk her eyes around. But I don’t know what else it could be. Honestly? I was about to start coding her when she came to. The doc said that if she’s not back to normal by eight this morning, we’re going to start a bunch of lab panels and get a CT scan. Which won’t be fun, because she literally will not be still.”

Sure enough, she was fidgeting in the bed, occasionally mumbling to herself, pushing at the blankets with her hands and then pulling them back up. God, putting her in a CT scanner was gonna be hell. But hey, 0715, she had forty-five minutes to get some sunlight and snap out of it. My other pt was my little GI bleed fella again, so I got a ten-second “nothing new, discharge today” from the nurse and came back to see about getting my fidgeter out of sundown land.

Rose was a huge help. “We can just get her up to the commode,” she said, “and then maybe if she does well we can put her in the chair for breakfast, have her look outside. That should bring her around.”

So we hoisted her up to the commode, and she immediately dumped a gallon of dilute urine and let out a huge sigh of relief.

I fixed her gown. “Better?”

She nodded, then looked up at me with a puzzled expression on her face. “My name is Martha*,” she said, as if just remembering this fact.

“Yeah,” I said. “You ready to sit in the chair, Martha? We have some toast and scrambled eggs for you.”

A big emphatic nod. She looked really confused, kind of blindsided, and I didn’t blame her—if she was snapping out of sundowners, she would just now be entering the period where she starts genuinely waking up, the way I often stagger to the toilet in the morning without being quite sure whether it’s day or night. Rose helped me stand her up in the waltz position—her hands on my shoulders, my hands gripping her gait belt, my knees braced against hers in case hers buckle—and we started the process of pivoting to sit in the chair.

About halfway there, she made a strange expression. “My name is Martha,” she said again, and her pupils spilled wide, and her body went completely slack.

Rose and I barely kept her from hitting the floor, mostly by hauling on her gait belt and thighmastering her lower body with our knees up into the waiting recliner. She was completely limp, taking little hiccup-breaths, going gray in the face. Her eyes stared into the middle distance. “She’s having a seizure,” said Rose. On the monitor, her heart raced, then fell into a high bradycardia, rate of 55. Her bladder emptied. She wasn’t really breathing, and even the hiccup-breaths were diminishing into nothing.

We kicked the chair into full recline and I grabbed the ambu breath bag. “Check her pulse,” I said. On the monitor, her heart rate cruised down into the forties. “Check her pulse! Does she have a pulse!”

“It’s a seizure,” said Rose, but she fumbled for a pulse—wrist, throat, groin. “It’s just a seizure!” Meanwhile she kicked the bed into flat mode, max inflate, pulled the CPR board off the head, and slapped her walkie-talkie to call for a respiratory therapist and the flex nurse. We all do this: we say what we really hope is true, and the whole time we prepare for what we really hope isn’t true. Rose moves very quickly; the flex nurse, Franklin*, ducked into the room within seconds.

“You guys need help getting her back to the chair?” He looked at Rose prepping the bed, me bagging air into the pt’s lungs while still trying to find the flicker of pulse I’d felt before, and raised his eyebrows.

“Code,” I said. “Press the button!” Rose smacked the alarm and the whole unit dissolved into organized chaos.

“Jesus,” said Franklin. “You don’t fuckin do half of report, do you?” He dove over the bedside commode, nearly slipped in the lake of urine from my technically-dead pt, and helped me cradle-lift her in one adrenaline-filled swoop back into the bed, where we laid her flat and started compressions. On the monitor, her heart rate alarmed in the twenties with a wide complex—slow movement of electricity throughout the heart, a very bad sign—until we took up the lead-hammering pace of CPR.

Good pulses with compressions. The RT took over bagging. The intensivist—one I forgot to introduce before, a mild-mannered fellow with a soothing presence and a way with difficult families—pushed into the room just behind the code cart, which the charge nurse was plugging into the wall while Franklin stuck defibrillation pads to the pt’s chest. “What happened,” he shouted—codes are incredibly loud—and I told him the very short, very confusing story: she was on the commode, she stood up, she died.

We coded the ever-loving shit out of her. Pulseless Electrical Activity was all we got—not even a shockable rhythm, just that useless, flaccid bradycardia on the monitor with no physical pulse at all. PEA arrests tend to have incredibly bad outcomes; the heart is too fucked for the electrical system to even realize the muscle is dead.

In the middle of all this I walkie-talkied the unit secretary to ask her not to let any visitors past the desk for this pt. I mean, god for-fucking-bid that her daughters walk into this shit: their mother blank and staring in a bed, her few unbroken ribs mashing into pieces under my hands, blood foaming up in the breathing tube we’d just crammed down her throat, naked violent death at its least lovely.

Nothing worked. Nothing even started to work. Rose and I were both in a pretty bad emotional state—this was not the pt we’d have expected to code. For fuck’s sake, she had broken ribs and a UTI! And, okay, it looked like she’d thrown a clot and had a pulmonary embolism—the blood clotted in the tube as the lab tech drew it from her arm—and there wasn’t much we could have done about that, but I thought about last night’s syncopal episode and about the expression on her face as she died in my arms and felt absolutely, bottomlessly sick.

We called it after thirty-five minutes, a lifetime to code a woman in her eighties. The intensivist went in the hallway to call her family, and managed to get through to the two most anxious daughters, both of whom went completely to pieces over the phone. The other daughter wasn’t picking up her phone.

I arranged her as best I could, then took over the phone after the intensivist, calling the organ donation group (a legal requirement, typically to rule a pt out for donation) and the medical examiner’s office (another legal requirement, in case someone dies under suspicious circumstances or there’s a chance of hospital wrongdoing), trying to get the okay quickly to take the breathing tube and IVs out. You can’t take anything off or out of the pt until you get the ME’s okay.

While I was on the phone with the ME, the daughter whose phone had been off rounded the corner, ignored my attempt to flag her down, and pushed into the room. “Mom,” she started, then screamed: “Mom! MOM! Somebody help!”

God almighty, the unit sec hadn’t stopped her at the desk. Her sisters hadn’t got through to her either. She hadn’t answered because she’d been on the road, coming here, to visit with her mother over breakfast.

I’m just glad it was the more level-headed one. Of course she was devastated, absolutely wrecked—but she’s more familiar with death, and she was able to integrate it and understand it much sooner than her sisters would have. By the time her sisters arrived, I had taken out all the tubes and wires, brushed her hair, tucked her in, and had her looking halfway like herself again, except for a smear of blood beside her pillow that I covered with a washcloth.

I called the chaplain. Turns out the chaplain was off that day. The family hovered in the waiting room, terrified to go see their mother’s body, wailing and crying, at least one daughter nearly fainting twice. I called the weekend chaplain, who often covers on her days off, and asked if she’d be willing to come in and sit with the family while I finished up their paperwork and helped them get to a settling point.

She came in. I owe her big. Unfortunately, after she talked the family into going home and awaiting a call from the funeral home to go see her recovered body there, she hung around and tried to be emotionally supportive to me, at a time when I had a shit-ton of paperwork to manage and really wasn’t feeling terribly in need of a shoulder to cry on.

Mostly I was pissed as fuck, and frustrated, and I wanted to punch something. Every last fucking thing that could have gone wrong seemed to have gone wrong. I couldn’t believe she was dead; I could not believe that we had failed to keep her daughter from being surprised with her death. I was very polite with the chaplain, but finally I hid in the bathroom until she left.

Then I went into my GIB guy’s room for the first fucking time that whole shift. It was now 0830.

I gave him his breakfast, which was mostly cold by now, and took his blood sugar so he could eat it. I smiled graciously the entire time and apologized for taking so long. “I guess you heard everyone in the unit running around like crazy,” I said. “We were trying to save another pt who had taken a bad turn.”

He dug into his toast and asked: “Were they okay?”

“Not as okay as I hoped.” I don’t want to lie to people, but I can’t always tell them the truth, and either way it’s bad form to bomb somebody’s day with a spiel about how their neighbor just died.

As I emerged into the hallway, Alex appeared, expression of stern disapproval firmly in place. “That went badly,” she said, and I braced myself to defend my actions. “Here, I got you this.”

It was a Starbucks latte. A real, honest to god Starbucks latte. I am a little ashamed, but not much, to tell you that I got a little misty. “Thank you so much,” I said.

“You did really well,” she said. “I can’t believe she just coded like that. And her family… You handled that really well.” Then she left for home, while I sipped my latte and rejoiced in the knowledge that her chronic bitchface doesn’t reflect her actual opinion of me.

Ten minutes later, the guy showed up to carry Martha’s body away, and I finally gave the GIB guy’s morning meds and helped him to the bedside commode. I don’t mind telling you I was sweating like a horse the whole time. Waltz position and pivot, knees locked to knees, the whole time I’m chanting in my head: Please don’t code, please don’t code.

He didn’t code. He did shit an absolute lake of filth. I bet he felt better after that.

After this I took a nap. My blessed coworker and patron saint Mavi covered me for what we euphemistically called an “extended break,” and I spent forty-five minutes facedown on the break room sofa, dreaming about a bubble bath full of little adorable swimming mammals that would pop up through the bubbles and squeak, then dive like otters.

I awakened to the charge nurse shaking me gently. “Can you take the guy in twelve*? He has a sitter.”

Okay. Whatever. “What’s going on in twelve?”

“His nurse is getting a fresh VATS and he’s just… a little heavy.”

“Oh good. Sure. Whatever.”

He wasn’t just a little heavy. I mean, physically, he weighed maybe 200lb, but he was in four-point locking Velcro restraints with a bedside sitter and an ass full of Haldol injections. The dude is in his late twenties, a Type 1 diabetic, with a serious drug problem.

I don’t mean that he’s addicted to something, although I’m sure he is. I don’t even mean that he’s taking something nasty on the regular, although I’m sure he is. I mean that this guy will, apparently, do literally anything to avoid sobriety, up to and including begging Robitussin from a pt family member in the waiting room. I don’t think he even got enough Robitussin to get high.

And at any rate this was two days ago, when he was on the med-surg floor, before he went completely apeshit, ripped the whiteboard off the wall, threw a chair at his nurse, and ran down the stairwell to escape from the hospital. He was in for DKA and pancreatitis, and definitely didn’t seem to be in control of his faculties, so we hunted him down; he was in his truck in the parking garage, screaming and banging on the window because he couldn’t figure out how to get the door open.

He had taken a whole bunch of god-knows-what—tested positive for amphetamines, cocaine, opioids, and benzos, although the latter two he’d had in-hospital with his pancreatitis pain and his alcohol withdrawal. Oh yeah, his blood alcohol level was elevated too.

We weren’t able to figure this out until he had been thoroughly restrained, jabbed with an obscene amount of Haldol, shot up with about 4mg of IV Ativan, and strapped down while he drifted off into a mumbling daze. His blood pressure was out the roof—not uncommon for cocaine, especially crack, which we suspected because a) he’s homeless and poor as shit and b) he had a bunch of copper brillo pads in his passenger seat. He was also difficult to sedate, which we expect with meth usage… and he was insanely violent and psychotic, which we expect with the kind of bullshit gas-station drugs that get sold as ‘potpourri’.

I mean, he successfully tricked us into keeping him from being sober for another 12 hours. But he did not endear himself to us, what with all the punching and broken furniture.

By the time I got him, he was starting to calm down, and I was able to ease him off the restraints, although the sitter remained. His girlfriend came in, tearful, also obviously accustomed to sleeping in cars and shooting up, and I got her a sandwich and a warm blanket and told her to go ahead and sleep in the recliner for a while. When she woke up, her boyfriend was still semiconscious and mumbling, so she and I had a little contract chat: she goes to the methadone clinic, so I promised her that while her boyfriend was in the hospital, she could stay here and sleep in the chair and have three meals a day—as long as she attends her methadone clinic meeting times and doesn’t bring in any drugs or alcohol, which are absolutely forbidden on campus.

An hour later I caught her rolling a cigarette (no, not even a joint, a cigarette—loose tobacco leaves in a greasy recycled lunch-meat Tupperware), and explained that if she lit it up in here, the ceiling sprinklers would come on and drench everything. “It’ll ruin your phone,” I noted, and the pt spoke up from his groggy muttering to shout: “Put my phone in the drawer!”

I started to suspect that he wasn’t as gorked out as he seemed.

An hour after that I took his blood sugar and it resulted at 422. “What did you eat,” I asked him.

“Nothing! I haven’t eaten in, like, days.”

A cursory bed-shake revealed four full-sized Butterfinger wrappers and an unmistakable pile of Oreo crumbs. Like really, dude. We had a talk: “I know you want to get out of here as fast as possible, but you realize if you drive your blood sugar up, you’re just gonna end up back here, right? And if you have to have an insulin drip started again, you won’t be able to leave easily?”

He shrugged. “I’m leaving here tonight, even if I have to escape.” Big smile. “Hey, you wanna come with me? There’s always room in my truck.”

His girlfriend started complaining, then called me a whore. I left the room “to let you guys get control of yourselves,” and heard her berating him as I left.

“Why do you say shit like that? It’s not even funny!”

“It’s just my sense of humor, babe. Roll me a cig?”

God. Gaaaaaawd. By this point he was 100% conscious and aware, just being a total asshole. Every time I went in the room, he gave me a steady stream of “humor” about how he was leaving in an hour even if he had to hit someone, how the doctor had dropped by and said he could have dilaudid, how he would “sign whatever you guys say” to get out this evening because “I gotta meet a guy for some drugs. Just kidding!”

His expression didn’t say ‘joking’. His expression said that he thought I was stupid enough to believe he was joking.

A lot of people tell inappropriate jokes in the ICU. It’s a stress-coping mechanism, usually, if not a flattering one. A lot of people who feel out of control of their lives and bodies try to make the staff uncomfortable to re-establish their own feeling of autonomy. Typically I’ll handle this by setting strict boundaries, leaving the room with an admonition for the pt to get themselves under control, and looking for other places to give the pt some perception of autonomy. You can tell that it’s a stress response—they laugh with brittle force, they make lame uncreative jokes and remarks, they show their teeth and the whites of their eyes. There’s a little panic in their voices, a little aggression in their eyes.

Some people harass staff because they’re depressed, detached, feeling hopeless. They’re terminal, or their condition may never improve. They feel out of control, but they also feel like the world around them is hostile and unsafe. They self-deprecate as much as they attack; they have a bleak laugh, monotone voice, the kind of jokes that cut deeper than they should. They kinda joke like Robin Williams: all mania and grief.

(I could never watch Robin Williams comedy. He just looked so sad all the time. He looked like he was joking so he wouldn’t cry, or like he was trying to make someone laugh to keep them from swinging at him.)

These people need to feel control, but they also need to feel safe. They need palliative care, to help them find ways to live meaningfully at the end of their lives. They need a wry sense of humor to deflect their jabs, and to help their grim outlook become an enemy they can despise instead of surrendering to.

This guy… well. Some pts have zero intent of changing their lives, and resent being in the hospital at all. Some pts think they’ve tricked you, because here you are taking care of them when they hate you and would gladly hurt you if they could get away with it. Some pts think you’re a sucker, their bitch, their waitress; they make remarks and take potshots because they can, and they want to remind you that in their minds, they’ve already won.

I can’t stand pts like that. I hate seeing the expressions on their faces: the smirking challenge, the gloating, the certainty that they can get away with anything they try to pull. It turns my job from a joy and a labor of love into a gross afternoon of feeling wasted and exploited.

About an hour before end of shift, I got to give up my GIB guy and take on a new admit from the OR, a tiny old woman with Alzheimer’s who fell in her assisted living facility and now has a broken clavicle, broken facial bones, and a brand-new left hip repair. I barely had time to get her settled before shift change.

As I was waiting to give report, the afternoon charge came up to check on me. This is the same charge from yesterday afternoon, the one who knew my pt. “Oh,” she said, “did you transfer Martha to the floor?”

Explaining that was not fun.

After I gave report and was headed to clock out, I passed my tiny old lady from the other day, the one with the Diet Dr. Pepper and the razor-edged, if slightly unhinged, wit. “Hey,” she called, “can you come get these men out of my bed?”

“Which men,” I asked, poking my head into the room. She was alone, lying in a bundle of blankets.

“These men behind me,” she said, gesturing to the pillows shoved under her left side. “I’m all wore out! I’ve had enough. Tell ‘em to go home.”

I took the pillows out and told her the gentlemen wouldn’t be bothering her any longer. Then I made it halfway to the garage before I started wondering what, exactly, she’d thought those “men” were up to in her bed, wearing her out.

I hope I grow up to be an old lady just like her.

With an hour to go til report, I took a walkie-talkie call from the charge. “I need you to give report to Franklin on your GIB guy,” she said. “There’s a fresh hip coming up from the OR who went into a-fib on the table, and I need you to recover her until the nocs get here.”

“Shit, why can’t Franklin land her?”

“Franklin has the heart. So you’ll need to keep an eye on the GIB guy for him, and give your 1800 meds, because he won’t be able to get into the room easily.”

Sigh. “How about I just keep GIB for an hour and give report to the night nurse, and not waste time reporting to Franklin before the hip gets here?”

“Oh, could you do that? Thanks!” Click.

Yeah, whatever. GIB guy was happily chowing down on dinner, and I brought him his 1800 phosphorus-binding med (oh yeah, he was on dialysis too, and required medications to prevent his phos from climbing too high between trips to the fridge).

(The fridge here refers to the huge chunky dialysis machines that our dialysis nurses push up and down the hallways and use to scrub our pts’ blood. We call them “fridge nurses” and exchange good-natured jabs about the relative superiority of our respective nursing careers. Most of the hospitals in this area either keep their own dialysis fleet or employ the major dialysis-nurse agency in the city, which means that I’ve known most of them for years even though I changed facilities last year.)

The fresh hip was a little old lady with Alzheimers who had taken a dive while going to the bathroom and ended up with a broken clavicle, hip, and left hand. The stress of surgery had irritated the shit out of her heart, which went into a-fib, raising her risk of clotting. When the top chamber of your heart is just wiggling around ineffectively, it forms the perfect environment for clots to form—a warm, open compartment with walls that massage the blood rather than pushing it. And since she’d just had surgery, anticoagulating her was not an option.

So we started her on a diltiazem drip to slow her heart rate—she was quite fast—and laid her flat to recover. And then it was time to give report.

After which I went the fuck home and made dinner, checked with my sister to make sure she was doing okay at the GED tutoring sessions and to ask if she has an internship lined up yet, and then went out for an hour with my writing buddy to work on something besides a shift report: a highly simplified D&D campaign I’ve been running for some friends who wanted to learn tabletop RPGs but were intimidated by all the numbers and charts. It’s a small dumb thing that’s more story and flimflam than hard game-crunching, but I’ve been enjoying it, and it’s adapted well enough to a beginning group that it’s keeping ten simultaneous players occupied nicely. Plus my writing buddy is a game designer type so I can pick his brain for help when shit gets real, and he plays NPCs when I need them.

This is my first time DMing since I was in college. I am not good at it, I don’t think. But we have fun. 

Week 5 Shift 3

Day three with Tiberius. I showed up at work a little early, caught up with the night nurse, then headed to the charge nurse station and insisted that he MUST be made 1:1. They asked if I could take a telemetry overflow admit on the side, and I gently but firmly reminded them that I regularly balance absolutely unreal workloads and am very good at handling high-acuity spreads, and that the last time I insisted on a 1:1 the guy ended up with an open abdomen that afternoon. I got Tiberius 1:1.

Which is a good thing. His sedation was cranked way the hell up, which was appropriate-- even his breathing impulse was completely knocked out on 250mcg of fentanyl per hour + precedex at an obscenely high dosage (got an MD order to double the hourly dosage if necessary, rounded out about 150% of the normal max). And yet he was still waking up from time to time, glaring rings of white around his irises, the expression of puzzled horror that comes with sudden sharp agony. I've had my share of dental work done-- consequences of growing up without owning a toothbrush-- and I recognize the expression well enough, although I'm sure nothing that's happened to my mouth even comes close to the torture of two chest tubes, a partially-closed thoracotomy, a pneumonectomy, and multiple bronchoscopies per day. I dosed him with fentanyl until his blood pressure bombed, and his pressure was still labile for the rest of the morning, dumping whenever he dozed off and soaring whenever he awakened to stabbing pain.

The intensivists had switched out; Dr Sunny was covering him today, and I pitched my case for a new sedative. Given that he was still periodically vomiting, even though we weren't giving him anything by mouth/feeding tube except for a few ground-up pills every day, I was slinging antiemetics at him left and right, and the night nurse had reported a significant prolongation of the QT interval-- the time it takes for the heart to recover from each beat. (The risk being that his heart would try to start the next beat before his ventricles were fully recovered, which could cause his ventricles to freak out and fibrillate, a deadly arrhythmia.) I did some crazy ECG analysis and research and determined that his T wave-- the marker of repolarization, or post-beat recovery-- wasn't prolonged, but he did have a U wave, which is not uncommon for a pt on amiodarone (an antiarrhythmic we were giving him to control atrial fibrillation). The U wave is an extra little bump after the big T bump (after the jagged QRS complex), and apparently it represents the post-beat recovery of the papillary muscles, the little muscle-fingers that anchor and pull your heartstrings to stabilize and open your heart valves. The night nurse had measured from the beginning of the QRS to the end of the U, which made for an incredibly prolonged QT interval, but after a little fishing around on the internet (hey, we google stuff all the time on the ICU!) I found that most cardiologists recommend a slightly different approach.

You measure from the beginning of Q to the end of U only if the U wave is conjoined to the T wave, obscuring the end of the T. If the line returns to its baseline before the U starts, you only measure to the end of the T. Measured this way, he had a perfectly normal QT interval, and I was able to hand Dr Sunny a spittle-flecked piece of paper covered in deranged scribbling and caliper scratch marks and walk away five minutes later with an order for propofol.

It worked beautifully. Thirty mcg/hr of propofol later and Tiberius was sleeping like a baby. 

His wife, Amanda*, was finally joined by a bunch of family from around the country. They have a pretty large family, with various health issues and other things delaying their travels, but the trickling-in of relatives became a steady influx. They are a delightful family, some of them members of a very conservative religion, but free with their affection and bright in their humor and generous with their love. I am not a religious person-- I have some deep and intense spiritual drives that are still bleeding where they were severed, and I still dream of something more satisfyingly divine than the mannequin-god behind the curtain of my milk-faith, but I also have some major bones to pick with organized religion-- but if I had to live in a church faith, I would want one that let me laugh and gossip and cry with my husband's sister and her wife, one that made his grandmother's travel-induced diarrhea an affectionate family joke instead of an unclean shame, one that gave me stories and hope and peace with either life or death, whatever pain or loss followed in its wake.

Good people. Dear people. I wish I could give them the miracle they're hoping for.

While all this was happening, there was a code blue in the ER, followed by a rapid transfer of the pt to the room two doors down, where the horrible family had been before. (They were moved last night because the workstation-computer-cart caught on fire, shortly after which the grandfather had another hypoglycemic episode because the family paused his tube feeds again while they were trying to turn him WHILE THE STAFF WERE TRYING TO EVACUATE THEM FROM THE ROOM. Security was called and the family was limited to one member in the room at a time, with a warning that whichever of them was present next time he had an episode would be banned from hospital grounds.)

This new pt was an older man with a medical-condition necklace on: heart failure, diabetes, etc. It didn't matter much to me, since I didn't get report on him and didn't have any part in his actual care. Except that, ten minutes after arrival, he coded again, and because I was close by I jumped in to help. There wasn't much to do, as everyone else had their hands on the code stations: med nurse, push nurse, chart nurse, resp therapist, and shock nurse. However, from the door I could see that the two-man rotation on chest compressions was having a hard time, mostly because the pt had nothing hard under his back and had to be compressed deeply into the bed to get enough smash to move his ventricles. So I dove in, spiderwebbed through the lines and tubes to the head of the bed, ripped off the CPR board, and shoved it under him at the next compression switch, put the bed on max inflate for a harder surface, and jumped in at the next round to be the third man in the compression chain. Three is a good number; otherwise your arms get really tired.

I am relatively new at this facility, and we are pretty good at preventing codes, which means that I haven't been in a full-bore code in a major role yet. I've carried flushes and even pushed meds, but codes are fast and wild and require strong communication, which means that I'm still at the stage where chest compressions are an appropriate role for me to fill-- a role I share with CNAs and even housekeeping staff in a pinch. I don't mind-- compressions are a workout, and good compressions can make all the difference.

However, this dude was completely fucked. Flash pulmonary edema filled his breathing tube with bubbling red at every compression. His heart wobbled through ventricular fibrillation with the kind of half-assed exhaustion that doesn't respond to shocks. Med after med failed to get a response; shocks and compressions were like rocks thrown down a well. In the hall, his family wailed and collapsed against the wall, and shouted for us to save him. A nurse from down the hall gently guarded the door to keep the more frantic family members from seeing the bloody wreck of a corpse that we were preparing to stop beating.

We called it after twenty minutes. His chest was the texture of new banana pudding, before the cookies have a chance to get soggy-- bone fragments scraping the sternum, muscle and fiber pounded to a pulp. 

CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest.

The family burst into the room, still screaming, still demanding that we bring him back. "Keep going," they said, "he's strong, he'll be fine."

The RT popped the ambu bag off his breathing tube, and blood flecked my left elbow where I stood, wringing the numbness from my fingers over his demolished chest. Someone had thrown a pillowcase over his genitals. His skin was the mottled color and temperature of cheap cotto salami. "Wake him up," his son shouted at me from the door.

Instead I leaned over him and closed his eyes. "I'm so sorry," I said. I don't think his son heard me over the post-code chatter in the room, but he fell silent and white. There's a finality to that gesture that speaks more to our sense of gone, lost, dead than any words or blood or broken bones. They retreated into the hallway and sobbed there until the chaplain ushered them away to a private room. I scrubbed my bloody elbow in the sink and slipped out among the other staff, back to Tiberius, back to smile and offer support to Amanda while she and her family told stories about his childhood.

That disconnect is like a ringing in the ears. Death is touch and go: it touches you, and you go. If you're the lucky asshole in scrubs, you go into a different room, and think about it later. If you're the unlucky asshole in the gown, you go where we all go, eventually.

Anyway, after that I insulted the living hell of out an RT by accident, calling her a "respiratory technician" instead of a "respiratory therapist." I actually am shit at terminology like that sometimes and I felt terrible, but I think she understood my ignorance. Any RTs reading this probably just bared their teeth at me a little. Sorry, dudes, I couldn't do a quarter of my job without you. My apologies for fucking with your fiO2.

After that, I spent the evening fine-tuning Tiberius. He needs another surgery, a repeat thoracotomy to finish closing the stump and properly close his back, which looks like fucking hell. Before we can do that, we need every possible advantage to keep him alive, which means crazy tuning up and blood pressure management and cardiac output optimization. I can't describe to you how boring this process is, or how riveting. It's a game; manipulating numbers, one up one down, tightening your margins and leaving wiggle room; it's also a slog, poking this button and that button and making puckered mouths at the monitor while you try to decide whether this is a fluke or a trend. Overall, though, he trended upward. 

By the time night shift arrived, I was beyond exhausted, and worried sick because I knew I would have a day off tomorrow. I wrote up an extensive report sheet on him to be handed off to night shift, complete with goals, responses to titration on each drip, and precipitating events associated with each previous destabilization. I think the night nurse was a little insulted when I handed it to her, until she started looking over it and asking questions. By the time I left she was making a few addenda of her own to the list, and running off copies. I wished her good luck and godspeed, said goodbye to Amanda, and staggered to the breakroom to clock out and take a fifteen-minute nap before trying to drive home.

I called in the next day and asked how he was doing. Fine, they said. Stable and gaining. Still in ARDS, still on pressors, still requiring extensive sedation, but still alive.

Week 1 Shift 3 (7 of 7)

I slept until 0900 this morning, laid in bed playing Monument Valley on my phone until 1045 (I have legitimately not played this game at all despite all my friends telling me I would love it), then convinced myself that brunch and a shower sounded better than just lying in bed forever. The shower was amazing because it took place in the middle of the day with no time constraints and I could shave everything and spend plenty of time staring at the wall and thinking about absolutely nothing. Showers are usually ten minutes of scrubbing, shampooing, and telling myself aloud: "Come on, come on, you're okay." They usually take place at 0530. 

This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.

Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.

The point of all this is: I will write up this report in extreme comfort.

Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)

Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.

Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?

Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.

Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down. 

One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.

Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.

Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker). 

The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.

The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.

And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.

Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable. 

Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right. 

He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.

The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.

Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.

Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.

This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.

The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"

Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.

She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point. 

Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.

PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.

I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.