Lucy, Ed, and Carl Hamilton Park

First impressions, outside the hospital, are predictable. Height, weight, color of skin, expression; handshake, attention span, first and last name. Maybe you find out what their laugh sounds like, or you notice how everyone else in the room watches them with wary admiration, or you discover that they spit when they pronounce their sibilants.

Inside the hospital, first impressions are just as predictable, but in different ways. Every shift begins and ends with report, and every report follows the same structure, a whole unit reciting the history and status of each patient every eight to twelve hours, in unison.

This is an anxious fifty-year-old woman, the night nurse told me, patient of Dr. Ling, here for hyperkalemia and possible sepsis secondary to C.diff superinfection. Here is her entire medical history: bowel cancer, diarrhea, multiple intestinal fistulae to both internal and external abdomen, repeated surgical revisions, perineal remodeling with multiple additional fistulae, urinary tract infections, incontinence. Here, look at these reports: learn all about her rectum, her vagina, her most private processes.

Here is a picture of her chest, a scan of her abdomen. Look at her body, right down to the bones. Look inside her. Here are all the molecules we’ve found in her blood, in their rightful and wrongful proportions. Here is a transcription of her heartbeat from twelve separate axes.

Oh, her name is Lucita. She goes by Lucy. Want to go in and meet her now?

Week 8 Shift 4 (I picked up an extra shift)

I didn’t sleep well after that last shift, and coming back in the next morning was an act of sheer will. This summer has been broiling hot, and I moved out of Texas for a reason, namely that for humans to live in Texas is an act of defiance against the great god Ra, and that if the away team of the Enterprise were to visit Texas in the summer they would refer to this entire world as a “desert planet” and four redshirts would die of fatal solar radiation. I did not move across the continent to a cooler climate so I could sweat like a wrung dishrag all day and all night.

One of my pts was exactly to my tastes: somnolent and needing very little intervention. She lives in an assisted living facility, where she’s mostly independent and hooks herself up to his peritoneal dialysis every night before bed. For the past few nights, though, she’s been “sick,” and hasn’t been running her PD, which has only made her sicker.

Hemodialysis involves sucking your blood out, running it through a machine the size of a Volkswagen that scrubs and washes and concentrates it, and pumping it back in to pick up more trash and water from your overloaded tissues. Peritoneal dialysis is a much less common form of dialysis, and one that doesn’t work for everyone, but which can be much less troublesome if it works right. A PD catheter is inserted through the wall of the pt’s abdomen, and dialysate fluid is pumped in and out, washing toxins from their body and blood through the permeable membranes of their gut. The fluid typically contains sugar, so pts have higher blood sugars on PD, but if it works for the pt… well.

After HD, a pt is typically sick as shit, often confused and shaky, usually weak and exhausted, and frequently nauseated. Regularly dialyzed HD pts tend to go in for a scrub three times a week, and with each round of HD the pt can count on being completely wiped out and useless for the rest of the day. This tends to really interfere in little things like “having a job” and “functioning for a majority of the week,” and that’s before travel time and expenses, interacting with health care staff (I will be the first to admit that we are terrible company), and having to rub elbows with other gross people from your medical community while hoping that they aren’t crawling with MRSA. So if you have the option of doing dialysis in the privacy of your own home, while you’re sleeping, and waking up the next morning ready to go about your day… PD is a total godsend.

The learning curve is a little high though. The pt needs to be thoroughly educated on how to maintain sterility, how to use and troubleshoot the machine, and how to recognize when something has gone wrong. A pt who skips days, who doesn’t follow up on appointments, who cuts corners—that pt is likely to have some really nasty outcomes. A PD catheter is a fast way to fill your belly with all sorts of microorganisms if you aren’t safe and clean with the thing.

Anyway, she had a UTI, which explains both the “sick” part and the reason she, a normally very sharp and independent older lady, made the very bad decision to stop doing dialysis rather than going to the doctor. Those of you with vaginas have likely experienced the burning agony of the UTI, with its bloody boiling lava piss and its ability to leave you feeling like you slept in a dumpster and were picked up by the trash truck before dawn. Sad fact: that shit is a blessing, because you think to yourself: gosh, I have a UTI, I should go get antibiotics. Older women are less likely to have the burning pee sensation, and sometimes their earliest clue to the presence of e.coli in their bladder is the fact that they lose their ever-loving goddamn minds.

That’s right: old ladies with bladder infections go fucking crazy. I’ve seen sweet grandmothers cursing and biting at their descendents, calm-faced knitters who turned into screaming paranoid kung-fu masters, and even a deacon’s wife railing about shit-eating demons crawling into her body and jacking off into her belly button from behind. Forgetting to plug in your advanced medical equipment is kind of tame in comparison.

But hey, no matter how well you handle a pelvis full of creepy crawlies, a few days without dialysis will absolutely make you loopier than a tatted doily, and sicker than shit to boot. This poor lady had no idea where she was or what was going on, except that she was nauseated and unhappy. I came into the room, scrubbing my hands with Purell and offering a chipper greeting, and she groaned and leaned over and barfed corn chowder down her shoulder and off the side of the bed.

There’s this thing, right, where you see or hear someone puking and you feel like puking too, right? I guess the evolutionary advantage is that, if your fellow cave-dwellers start horking up last week’s mammoth, you can get a head start on the mammoth evacuation process before the salmonella poisoning really gets a grip on your duodenum. Being a nurse for more than a few months will completely destroy that impulse. My immediate instinct when someone starts throwing up is to grab the nearest wad of laundry and jam it into the flood to keep it from spreading.

The last time my husband ate bad sushi, I nearly ruined our feather duvet.

God, the best thing about working in a hospital is that so much of the really gross shit gets done where I don’t have to see it. Laundry absolutely saturated with a grainy flood of shit? Put it in the big white bag and throw it down the chute and forget it! Pt took a whiz over the bedrail and threw his dinner into the results? Mop up what you can, and call the long-suffering housekeepers to do a bleach mop. I swear to god, I am not anywhere near this obsessively clean in my daily life, and I am 100% sure it’s because I can’t just page someone for backup whenever shit gets literal. I hope to sweet sainted fuck that the laundry is done by soulless aluminum launder-bots. I have this awful hunch, though, that it’s not, so I’m that picky nurse loser who separates all the plastic padding from the cheap muslin to minimize the necessary sorting before the blankets go in the wash.

But lord almighty, it is so good to be able to get rid of the stench immediately and start forgetting I ever smelled it.

A dose of Zofran and a housekeeping call later, the corn chowder was a distant memory and my pt was sleeping like your dad in church. On her left side, of course. The right lung is set at an angle that makes it easier for inhaled food and puke to slide down the right mainstem bronchus before you can cough it up, which means you want the right side elevated if your pt is at any risk of throwing up and drowning in it. Left side fetal position is often called the “recovery position,” because if you’ve had CPR or had a seizure or been very close to death, you’re likely to throw up at some point in the immediate future and you might not be awake enough to make sure it leaves your mouth and goes all over your nurse’s arm like it’s supposed to. (There are some other benefits to this position too, but my god, how much do you guys really want me to talk about hemodynamics right now?)

My other pt was a gentleman in for placement of an AICD, an automatic implanted cardioverter/defibrillator, which functions much like a pacemaker except that instead of reminding your heart to beat (although some of them do this too), it listens for your heart to have a dysrhythmic freakout and shocks the shit out of its unruly ventricular ass like a neighbor banging on the wall during a party. Pts who frequently go into dangerous dysrhythmias (also called arrhythmias), like ventricular tachycardia, or whose heart damage from MIs and heart failure puts them at high risk of deadly arrhythmias, get AICDs put in so they don’t suddenly die. If parts of your heart are especially irritable or not getting good communication with the rest of the heart, they panic and assume that they’re going to have to run the whole heartbeat show, and start yelling disorganized orders over the actual heartbeat signal. This can cause the whole heart to spasm and lose track of what it’s supposed to be doing, preventing it from actually moving any blood—this is called cardiac arrest. A good jolt of electricity stuns the panicked parts, giving the normal heartbeat a chance to pick itself back up.

That freakout is called fibrillation. The shock is called defibrillation. It’s one of the best tools we have for fixing deadly arrhythmias.

If the AICD shocks you, you know it. We get a lot of pts in because they were having Thursday night dinner when their AICD went off and kicked them facefirst into the meatloaf. Very uncomfortable and sticky.

So this guy had suffered a major heart attack that left part of his heart withered and necrotic—a part that, unfortunately, carried a lot of electrical impulse. As a result, one little area of his ventricles is now deaf to the electrical marching orders of the rest of his heart, and occasionally it gets the idea that it should be doing something and starts barking its own confused orders at its neighbors. He’s gone into ventricular fibrillation several times already, and had multiple rounds of CPR. Fortunately, since he’s been on the ICU hooked up to a heart monitor, we’ve been able to shock him immediately each time; the sticky electric-shock pads that we use to defibrillate him are just staying on his chest at all times now, until the AICD goes in. Because the defibrillation is happening very quickly and he’s only had to rely on CPR for circulation for a few minutes total, his organs haven’t really taken a lot of damage and he’s had good outcomes each time.

Despite three code blues this week with accompanying chest-crushing CPR, this guy is in good enough shape to be sitting in a chair, grumbling because he can’t have breakfast this morning. (No breakfast before surgery—anything in your stomach when you get anesthesia is going to be ejected at some point, and you definitely can’t spit your barf out while you’re unconscious, so breakfast before surgery leads directly to aspiration pneumonia and ARDS.)

When I walked into the room, he greeted me with one of my absolute least favorite quotes: “Hellooooooo nurse!”

Now, I get that it’s meant to be a compliment in some backward way. I understand that if you’re white and male and sixty-five you probably think the highest praise you can give a woman is aesthetic; you might even, if you’ve been reading a lot of noiresque literature, assume that complimenting a woman on her looks is a way of acknowledging her power and independence. But man, I got two problems with pts expressing attraction to me:

--I am pretty obviously not here to look hot. I am wearing pajamas, no makeup, an expression of exhausted patience, and about a pound of someone else’s bile. If you tell me I have lovely eyes with an earnest tone, I will probably accept that gracefully, because while I may check you extra-thoroughly for delirium I can at least appreciate that maybe you have strange tastes. If you react to my entrance like you’ve just been offered a hayjay by Jessica Rabbit, I’m gonna assume that your compliment is the disingenuous flattery of someone who thinks they’re gonna win my favor by introducing a sexual element to our professional relationship, and who intends to milk it for morphine.

--I am far from the most experienced nurse on the unit; I have about five years of ICU under my belt and I showed up for work in critical care two days after my NCLEX with dewy eyes and a trembling chin. But I worked obscenely hard to get where I am, both in my personal and in my professional life, and I am a formidable member of an elite team of life-saving medical staff, and to have that hard-earned accomplishment reduced to a catcall is absolutely intolerable. It reeks of disrespect and inappropriate sexual aggression.

This guy has had several rounds of CPR this week, though, so I gave him the benefit of a quick boundary: “That’s pretty inappropriate, would you like to try a different greeting?”

“Come on over here, little girl, and I’ll give you a different greeting.” Ugh. Uuuuuugh. At moments like this I just remember that I get paid not according to how many lives I save but according to how Disneyland-pampered my pts feel. I picture the dollar signs and bar graphs and ratings, and I grit my teeth and remind my pt that I’m here to provide him with medical care and that I’ll come back in a bit when he’s able to get his behavior under better control.

I’ve learned to be very comfortable with varying degrees of confrontation. I was raised, like many women, to think that the scale goes from “everyone is acting like nothing is wrong” directly to “EVERYTHING IS TERRIBLE” the moment a hint of conflict is introduced. Nursing has taught me that a little conflict in a conversation, like a little pepper on your scrambled eggs, is not only an acceptable thing but even a delicious thing—a thing to be savored, a thing that makes relationships and interactions exciting instead of bland.

I still have the instinct to flee, to placate, to absorb the unpleasantness and smile right through it. And I do keep my smile, and behave politely; but I also have learned to say, That’s super awkward of you, aren’t you embarrassed, and to tilt my head and smile with my eyes and watch that asshole twist.

This was a theme throughout the day. It got very tedious.  

My PD lady continued to vomit, and the doc ordered her an MRI with contrast, which meant I had to take her down to MRI for a full forty-five-minute scan without letting her drown in her vomit. I loaded her with Phenergan, popped a scopolamine patch behind her ear, and borrowed a subglottal suction catheter so I could keep her mouth empty if she vomited while I couldn’t reach her.

Then we moved her down to the MRI chamber and loaded her into the tube. The suction system in the MRI chamber was doing something really weird—like most hospitals, ours has been forced to prioritize its expenses, so some non-critical systems are a bit primitive—so I hooked a big syringe up to the subglottal catheter and stood by her feet as she went into the tube, watching and listening for any signs of vomiting so I could hand-suction her mouth.

The MRI is so loud. I was wearing earplugs and the sound went through me like a bore hole to the terrestrial mantle. If you’ve never heard this sound, I urge you to hit up youtube and have a listen, because no words can do it justice: clanging and crashing, and an all-consuming power-chord thrum of metallic force: DAH DAH DAH DAH DAH. DUM DUM DUM DUM DUM. DRRRR DRRRRR DRRRRRRR.

 It jarred my teeth. My feet ached with the force of the noise. There is an arcane quality to it, a rhythmic intent of pure alien purpose that wants nothing of your sanity and only stops to breathe when it’s finished its task.

While I was in the MRI, my annoying pt was shuffled off to have his AICD placed, and as I returned to the unit the charge nurse told me he would go to the special care unit after the procedure.

So by the time my PD pt was settled, I was ready to take another pt: a craniotomy who had fallen in her home and developed a subdural hematoma. After surgical evacuation of the blood blister inside her skull, they brought her up to me intubated and sedated with a C-collar to keep her spine immobilized. We hoped that the pressure damage to her brain wouldn’t be fatal, but there’s really no way to tell yet, so we’ll wait and see how the swelling goes, and support her medically until then.

She has fake breasts. They are extremely rigid and strangely shaped. The CNA and I noted this and carried on; we see many pts with breast implants and other surgical reconstructions, and I have long since learned that as soon as you start judging a pt for some seemingly voluntary aspect of their looks, you’ll discover that they had reconstructive surgery for cancer or some other thing that makes you feel like shit, and deserve to.

So we made sure that everything on the bed was arranged in such a way that visitors couldn’t see either her nipples poking through the gown, or the unnatural rigidity and wide placement of the breasts themselves. I’m certain that this woman spent a great deal of effort in making her breasts look natural, and it would be cruel and spiteful to let the secret out if she hadn’t already told any of her guests.

It feels very strange to carefully pad a pt’s breasts, let me tell you. I felt a little gross and intrusive. But even if she got them for purely cosmetic reasons, it’s her body, and I wouldn’t leave an embarrassing tattoo out for the neighbors to gawk at either.

The MRI showed no signs of anything wrong in the PD lady’s belly. Thank goodness, she just needs lots of dialysis and antibiotics; we can have her fixed up and home by the weekend. The dialysis nurse dropped by just before shift report and started her on her nightly PD, and I hope that by morning she’s closer to her normal self.

During report, my pt from the last two shifts, the sepsis pt with liver failure, died. An estranged sister had got in contact with us and given us the okay to allow him a natural death according to his wishes, and they turned off the drips, loaded him with painkillers and benzos, and pulled the breathing tube. He breathed on his own for ten minutes, then slipped away gently and comfortably at last.

I am glad for him. He earned his rest.

And after this shift, I’ve earned mine too.

Week 8 Shift 1

By the time I got back, my DKA/wannabe escapee guy had not escaped, but had made everyone on the unit so angry they wished he would. His nonstop bitching and creepy remarks, combined with his gross treatment of his girlfriend and his frequent not-jokes about how we should just let him shoot up because he was going to anyway, had really not endeared him to any of the staff.

When I arrived, he smirked at me, then informed me that he would be leaving at 0930 whether I wanted him to or not, and if I had any shit left to do for him I better get it done in a hurry. And that he would have a long list of breakfast foods from the cafeteria, but didn’t want to stay on the line and wait to order, so he would just tell me and I would have to call down and order for him. When I told him he could either order his breakfast or go hungry, he shrugged. “Fine,” he said. “I have my own insulin, I’ll give myself a dose and go into hypoglycemia, and you’ll get fired.”

I have honestly never had a pt so openly threaten to harm himself to manipulate me. “I’ll give you IV dextrose,” I said, “and your insulin will mysteriously go missing while you’re unconscious, and you’ll wake up just fine except you’ll be hungry. Here’s your phone, you decide if you want breakfast or not.” Then I went and reported all this to the charge nurse and documented it.

His girlfriend met me in the hallway a little later. I won’t tire you with the entire conversation—it was very long and wandering and difficult to listen to—but the gist of it seemed to be that she wanted to stay in the methadone program and get clean. If she stayed with him, she said, he would never let her get clean; but if she left him, who would take care of him?

“I think you’re right,” I said. “He’s gotta find his own rock bottom, and hope that it isn’t a grave. If you want to get better, you’re definitely going to have to get away from him, and you’re going to need some professional support while you’re remodeling your life.”

“But what if he dies?”

“Then he dies, chickadee. Maybe you won’t die too. When you’re drowning, you gotta kick off your shoes.”

I know there’s not much hope for her. But I really hope, if she dies of this, she’ll at least die without that asshole being rude to her the whole time.

At any rate, I got that dude’s discharge paperwork done in record time. I am already a lightning discharge nurse, which usually helps out my pts who really really want to get home in time for the game, but I had him ready to go by 9:15. I cornered the hospitalist that was seeing him and told her she could either give him discharge orders or sign his AMA*, that I had everything ready to go for him to leave, and that the only medical reason I could see to keep him was that he’d threatened to inject himself with insulin so I’d have to order his breakfast. We could have stretched that into a suicide threat, but honestly, it wasn’t. And there wasn’t much else we could do to help him.

(*AMA, in this case, has nothing to do with reddit—it just means Against Medical Advice.)

If I seem callous about this, know that I have zero interest in whether a person is addicted to a substance—it’s a disease we understand very little about, and one that destroys lives as ruthlessly as any sepsis or stroke. The mental health issues that so often accompany addiction, those I have even more sympathy for: my family is not without its comorbidities, and I have seen firsthand over many years the impact of addiction, bipolar disorder, major depression, personality disorders, and post-abuse trauma, all untreated and all devastating. I see this shit every day on the ICU, and it’s a parade of tragedies that never fails to make me sick with frustration that I can’t save them.

But there are, among the tragedies, people who victimize others in their tragedy. Just as it’s hard to feel fully sympathetic for a person who survived horrific childhood abuse and goes on to abuse their own children, it’s very difficult to feel that sympathy for a person whose lifestyle is so self-destructive and so poisonous that they won’t let their loved ones escape the same trap, and whose attitude toward the people they’re hurting and the people who care for them is one of loathing and snide gloating.

And there are people who are offered the help and support they need, and laugh at the people who offer and how disappointed they are when those gifts are refused.

Not a lot of sympathy, no. I was glad to see him go. He asked if he could keep his IV “for convenience.” I gave him an incredulous look and then “accidentally” pulled his IV out with one sharp yank.

“Oops,” I said. “Usually I leave those in until right before discharge. Oh well, you’re leaving soon anyway.”

He and his girlfriend sat in the room, rolling cigarettes from the tupperware of tobacco, until I escorted them to the door. On the way out he joked that maybe he’d offer me a ride in his truck sometime. I couldn’t even feign a farewell smile.

Meanwhile, next door, a coworker of mine landed a pt with Evans Syndrome, a rare autoimmune disease that causes your body to eat all its blood. The pt was acutely psychotic for some unknown reason and lay in bed screaming as if being burned with hot irons. Pain medication did nothing; anxiety medication helped. He couldn’t tolerate anything touching his body and ripped off his ECG leads and clothing constantly. We didn’t bother putting in a foley, but any time he needed to urinate, he would start screaming extra loud and rolling back and forth, cursing and wailing, until he finally let it all loose and soaked the bed/floor/wall/everything in the room.

The second time this happened, I was helping hold his legs down while he struggled to kick and bite the nurse, and the dam broke just as he started bucking. The ensuing arc of piss undulated across the room like one of those floppy-hose kids’ toys that squirts water at shrieking babies in the back yard. He got himself in the face pretty good, and it shut him up for a minute, his whole face contorting in puzzlement as he smacked his lips and snorted. Then he saw that he’d peed comprehensively all over the other nurse—he only got my arm a little—and started laughing hysterically until he passed out from more Ativan.

Meanwhile I had a second pt to take care of: a woman whose uterus had been removed earlier this year for cervical cancer, whose extensive internal scarring had formed massive adhesions and twisted her small intestines until pieces of them died. She’d undergone immediate surgery to resect the dead bowel, and been in pretty good shape afterward. Yesterday morning, however, she had become confused, then gone into respiratory distress. Early in her confused state, she’d pulled out her feeding tube, vomited, and possibly aspirated before finally being intubated and sedated. My job, today, was to support her through what could either be the return of bowel ischemia, or the beginning of ARDS.

She required lots of fluid support and plentiful pressors. She could hardly tolerate turns, and her urine output was minimal at first, though it picked up as we started Lasix to get rid of her sixteen liters of extra fluid. She was in Tiberius’s room, which felt very strange, because her family was also delightful and friendly and religious.

By midafternoon it was pretty obvious that she had ARDS. What’s more, her intestines started to pick up slack and give me some really gross noises, which is fantastic to hear in a pt whose guts are still stunned from massive injury and surgery. But man, that ARDS was not treating her well, and we kept cranking her fiO2 and PEEP up to keep her ventilated… and, eventually, oxygenated. It takes a lot for your lung tissues to stop exchanging oxygen well. We finally found a nice plateau at a whalloping PEEP of fourteen. (Five is the average. Ten is what you get when you’re ARDSy. Twelve is considered a bit much.)

The rest of the day was a matter of balancing her pressures with her body’s ability to tolerate pressors. Levophed made her arms and legs mottle deeply and turn icy cold, and didn’t have as much impact as I would have hoped on her blood pressure. The PEEP was making it hard for her heart to fill and squeeze effectively, which dumped her BP, which in turn made it difficult for her body to get rid of the excess fluid that had accumulated in her body.

There are three spaces in your body where fluid can hang out. Well, I mean, there are lots of places where fluid hangs out, but there are really only three we care about when we’re thinking about fluid overload and blood pressure.

One space is inside your cells. They’re just little water balloons, right? Some DNA and RNA and a mitochondria or two floating around in there, maybe some enzymes doing heavy lifting, some proteins grabbing shit and gluing it together… and, you know, water. This part is pretty boring to me unless a) my pt has been exposed to cyanide or b) my pt is going to need some kind of insulin fuckery to move sugar or potassium into their cells.

Another space, which I am HIGHLY obsessed with, is the vascular space—your actual bloodstream. Water, albumin to thicken the water and keep it osmotically the same as everything else, blood cells, dissolved gasses and sugars and shit… but mainly, blood pressure. Blood volume. If you’re bleeding out, the first thing I’ll give you won’t be blood, it’ll be saline; it’s the same salt concentration as your blood, and it will expand your blood volume so that the blood cells you have left can actually get around and your heart has something to pump.

Remember: if you ain’t got pressure, you ain’t got shit.

But there’s a third space: the areas between the cells, the structural nooks and crannies of the flesh. And when you’re massively inflamed, that space fills up. When your finger gets stung by a bee and swells up, you don’t suddenly get twice as many finger cells—rather, your inflamed cells call out for help, and your body responds by flooding the areas between them with water so that your white blood cells and antibodies can move around more easily and clean up the toxins. Your finger swells up.

When your whole body undergoes systemic inflammation, as with sepsis, that is a whoooooole lot of swelling. And all that water has to come from somewhere—namely, your vascular space. Pretty soon, there’s not enough water volume in your blood for your heart to circulate effectively, and your bloodstream is drying up, and your organs are dying for lack of blood flow while your body happily carries on dumping all its water into your puffy fingers like it’s gonna do any good there.

That’s the basic dynamic of sepsis. And this lady, with her aspiration pneumonia and her fucked-up guts, was septic as all hell. We had boosted her blood volume over and over with fluid boluses, and done our damnedest to pull the fluid back from her third space into her vascular space, but in the end all you can really do is try to interrupt the septic/inflammatory processes with antibiotics and other drugs, support their blood pressure with volume and pressors, and wait for them to pull out of it so you can dry them out again.

Thus, we gave her Lasix. Albumin first, to draw the fluid into her vascular space; then, after thirty minutes, Lasix to diurese her, to pee off the fluid so it didn't overload her struggling heart and increase the pressure and fluid drainage inside her lungs.

It was a long, exhausting afternoon, full of minutiae and sweating into my eyes. Her mottled flesh continued to spread, and her edema increased visibly from the beginning to the end of my time with her. I don't have a good feeling about her outcomes. I suspect she will never be stable again until she's dead.

Meanwhile, another crazy substance-abuse pt was admitted down the hall. I could hear him screaming and cursing even while I was turning my lady, and one of the other nurses poked her head in to ask if I still had the key to the velcro restraint box (I did not).

Things seem to come in waves on the ICU. We’ll get a bunch of STEMIs in a row, then a bunch of GIBs, then a bunch of ARDS. In reality, it’s probably just a normal distribution of all the shit that can go wrong in a decent-sized city; to the endlessly superstitious nurses on the ICU, it means that once you get two pts with similar symptoms, you are destined to get at least two more in the next week or so. This happens often enough to turn our confirmation bias into rock-solid religious conviction. Not looking forward to the next round of crazy.

But who knows? I could just be destined for admit after admit with stuck gut and sepsis. Or I could be too tired to think straight. I suspect the latter is more accurate. Time to pass out.