A young stroke pt, a bit of fetal physiology, and some pettiness on my part

I genuinely wasn’t prepared for the popularity of this blog, or for some of the sequelae that followed it. I thought a few people might read it, get a chuckle, and glide on by. So I wrote like the blog would be gone in a month, a forgotten vanity, an echo chamber for my rambling thoughts.

Instead, you liked it. Which is alien and bizarre to me, like discovering that other people really do like the smell of your farts. Are you guys… okay?

Anyway, a lot of things happened while I was on hiatus.

I launched my kid sister at the end of the summer. It was not easy and I spent virtually all my downtime helping her fill out paperwork, set up and attend interviews, and move into her own tiny room in a house where girls rent rooms to sleep in between classes. She has a job now, and passed her GED. I am so proud.

Also, I am so glad that I can flop on my sofa in my underwear when I get home from a shift.

Aside from all that, I also went to Yellowstone for five days because I was losing my mind and my first response to stress is to go camping, and I went to a cheese festival and got constipated and drunk, and I had a shitty run-in with a pt family who heard only what they wanted to hear and reported to my manager that I had lied to them. Fortunately, my manager knows that I am a thousand percent more likely to overshare than I am to conceal, and has been my facebook friend long enough to know that withholding information about medications is not something I am physically capable of doing.

Week ???? Shift ???????????

Some things I forgot to mention last time:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But they died anyway.

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 3 Shift 3

Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.

Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.

This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.

The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.

It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.

So down he goes for his cath.

My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.

(We typically refer to this procedure as an EGD, for obvious reasons.)

So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.

She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.

The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.

She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.

Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.

Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.

This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.

Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.

And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?

If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.

Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.

While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.

Well, maybe a few people. But judgement like that isn’t mine to make.

I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?

Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.

No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.

Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.

Favorite memories of the two departing nurses:

--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.

--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.

Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.

The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?

I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.

Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.

She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.

Hopefully I won’t die of anaphylactic shock.

Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.

If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.

There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).

My stories are short stories. My endings are reports at the end of shift.