Dix, Hamm, and Pulmonary Fibrosis

I mentioned pulmonary fibrosis in my last post. We had three big cases on our ICU in April, all three of them pretty difficult.

Pulmonary fibrosis is essentially scar tissue-- the formation of thick, tough, fibrous tissue that grows through and fucks with your lungs until you die of not being able to breathe. Imagine a transporter accident like in The Fly, but between a pile of wet cardboard and your dick, and you’ve got a little of the idea.

The treatments for pulmonary fibrosis include nebulizers to help open the parts that aren’t scarred up; steroids to reduce the growth of scar tissue (not always effective); and a host of other last-chance drugs that might have been helpful, maybe once, to some other pt whose pulmonary fibrosis took a little longer than usual to kill them. It might have been another drug, or luck, or fucking homeopathy for all the proof we have, but if it might have worked, we’re probably gonna try it.

The cure for pulmonary fibrosis is a lung transplant.

So when our first pulm fibrosis pt turned up eligible for an eventual transplant, we transferred them to the hospital where they would live until they either died or went on the table. We don’t do lung transplants here. They’re complicated.

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?

Whitney the Muslim

I apologize for the brevity of this post. For those of you that follow my scrawlings on Something Awful, I’ve been doing an AMA for the last twenty-four hours on the BYOB forum, which has diverted just a little of my writing powers.

I did manage to rant with embarrassing fervor about fruit that I like.

Anyway.

Sometimes the ICU runs like you expect it to: occasional periods of panic, lots of gross chores, and a slump around 1600 when you can catch up on your charting. Sometimes it gets a little crazy, and if you have a really rowdy pt with a lot of things going wrong, you can easily spend a whole shift on your feet and do all your charting after you’ve passed your pt to the next shift. And sometimes, the whole ICU loses its goddamn mind at once, and all your pts are desperately high-acuity and breaks only happen if everyone works together, and staffing calls random people on their days off and begs them to come in—not to take pts, but to serve as an extra flex nurse, just to help people get all their chores done.

When this happens, you have to be a special kind of dumbass to actually answer your phone, let alone come in extra. Unfortunately for me, I am that exact kind of dumbass. That week, I worked a lot.

Wishbone, Leah, and the Return of Crowbarrens

Every shift, we introduce ourselves to our pts, explain how long we’ll be there today, and talk about our goals for the day. Some people have very simple goals: don’t die is popular, as are things like control pain and get out of bed. Some people will have procedures during the day, endoscopies or central line placements or dialysis.

Occasionally, the most important goals aren’t things we can cheerfully schedule with our pts: come to peace with impending death, or manage not to shit directly on anyone’s scrubs. In those cases, we find simpler goals: order breakfast and lunch early so they don’t have to wait, take a walk and get some sunlight, that kind of thing.

Then we do our assessments, because nothing helps your day get moving like peering at some guy’s butt and hoping that pink spot on his tailbone isn’t turning into a pressure ulcer.

Hugging, Mrs. Beaumont, and the Fat Cunt Guy

Let’s just get this out of the way: I’m weird about hugging. I’m not the type to have anxiety attacks when someone invades my space, although I know plenty of people who are. I just grew up in Texas. The sheer number of people who’ve armpitted me in Wal-Mart on the grounds that our grandparents used to go to the same hairdresser…

And while we’re admitting things, I’ll get this off my chest: I think pts are gross. Their families are gross. I, while I’m inside the hospital, am gross. Literally everything and everyone within a block of my job is disgusting and I generally assume that anything touching me while I’m at work is probably covered in a thick fondant of shit and dead roaches.

It might be a little dysfunctional, but this is just how my brain works. It helps me keep track of who’s touching me and how much shit I have on my body at any given time.

So you can imagine how delighted I was when I introduced myself to my pt and her daughter and was immediately greeted with a full-frontal hug.

Lucy, Ed, and Carl Hamilton Park

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

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

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

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

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

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.

Mrs Leakey, Jelena, and Wen Li

So, uh, I’ve been on hiatus.

I’ve been working on a few chapters for a book proposal, and trying to get things pretty enough to be useful for publication, but I really REALLY prefer blogging to book writing (at least in this format) and I’d like to get back to this. So I plan to keep working on the blog, not necessarily shift-by-shift but following specific batches of pts, and work on the book between posts.

The upside to this is: I have a lot to tell you guys about. I expect to update once a week from here on out, and I actually have a backlog of posts ready to go, so there shouldn’t be any major hiccups for a while.

You have been wonderful and supportive, all of you, and I promise that if any of you is ever unfortunate enough to end up under my care, I will wipe your asses with the warm wet wipes.

(I also told a trio of trusted coworkers about my blog, so they could peek over it and make sure it’s both factual and HIPPA-compliant. All three of them immediately identified Crowbarrens. Life is good.)

Anyway. Let me tell you about Mrs. Leakey.

Week 9 Shift 1

I showed up late for work by about five minutes, having lost track of time while I was standing in the shower performing my usual morning devotional of cursing, groaning, and ordering myself grimly to wake up, come on, you can do it.

Any time I’m late to work I sort of creep in from the staff elevators and try to sidle up behind the group report cluster without being seen. No luck this time—a bright-faced unfamiliar nurse called out: “You must be Elise!”

Turns out I was precepting today. Okay. Surprise?

Maycee has moved on to another preceptor—each new nurse gets two days with each preceptor, to make sure they get a good variety of teaching methods. I like precepting and am pretty good at it, but everyone learns differently, and I have precepted more than one person who wasn’t really meshing with my style and needed someone a little more methodical and hands-on. Today I would be precepting Anne, who loves airplanes and hiking and pictures of gross wounds, and who was very patient while I poured half a carton of milk into a cup of ditchwater coffee from the supply room dispenser, then thousand-yard-stared my way through the first half of it before my brain came back online.

Our pt was a tall, strikingly pretty older woman who had been very active and independent before she fell last night, smacked her head on something, and developed a huge head bleed—a subdural hematoma. There are several different types of common head bleed, and this is not usually the deadliest, but an SDH can really wreck your shit.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I am glad for him. He earned his rest.

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

Week 8 Shift 1

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

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

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

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

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

“But what if he dies?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 7 Shift ACTUAL 1

I posted my reports out of order. Friday's was actually supposed to be today's, and vice versa. Mea maxima culpa, and also whatever dude.

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Started out this morning with a couple of sweet pts—my first day back since Tiberius died. I was kind of hoping for a pair of raucous assholes I could joke around with and care for without working too hard; instead I got two cute tiny old folks, both with Parkinson’s, both with lung cancer.

One had undergone a right mid-and-lower lobectomy, leaving him with nothing of his right lung but the upper lobe. The other had undergone chemo, had a really rough time of it, and then come back for her checkup to find that the cancer had spread quickly, after which she developed a UTI and sepsis.  The former will be going home in a few days—the surgery was successful. The latter will also be going home in a few days—antibiotics will have her comfortable enough to enjoy her remaining months at home.

The lobectomy pt had a little extra challenge to face. He’s orthostatic at home: when he sits or stands up quickly, his body can’t keep his blood pressure steady, and he faints. He fell a month ago and broke a small bone in his foot, requiring him to wear an immobilizer boot whenever he gets up to walk. Not that he was walking far; the previous shift had tried to take him for a walk down the hall, and he had made it as far as the med cabinet before his eyes rolled back in his head and he dropped like a rock. His chest tube made it even trickier to mobilize him, since it drained into a big square box called an atrium that had to be carried along everywhere he went.

And he really wanted to walk around. His pain was well-controlled with an epidural in his back, which numbed him from nipples to liver, preventing him from feeling the full impact of the huge surgery. Pain control is crucial in major thoracotomies like this one—I think Tiberius had an epidural too, immediately after his pneumonectomy and before things went south—because, as with cardiac surgery pts, this pt population is at huge risk of death if they lie still for too long. They need the pulmonary hygiene of coughing, which is almost impossible to manage if you’re in agony every time you breathe in; they need the blood-pumping action of muscles massaging their legs’ veins to return the blood to their hearts; they need to be able to breathe deeply, so their lungs don’t collapse, and the volume of air you breathe in declines sharply when you’re in bed all day.

None of these things are particularly compatible with a fresh open chest. If you’ve ever cracked a rib, you know what I’m talking about: fighting the urge to cough, breathing in sips and whispers, cursing your significant other like the Nosferatu because he strolled through the room and made a stupid pun and you laughed unexpectedly.

I cracked a rib about a year ago because I was at the pub for Drink & Draw with a bunch of my artist friends, and was invited by one of them—a massive Hawaiian man whose job is an even split between “draw monsters for video games” and “travel around the world giving workshops on how to draw monsters for video games,” both of which are hard-drinkin’ jobs—to help him finish off some shots that a group of art students had bought for him. I am an inveterate lightweight who gets a little woozy after a couple glasses of wine, so it was deeply stupid of me to take him up on his offer. At some point I asked him if people tried to fight him in bars, and joked that I (one hundred twenty-five pounds of hair and freckles) should totally fight him sometime. He responded by picking me up in a bear hug, which cracked my rib. He was very sorry and expressed disbelief that anybody could break that easily; I was very sorry and expressed a lot of vomit and groaning.

Anyway. This dude had to walk if at all possible. With fear and trembling we propped him up on the edge of the bed, and let him sit there for a while, reminding him over and over that he needed to wait to stand up until his body caught up with its new position. A few false starts later, and we propped him up on the cardiac walker—its big elbow cushions make it easy to walk with, and staff are known to rest their forearms on it and dangle their feet to help relax their spines during a hard shift. Heck, I like to lean on it and sail down the hallway, propelling myself with gentle taps of the toes, scaring the piss out of the CNAs and smacking into the medicine cabinets as I go. (This only happens in the late afternoon, when things have calmed down a bit.)

On the walker, he made it out into the hallway and down the hall before he turned white, slumped sideways, and said: “Leave me alone, I feel fine.” His eyes stayed open, but his head sagged and his knees wobbled. The charge nurse came running up, pushing a rolling recliner she’d snagged from a nearby room. “I ain’t sittin down,” said the gentleman as he slowly toppled, trailing his chest tube behind him.

“Sir, you’re passing out,” I said, trying to maneuver his swerving backside into the recliner while bending around the walker and juggling the chest tube atrium. “Please, sit down.”

“I feel fine,” he repeated. He was definitely staying awake, but his body was absolutely done with this standing-up bullshit.

“You look like a package of used hot dogs,” I said. “Sit the hell down.”

He started laughing, which I guess was too much for him, because he lost consciousness and slumped back (mostly) into the recliner like a sack of wet bricks. Thirty seconds later, as his body caught up with the change, he came back to… still laughing. “Hot dogs,” he said. “Hot dawgs. This girl’s a pistol, bang bang.”

I’ve had worse compliments. Once a pt told me: “I’d marry you, honey, but you’re a bitch from hell.” Still a little heartbroken over that one. But I have to agree with him.

His chest tube had kinked off when he flopped over on it, and the pressure differential had him feeling a little stuffy by the time we got him back in his room. I straightened the tube and hooked the atrium up to wall suction, and he gave a little start as a huge bubble slurped from the tube through the water seal. “Whatna hell was that,” he barked.

“Well, sir… your chest farted.”

More laughter. “Does your mama know bout your mouth?”

I assured him that my mother was a good, upstanding Baptist woman who would rather not know about my mouth, locked the chair brakes, and went to the break room to open palm slam a cup of coffee and two ibuprofen for my unhappy back.

I try to take care of my back. Lots of nurses get hurt and end up on disability. Back injuries build up over time and then suddenly seem to happen all at once, and I don’t want to end up slipping a disk mid-turn. I use the equipment at hand, follow strict body mechanics protocols, and am shameless about demanding help from other staff. Still, nursing is a high-contact sport, and sometimes you just throw yourself between someone else and the floor.

I’m not always funny, either. Sometimes I hit a charming, exhausted zone where my filters are down and the words fly fast, but shortly after that I turn into a blathering mule who can’t get three words out in a row. Panic increases my chances of witticism; exhaustion makes me sound clever. People are often surprised that I can tell a quippy story with a solid punch line and then be asleep before everyone is done laughing.

So I tell people about black holes. They come from supermassive stars, I tell them: huge flaming whirling nightmares so massive that hydrogen is crushed into iron at their cores. At last each one collapses under its own weight, crushing itself into nothing, waves and particles of radiation squirting out of its terrible fist at every crack and seam. And just as the star reaches the point of no return, ripping through space-time itself, swirling into the inescapable singularity, an enormous gout of brilliant blue light pours out, scouring everything in its path with searing, perfect illumination: Cherenkov blue.

That’s me, right before I collapse. I get tired, groggy, lazy; then, for a few moments, I am brilliant and clever and unstoppable and incisive; then I am lying on the break room sofa in a puddle of my own drool.

Anyway. I digress, boringly.

My other pt, the one who will go home on comfort care, is loopy as a rabbit in the grass. She is also deaf as a loaf of bread. She has hearing aids, which she hates wearing, and I don’t blame her because they scream constantly from the feedback hell of being turned up to max and shoved into her wax-plastered brain-holes. She grimaces and nods and looks completely confused while you try to talk to her, and the whole time there’s this distant metallic squeal like robots fucking. She is, however, so cute I can hardly stand it.

She keeps saying these things that sound like complete wacko non sequiturs, that make sense a few minutes later in context. She was cold, so I brought her a blanket from the warmer, one with blue stripes on it. She declined it: “Not with the red! I’m not a traitor!” Okaaaaaay. She did have a big red allergy bracelet on. I got her another blanket, one with no stripes, which she accepted.

A little later her family arrived, and as I relayed this story to them, they nodded sagely. “Of course,” they said, “those are XXXX University colors, and she cheers for XXXX State.”

I mean, I like football. I hated it when I lived in Texas, where football is a religion and the weather during football season is the best evidence we’ll ever have of God’s wrath, but since I moved to Seattle I’ve learned to enjoy it. (Something about how obnoxious and balls-out gleeful the fans are, and also about how Richard Sherman was fucking hot even before he opened his gorgeous mouth and a whole higher education drifted out of it like a fleet of sexy butterflies. Pardon me, I’m going to have a drink of water now.) I am the worst possible kind of football fan, and I still don’t think I could maintain that level of team spirit while slowly dying in a hospital bed.

We got her up to the chair for a while—yes, we ICU beasts have a total obsession with mobilizing our pts—and then had trouble getting her back into bed a few hours later, during shift change as I passed her off to the next nurse. Fortunately the oncoming guy was strong and good-spirited, and we wrestled her back into bed without dropping her somehow, even when she wobbled and her knees went completely limp. “The black-eyed ones always did that to me,” she quavered as we tucked her in. “Weak in the knees.” I was halfway home before I realized she was talking about the night nurse, who is a genuinely attractive young man with lots of muscles who quite literally swept her off her feet.

My lobectomy pt transferred up to telemetry immediately after that, keeping me late to give report to the upstairs nurse. I stressed the importance of taking things VERY SLOWLY with him, and told the whole grisly story of his afternoon walk. “Are you sure he’s tele status,” protested the nurse, and I don’t blame her, because nobody wants a pt who can turn into a floppy lump at a moment’s notice.

“Yeah,” I said. “Bye!”

I am a dick. Sorry, folks, that you have to know that about me.

(Generally speaking, orthostatic hypotension isn’t a reason to keep a pt on the ICU, especially if they’re orthostatic at baseline and need exercise to get moving again, which the tele floors are better at administering since ICU is focused on early mobility. It would have been very bad form, and dangerous to the pt, for me to pass him off without explaining how serious his orthostatic hypotension could be, but I honestly didn’t have time to coax the upstairs nurse into recognizing all this.)

As I left, they were already moving a new pt in, a tiny little lady who screamed and thrashed and hit everyone within reach. Her daughter stood in the hallway, dancing from foot to foot in that telltale hand-to-breastbone posture of a family member who is going to be ridiculously anxious the whole time. I will bet you one US dollar that I get that pt in the morning, and that she hits me.

Maybe I can jinx her into being a perfect doll.

Week 7, Shift 1

Well, I definitely got the crazy little lady this morning, and no, my attempt at jinxing her didn’t work. But more on that in a bit.

My adorable pt with the screaming hearing aids had really bad sundowners last night, and spent all morning groggy and slow to communicate. Even after I put in her hearing aids, she mostly just lay in bed napping, drifting off mid-sentence every time I tried to have a conversation with her. Somebody had given her a bump of dilaudid last night for an episode of back pain, and she apparently processes opioids slower than I process an entire brick of cheddar cheese, so she was completely zorked most of the morning.

Her family came in and stood around the bed, morose, watching her mutter in her sleep. “She’s really gone downhill,” said her son. “Yesterday she was so bright and awake, and she was up in the chair for hours… Today she barely wakes up to say hello. What happened?”

I explained about the pain medicine and our plan to closely limit her opioid administration from here on out, and added that her labs were all improving and her vital signs were solid, and that I was recommending to the MD for her to be transferred to a unit with a lower level of acuity. The family was uneasy, and I don’t blame them—I was keeping a weather eye out for weirdness myself, because while I had a pretty good explanation for her behavior (or lack of behavior), any time family says their loved one is different, I pay attention. I can’t tell you how many times I’ve caught something that would have gone unrecognized—a heart attack, a stroke, a major status change—just because I pay attention when family is worried.

(Sometimes I have to completely ignore worried family, when their worry is pathological and they’re doing themselves and their families no favors… more on that later. And yet, if the family is worried, even if it’s just because they’re always worried, I stay at a higher level of worry all day. Not necessarily about the pt, especially if I can look at them and tell that they’re doing fine, but I have plenty of my own shit to worry about and if we’re having a party anyway, heeeey!)

In this case, I was definitely watching her closely, especially when family brought in some edible and drinkable treats to try and coax her into eating. I was concerned that, despite her passing her swallow eval earlier, she would (in her current groggy state) fall asleep while chewing and end up with a hamburger in her lung. I hovered by the bed while her daughter leaned over and bellowed in her ear: “MOM. DO YOU WANT SOME DIET DR. PEPPER.”

And man, her face lit up like Mardi Gras in Las Vegas. Her eyes popped wide open and she levered herself upright in bed like a vampire popping out of the coffin. “Do you have any?”

After that, she was still prone to drifting off, but now she had a vested interest in staying awake. Family? Pssshhh, you can see them anytime. Diet Dr. Pepper? Now that is worth feigning alertness.

Fortunately, she really wasn’t in need of a lot of care, and the doc agreed around 0900 to downgrade her acuity to telemetry. I say ‘fortunately’ because my other pt Martha*, the crazy lady from last night, demanded almost all of my time.

Her history of bipolar disorder has provided her with a history of lithium use, and last year she attempted suicide by taking all of her lithium pills at once. The ways in which people attempt to kill themselves just horrify me. Taking two bottles of Tylenol? Finishing off your Wellbutrin in a single go? Jesus, are you trying to make sure you suffer on your way out? I mean, I sincerely hate the idea that anyone has to deal with the utter bleakness of chronic depression and the spiral that leads down to suicide, and I wish to god nobody killed themselves at all, and I hate that our society makes mental illness such a hush-hush no-funding issue that people can reach that point of suffering without having the resources they need to escape… But the shit that people do to themselves trying to kill themselves, that shit is like an Eli Roth porno. Even handguns fail frequently enough; it’s not uncommon for a person to attempt suicide, fail, and have an entire lifetime of medical fallout to deal with… or six weeks of pure torture in the ICU before they finally manage to actually die.

And of those who succeed in slow motion… they all want to live by the time they die. It’s awful.

Please don’t fucking kill yourself. Entirely aside from the fact that you’ll miss all the movies of the next few decades, that you’ll miss the chance to fake your own death and escape to a South American country and become the mysterious foreigner who lives in the jungle, that you’ll leave behind a body that somebody has to clean up… you have a pretty significant chance of ending up in a nursing home, just conscious enough to feel pain and humiliation, for the rest of your life.

Give it another year. Do something different. Talk to somebody about it. Don’t end up on my unit with ARDS from inhaling your own vomit when the pills kick in. If the Huntington’s is closing in and you really gotta go before you turn into a slack-lipped veggie on a vent, plan that shit out and have your family by your bed. If you don’t think you could convince someone to sit by your bedside while you die, it’s not time for you to die yet.

Anyway, that’s a grim little side note. The point is, this lady took all her lithium pills, and after a major round of dialysis, she ended up with a seizure disorder, diabetes insipidus, and maybe about two-thirds of her original IQ. This time around, she’s in the hospital because a week ago she tripped and fell at home, broke most of her ribs on the left side, and ended up with a hemothorax—a big pool of blood in the space her left lung was trying to occupy—plus pneumonia from her immobility and from being unable to breathe deeply and cough without pain, plus dehydration from the DI, plus a UTI.

Diabetes insipidus is a totally different animal from what we usually refer to as ‘diabetes’. Diabetes mellitus—those of you with some base in languages may recognize the root of ‘mellitus’ to mean ‘honey’—is sugar diabetes, which I have ranted about at length here. Type 1 diabetes mellitus means all the insulin cells in your pancreas were devoured by your immune system in a bizarre childhood autocannibalistic orgy, and you probably need an insulin pump; Type 2 diabetes mellitus means your body is growing resistant to insulin and your pancreas is maybe not pumping out as much as you need, often because you have a genetic predisposition or (more likely) your fat cells are overstuffed and trying to tell you to lay off the cheesecake.

It’s called ‘mellitus’ because your kidneys are dumping sugar, and your piss turns sweet. Doctors used to have to taste their pts’ urine to see if they were diabetic. It’s never been a good career for the mentally well.

Diabetes insipidus, therefore, means that your urine is insipid instead of sweet—it’s bland and watery. Lucky doctor. The problem here is that, inside your braincase, your pituitary gland (yes, the gland responsible for dragging you through puberty) has become fucked up somehow. In addition to hairy-armpit hormones, your pituitary gland regulates your water balance, secreting a hormone called vasopressin to remind your body that it actually needs water to survive. (In higher doses, vasopressin also causes your vasculature, your blood vessels, to constrict and increase your blood pressure… thus the name ‘vasopressin’. We use a synthetic version of this regularly on the ICU to raise blood pressure in septic pts.) So if you have a pituitary tumor, or massive brain trauma, or certain types of toxicity like lithium… you will constantly gush gallons of dilute watery fifteenth-beer piss, even though you’re dehydrated and dying of thirst and could really, really use all that water you’re filling your Depends with.

So this woman was constantly in desperate need of a trip to the ladies’ room, which is hard to manage when you’re completely deranged from a urinary tract infection, your entire left chest is hamburger on the inside, and you aren’t firing on all cylinders to begin with. She couldn’t bring herself to use a bedpan, and initially she was too dizzy and sick to get up to a bedside commode, so she would try to hold it until she just couldn’t, then fill the bed with a liter of water-pee and start screaming. Nothing we said to her made any sense to her. She hit and kicked and screamed, and it took her daughter and a sitter to keep her in bed and safe and calm.

Her daughter looked familiar. I’d seen her last night in the hallway, but now that I was in the room with her, she looked really familiar. After the first ten minutes of introductions, I recognized her with a start—she’d been the caretaker for a pt I cared for at my last facility, and she’d been an absolute nightmare. A few delicate questions confirmed my suspicion, and she recognized me too.

She had been enormously controlling, extremely anxious, convinced that we were neglecting her ward even though her nurse could never even get out of the room. She would regularly decide that the pt needed something—a breathing treatment, a new medication, a very specific positioning, an aggressive round of nasotracheal suctioning—and she would insist on it until the doc either gave in or had a stern, invariably ugly talk with her about appropriate care. She was absolutely unable to manage her stress, and this led to her ward being absolutely punished with unnecessary and uncomfortable turns every time she got comfortable.

But this just meant I’d had time to establish a rapport and a set of boundaries with her, and thank living fuck, I was able to get those back into place pretty quickly. I promised to genuinely consider any request she made, but told her I wouldn’t sugarcoat anything or perform any kind of care that I felt endangered her mother, and that if she got stressed out I would stay in the room for fifteen minutes at a time while she went to the waiting room to collect herself.

It worked pretty well.

Then she fired the sitter. The new guy who’d come in for the morning shift is this super sweet CNA I’ve worked with several times, a tall black guy with a genuine smile and dimples to boot, who spent thirty minutes with me last time he floated to our floor while we scrubbed a massive Code Brown off the walls even though he could by rights have ducked out halfway through. He is a wonderful, compassionate human being whose bedside manner is gentle as a lamb and soothing as a fifth of whiskey, and within thirty minutes of his assuming sitter duty, the daughter fired him for being ‘intimidating’.

“My mom is kind of old-school,” she said, clutching her elbows and speaking in low tones, trying her damnedest not to sound racist as hell. “She gets really scared if there’s anyone… intimidating around.” Inside the room, my pt was holding the CNA’s hand and smiling at him while he asked her about her grandchildren.

I told her I would see what I could do, and dove into the chart. Turns out, this cute little old lady with the crazy thrashing etc had not received any pain medication during her stay besides her scheduled toradol, which seemed unrealistic to me considering that she had six broken ribs and regularly freaked out like somebody had filled her bed with bees. She had PRN dilaudid IV available, and I drew it up and headed into the room.

“Are you having pain,” I asked her.

“No,” she said. “I want to go home.”

“Are you hurting?” Sometimes it helps to ask again a different way. “Maybe just a little bit?”

“Yeeeeeah. But I want to go home. So I’m not hurting.”

“We’re gonna get you home as fast as I can,” I said, and pushed the dilaudid. Pts with dementia often have trouble recognizing and expressing pain, and sometimes they think that if they tell you they’re not hurting, they can go home faster. Sure enough, five minutes later she was sleeping like a baby, had peed another liter without freaking out, and had gone from shallow rapid breathing to deeper, regular breathing.

So I sent the CNA off to the charge nurse to be reassigned, and gave her round-the-clock dilaudid coverage. She woke up nicely between doses, no thrashing, coughed on command, and gradually improved to the point that she could get up to the bedside commode.

Pain control is a big deal. And it amazes me that, with all her WebMD recommendations for care, her daughter hadn’t seemed to pick up on her pain. She didn’t need a sitter for the rest of the day.

Her two other daughters dropped by that afternoon. One was even more anxious than the first, terrified of the hospital, terrified of her mother’s condition, not wanting to talk about any of it. The other was fairly laid-back, having worked for a nursing home for a long time, and was mostly stressed out because her sisters were stressed out.

The pt did have a seizure. It started with her eyes jerking to the left, which apparently is her characteristic onset symptom; her daughter called me in, and I gave her Ativan to break the seizure as it kicked in, so she ended up having a few seconds of genuine tonic-clonic seizing before lapsing into post-ictal grogginess.

About 1300, just after my hastily-shoveled lunch of microwave burrito and cottage cheese, the charge nurse cornered me. “I hate to do this,” she said, “but we have a new pt coming in and nobody to admit them. Can you give your tele lady to this other nurse, and admit?”

Charge just seems like a position where you have to constantly deliver bad news and ask people for huge favors. I will definitely want to train for charge someday, but I also dread the thought of having to tell someone that I’m screwing them over because their assignment is too easy and I need somebody to land a clusterfuck and you’re it.

So I gave report and handed off my cute little lady, who was chugging her fifth Diet Dr. Pepper, and took report from the emergency room on a frequent flier.

This poor guy has been in the hospital five times already this year, and god knows how many times last year. He has some kind of GI bleed, probably in his small intestine, which recurs regularly for no reason anybody can pin down—no history of alcohol, no NSAID use, no fucking idea. Last year he had what our GI docs call the “million-dollar workup,” a cascade of diagnostic tests culminating in a literal swallowed camera capsule that films your entire gut as it passes through. No results.

This time his hematocrit was really, really low. I gave him several blood products and wiped his ass a few times while he shit out the last of the blood, and his GI bleed was over—just a couple days of blood transfusion and crit checks, and he’d be back home with his mystery bleed, happy as you please. He’s been here so often that the docs ordered him a full meal plan as soon as his crit stabilized, recognizing his telltale signs of recovery. Usually GI bleeders have to wait a while to eat… we just know that this poor guy is done bleeding once he starts getting hungry, and there’s no use in keeping him ravenous all the way up to discharge.

We did an EGD though, because we kind of have to, because it would be shitty to miss a bleeding ulcer just because he’s never had one before, and have him perf his stomach and die. It was a five-minute affair and he was damn near awake for the whole thing—he said he was used to it by now. That is not a thing I can imagine getting used to. He had a beautiful pink happy stomach lining though. His breakfast of scrambled eggs was still intact and recognizable and made me extremely hungry. I really need to start bringing multiple freezer burritos per shift.

I got hiccups toward the end of shift. I used to get them all the time on nights, usually between three and four in the morning, big whooping hiccups that sounded like some kind of lost stork wandering the darkened hallways calling for its young. My coworkers used to make relentless fun of me. Well, guess what, these coworkers also make fun of me when I start yelling HOOP uncontrollably in the middle of shift.

I could close my mouth and kind of muffle them, but that hurts. So fuck you, I’m gonna contribute to noise pollution, and you can all suck it and/or wear earplugs.

I hope this doesn’t become a regular thing.

At 1500 shift change, the new charge nurse dropped by and poked her head into the room. The pt’s daughter gasped. “Oh my god, I didn’t know you worked here now!” Turns out, this particular charge nurse once directed the adult family care center where my pt’s mother spent her declining years, had known my pt since she was a teenager, and had held all three anxious daughters while they were all still in diapers.  There was a distinct change in the dynamic after that—they seemed to trust us more, now that their old friend was in charge, and I didn’t have to enforce boundaries quite so stringently.

It’s a small fucking world, my friends. I never met this charge nurse before I started working here, and now here I am, taking care of a pt she practically raised, whose daughter I knew from another facility as a pt caregiver. This isn’t a huge city/region (technically the two facilities are in different cities, part of the sprawl of the central metro), but I am always amazed at how often I run into nurses I know from other places, pts I took care of years ago, and people I have to pretend not to recognize lest I violate HIPAA or make shit awkward.

Been checking up on my abd guy. Yeah, he’s still alive. Why, how, I’m not sure. His hemorrhagic necrotizing pancreatitis and total kidney failure have reduced his quality of life to “constant torture when he’s not in a coma.” Lots of legal pushing later, and they’ve assigned him a guardian ad litem… who now has to jump through a million legal hoops and decide whether or not to let him just die.

It’s not an easy choice. He’s very far removed from anyone who could speak for him. His roommate, who only realized he was hospitalized because nobody was using the toilet paper for three days, says he has a daughter somewhere…. But he’s never said her name, just called her ‘my daughter’. He left no living will, no advance directive, nobody with a durable power of attorney.

His coworkers keep coming by to check on him. They’ve all shelled out to get a rental storage unit for his belongings; they show up in their work uniforms, still sweaty and obviously exhausted from their shifts, to stand by his bedside for a few moments and tell him what’s going on at work. We can’t tell if he understands any of it. He opens his eyes sometimes to painful stimuli.

They obviously care about him a lot, and to me this means something. Most people who suffer from major addictions don’t have a lot of people who care about them; they sever their ties, drive away their families, and are slowly devoured by whatever chemical owns them, alone. Even recovering addicts usually spend a little while with their only friends being fellow recovering addicts, if they’ve been addicted for some time. At least that’s what it feels like.

But it’s telling that this guy, despite being a profound alcoholic, separated from family and friends, struggling with addiction, is still someone that his coworkers care about. They’ve worked with him for a long time. Some of them know that he had big issues with alcohol, and have delicately made the awkward effort to inform his nurses so we can “make sure that gets taken care of too.” They really miss him, and that means something to me—even feeling isolated, even in the throes of addiction, even sweating on his deathbed… he (like many other addicts) is still loved. And they are so glad to see him get help that they’re holding out hope he’ll recover, even though he’s long past the point where his death can be more than delayed.

It breaks my heart. I wish he’d got help sooner. He would have been surrounded with love.

In the meantime, all I can really hope for him is that he dies soon, and quickly. Maybe somebody will show up for him that has some legal authority.

Fucking depressing, man. On a bright note, today one of the consulting MDs accidentally locked himself into the staff bathroom, jamming the doorknob somehow. While the environmental services guys scrambled to try and get him out, he kept up a steady litany of exhortations and pleas: “You guys have to hurry, I gotta get out of here. I took a power dump in here. You gotta get me out, guys. Take off the hinges…”

I’d laugh harder if I didn’t occasionally get locked in a room with a pt who’s shitting uncontrollably. The aftermath of a three-pounder is nothing you wanna breathe in a closed space.