Ketamine

Somebody tried to tell me today that we aren't allowed to ride around dangling from the elbows on the cardiac walkers, making TIE fighter noises. Fortunately I was on a cardiac walker at the time so I just screeched away with my toes dangling over the linoleum, faster than they could shuffle after me in their Dansko mules.

We’ve had some extra-special pts on the ICU lately. Things seem to come in waves, a month at a time, and this month’s theme seems to be a tie between “exhausting psych” and “heartbreaking pulmonary fibrosis.” April started out with a seemingly straightforward admit: a woman with a fresh spinal fusion, history of chronic pain, and osteoporosis.

Ellen Hamm* was the first pt I took with my latest preceptee, Lizzie, who comes to us fresh from a psych hospital-- sharp and bright and already jaded as hell. “I hope my experience is useful on the ICU,” she said, and sighed when I toppled into chair-spinning gales of laughter.

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 2 Shift 2

Every morning at my main facility we all cluster around the front station, receive our assignments, collect our walkie-talkies, and get a quick summary of the daily shift news. Yesterday’s morning started out very strangely for me, because I was unusually late and clocked in at 0645 exactly, when group report starts. This meant that by the time I made it to the front desk, everyone else already knew who I’d be taking care of, and they all watched me approach with this blend of pity and relief that told me right away what was about to happen.

I was getting an albatross.

I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.

Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.

Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.

I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.

Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.

What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.

He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:

--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.

--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.

--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.

Lucky me.

So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.

HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.

I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.

My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.

After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?

At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.

She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."

I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.

Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever. 

To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.

The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.

So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.

CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.

This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.

It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.

Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.

Week 1 Shift 1 (technically five of seven)

Let me tell you about my days.

Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.

I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.

Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.

Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.

The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.

The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.

A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.

The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.

Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.

Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.

The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.

Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.

Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.