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 3

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

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

This disturbs me.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 3 Shift 4

My splenic rupture pt had a rough night. It’s not uncommon for people over the age of 70 to get confused at night when they’re in a strange place, sick, covered in tape and wires, and this can lead to some really risky situations. In her case, she pulled out her PICC line, which was put in yesterday to replace the internal-jugular central line she pulled out the night before. I came in to find her wrists strapped down and her nurse sitting at the bedside, gently talking to her to keep her occupied and soothed.

Used to be, as soon as you started acting like you might pull something out, you got your wrists strapped down with restraints. These days, we pay a lot more attention to delirium, and restraints dramatically increase both the incidence and severity of delirium. The night nurse who cared for her while I was sleeping is a damn good one and I trust him, so when I saw the soft bracelets on her wrists I knew things had gone to shit.

She’d pulled her PICC while making eye contact with him, holding his hand with her free hand, and saying that she felt pretty good. Grab and rip. After this she pulled two peripheral IVs, removed her oxygen a dozen times, and tried to pull out her foley catheter. The night nurse felt that restraints were the only way to keep her IV access in, so he sat beside her for the rest of the night, talking to her to keep her from going completely crazy.

Sunlight is the usual cure for this kind of delirium, which is so common we call it “sundowning” and expect it with certain age groups. Once the sun comes up, you can usually transition the pt from wrist restraints to puffy mittens, then open the fingertip part of the mittens, and finally free their hands entirely. Sometimes it’s even quicker than that.

Delirium is very different from dementia. Often, severe acute illness will combine with other factors like dehydration, sleep deprivation, and unfamiliar medications to make a patient forget where they are and what day it is, possibly even thinking they’re in a different country or it’s 1970 or that I’m a Nazi captor in a WWII prison. (This is depressingly common in older folks from Europe, many of whom were terrified as children that they would be captured and tortured by enemies of war.) We call that confusion, initially, but if confusion has an acute onset (they aren’t like this at home), the pt can’t focus long enough to follow a brief set of instructions (“I’m going to spell a few words, and I want you to squeeze my hand whenever I say ‘A’.”), and they can’t get their bearings enough to answer simple questions (“Will a stone float on water?”), they’ve moved past mere confusion and are delirious.

In a state of delirium, a pt is likely to hurt themselves—falling, pulling out tubes, etc—and is at very high risk of having weird delusions and hallucinations. These are a big deal because, in the delirious state, your mind can’t really differentiate between reality and the bizarre ideas that come with confusion and delirium, and it processes these as if they’re fact. You can end up having intense, vivid PTSD flashbacks to things like being smothered by aliens, raped and tortured by Nazis, shoved into a box and left there for hours, and burned alive—even though none of these things actually happened. The flashbacks and mental fuckery can last for literal years afterward. People who become delirious in the ICU generally have cognitive issues for a long time after discharge. (We see this a lot in re-admits, who aren’t quite themselves when they leave and return a month later completely whacked out.)

Perhaps most immediately worrying, delirium can disguise other major signs of danger, like altered level of consciousness, pain, and feelings of impending doom.

So I progressed her pretty quickly from restraints to mittens to open mittens. Too quickly—she pulled out one of her IVs. She has another, though, so I stopped the bleeding and let it rest. I feel like her mental status is one of the most vulnerable aspects of her health right now, and it would be awful if she (an independent woman who teaches music) ended up in a nursing home when she leaves here.

Anyway, as the shift progressed her lethargy continued, and she had trouble articulating almost anything she said. Head CT from yesterday was totally clean, neuro checks negative except for lethargy and verbal difficulty, blood sugar and hematocrit stable, abdomen stable, and finally we just settled in to “watch and wait.” I asked her son if she wears glasses, because although she claimed not to, she also didn’t know what state she lived in… Son brought in glasses and a novel she’d been reading, and a little later in the afternoon she came around just fine.

Still a little worried about her. Drowsiness after a splenic rupture is usually a sign that the pt is about to take a turn for the worse. But she had plenty of time to make that turn, and instead finished up my shift with a quick trip to the bedside commode and a bit of worrying-aloud about whether she would be able to get up the stairs at home. (She will be strong enough to get up the stairs by the time we send her home-- physical therapy opens almost every intial interview with, believe this or not: "Do you have stairs in your house?" This is a goon joke.)

As for my pt with the GI bleed, she was quite thoroughly recovered. She was downgraded to medical status halfway through the day, and after a bit of consultation with the blood bank, the doctor decided to go ahead and top her off with the last unit of matching, prewashed blood they had on hand, then send her home in the morning. Her family came in to visit during the afternoon, and her kids were so excited to see her that they literally jumped up and down, in place, for almost thirty minutes. One of them would settle down, and the other would kind of chill out, and then the first one would start bouncing again, and pretty soon they'd just be hopping in place, talking three hundred mph in their weird little shrieking voices. Kids are basically insects, is what I'm saying.

At three, afternoon shift change time, I traded out-- GI bleed passed off to a nurse with a group of other medical/telemetry overflow pts, new pt picked up. This guy was still critical care status, having been extubated around 1030, and he had a very distinct set of challenges to present me.

He is a developmentally delayed man, about forty, mentality between six and eight years old. Very polite-- turned his face and covered his mouth when he coughed, waved at everyone-- but easily frustrated and, for obvious reasons, very stressed out. He had been at his adult family home, eaten a bunch of dinner, aspirated it somehow, and gone into respiratory-cardiac arrest. 911, CPR, intubation, bronchoscopy with washout, extubation the next day. Really good outcome, no neuro deficit from baseline. 

His lungs were still pouring sputum in response to the dinner invasion. Listening to his chest was like sticking your stethoscope into a washing machine full of shoes. Every few minutes he would cough up huge rippling mountains of sputum, which he had a very hard time managing and would suck back down his windpipe maybe one out of three times, causing another coughing fit. He did NOT like having the suction catheter in his mouth. He also wanted dinner, and some soda, and the speech therapist unsurprisingly made him strict NPO (nil per os, aka nothing by mouth) because he genuinely couldn't swallow his own spit without choking.

He'll probably get that functionality back, to a degree, but we still have to assess what made him aspirate in the first place.

In the short term, I got a packet of honey from the condiment drawer, smeared a trace of it on the suction cath (also called a yankauer, a plastic wand for sucking things out of the mouth and upper throat), and offered it to him as a "honey straw." He loved it. There wasn't enough honey to cause any trouble, and honey doesn't come off easily, so I wasn't worried about choking... and it encouraged him to keep it in his mouth almost constantly, coughing up crap and immediately jamming the "honey straw" back in his mouth. I refreshed it every hour or so and he cleared his airway wonderfully the whole time.

The real challenge came from his severe chronic constipation. An abdominal CT performed yesterday on admit, for his hugely distended belly, revealed that his colon was PACKED with shit. Cecum to rectum, dilated to a terrifying degree, crammed full of poop that hadn't seen the light of day in months. They loaded him with a truly amazing volume of bowel meds, and the night before he had started out with a few semi-liquid stools-- the kind of thing that manages to seep through the shit tunnel gridlock and keep you from backing up so hard that you die.

And he was backed WAY up. He kept burping and it smelled distinctly of shit. His OG tube, pulled out with the breathing tube when he was extubated, had been pulling something that the doc initially worried about because it looked a little like coffee grounds (a sign of gastric bleeding)... but which, when the OG tube came out, was pretty clearly just backed-up shit. Shit from his STOMACH. That is not supposed to happen and is a very bad sign.

Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets.

As I sloshed through that cleanup, trying not to breathe more than strictly necessary, I realized that this shit had been inside him for one hell of a long time. The smell had that intense death-rot odor you get when you've been hoarding that particular nugget for quite a while. That corn wasn't last week's veggie side at the cafeteria, dude. I bet you a dollar he gnawed that shit off the cob at his grandma's house for Christmas. 

The fecal journey continued with inspiring diversity. One delicately-jointed, bubble-textured oblong came out looking like a Baby Ruth bar. One delivery was thick and slushy, but contained crumbly elements that glued themselves to everything they touched and pilled up like a hoodie in the dryer.

We attempted to get him up to the bedside commode at one point, hoping to catch the bounty in a bucket rather than the bed, but as he prepared to sit down he suddenly decided that there was a better potty out in the hall somewhere, and took off running with his gown flapping behind him. Two steps into his flight, his sphincter lost control. Spatters and ribbons festooned the tile in a pseudo-Farsi calligraphic scrawl. The CNA and I caught him before he could open the room door; she guided him by the shoulders back to his plastic throne, and I cupped my hands under a washcloth to form a towel-cup that I clamped to his backside, catching the steaming runoff to prevent any more modern art.

After a while, he exhausted himself on the bucket, and we got him back into bed. Five minutes after that he had another coughing fit and ripped a gargantuan chunky fart right into his disposable bed-liner. I heard the expulsion lap up against his thighs like the bubbles popping in a pot of boiling oatmeal. The pulmonologist came up to ask me a question and started coughing at the smell.

Some days are just like this. I passed that guy off to night shift with sincere condolences and warnings.

It occurs to me that I would not want to eat anything honey-flavored while in the room with a smell like that. But this pt happily smacked away on his "honey straw" even while his gut was blasting out everything he'd eaten this year, not so much as blinking. You know what? Whatever makes him happy. That's what.

The only real upside is that, being developmentally delayed, he could be convinced that this shit was hilarious, and wasn't really offended when we acknowledged that his shit stank. Some people get really upset if you don't manage to keep a straight face as you clean up their poop; some people just get incredibly embarrassed and feel horrible, and my heart goes out to those people, because I can't take a dump if anyone in the building knows I'm taking a dump and I would rather pretend at all times that I don't actually have bowel movements. (This is probably a leftover of my upbringing somehow, but I don't care to examine it too closely.) 

You just gotta be really good at keeping your poker face strapped on. Gross wound? Learn to smile through it. Gallons of liquid shit? Reassure the pt that you've seen so much worse. (You have.) Crusty vadge plopping out cheese curds the size of thumb joints while you're trying to scrub the area for a catheter? Keep your face pleasantly neutral and talk about something else.

This job is allllll about winning people's confidence. It's much harder to care for someone whose guard is up, who distrusts you, or who feels awkward when you walk into the room. If they can relax and feel comfortable, if they can trust you, they have a much better experience and will tolerate a lot more of the pain and indignity that comes with a hospital stay, knowing that you're not doing this shit for fun either and that you won't judge them for anything that happens. 

A particularly weird aspect of this is the importance of not reacting to anything with shock, panic, or visible distress. Like if you stub your toe and they see you wince and hop around, they're going to be wondering: is she gonna hurt me by accident too? Is she really in control of the situation? Can she be distracted at a critical moment, and possibly let me die because she just jammed her thumb in a drawer? These aren't conscious assessments, they're just part of the natural human reaction to being powerless and needing a team member you can trust. So one of the reflexes I've cultivated as a nurse is keeping a straight face when I bang my elbow, stub my toe, or otherwise remind myself that my body is pretty vulnerable and these hospital rooms are fucking crowded. If I drop something on my foot, I'm gonna politely excuse myself to another room before I descend into hissing and cursing. 

I don't want my pts to ever feel like they have to comfort or protect me. I don't want to seem physically or professionally vulnerable to a person whose life may depend on my capability and strength. I want questions to be surface-level, where I can encourage my pts to articulate them and have them answered. I want to avoid situations in which my pts have to assess the situation without full access to relevant information, which means that even if my toe-stubbing happens because I'm focused on their cardiac output, I don't expect them to be able to explain my priorities of attention to themselves and decide that I must have been looking at something more important.

I am probably a fucking nutjob. I overthink things. I am paranoid and obsessive. This might make me a better nurse, or it just might make me a crazy person thinly disguised as a medical professional. Either way, I am probably the only person most people will ever meet who can make them feel safer just by smiling noncommittally as I wipe their ass. 

Three days off after that shift. My kid sister moves in this evening, and will probably absorb most of my time for a couple of days.

Thank you guys so much for the encouraging messages and stuff. I get really shy sometimes when people praise my writing and I have to sit in a quiet place and squeak and drink tea, and eventually I muster up enough resistance to reply en masse while turning red and occasionally pausing to mash my hands against my mouth. You are all way too nice to me.