Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

This is just a fact of life: we can’t save everybody. Bodies fall apart if enough bad things happen to them. Sometimes we can keep part of the body alive, but not the rest; sometimes we can support consciousness even when the body is doomed, although eventually even consciousness will fade. More often, we can keep the body running even while the brain is completely dead.

You’ll notice that, with other organ systems, we use different terms than with the brain. If your kidneys have some working tissue, but aren’t strong enough to get your blood really clean, you have renal failure. If your kidneys are so fucked up they shrivel into black raisins and you never pee again and you depend on a dialysis machine to clear out all your nitrogen waste products forever, we call it end stage renal failure, not renal death.

If your liver is a huge lumpy pile of scar tissue and blood can’t flow through it at all, you aren’t experiencing liver death (although you will soon die unless you get a new liver), you’re in end stage liver failure. If your lungs are full of gross shit and require mechanical assistance to get oxygen and carbon dioxide in and out of your blood, you are in respiratory failure; if your lungs are filled with scar tissue and nodules and all the cilia are burned out and every breath uses up more oxygen than it gains, you are in end stage respiratory failure. All of these things lead directly to death, although we’ve learned to cheat them a little better over time, but they are not death.

We also talk about heart failure, in which the heart can’t move blood well enough to maintain equilibrium without medical help. We even talk about end stage heart failure sometimes, although this mostly means this person is about to be dead. The true end stage of heart failure is cardiac death.

We call it death, because for a very long time, the lack of a pulse was death. There was no way to get it back. Once you crossed that line, you were gone.

But we’ve learned to cheat even that death, sometimes, if we’re lucky. We can, if we’re willing to break ribs and insert tubes and flood the body with toxins, restart the heart. We can even support a fatally wrecked heart for a while with ventricular assist devices. What was once death is now closer to failure.

So if we’ve blurred the line between life and death, what’s left? Is there anything that can be so damaged that we can’t compensate for it? Is there anything that truly goes beyond failure into death?

Week 3 Shift 2

After six days off to hang out with my middle sister, the one who works as a CNA, and get my social life on (it's very sad and lame and involves babysitting and eating teriyaki), I went back to work this morning for a stretch of three days.

Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.

Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.

This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.

The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up. 

So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.

This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.

My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.

I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.

Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.

The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.

Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels. 

Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.

She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.

Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.

Frankly, I'd rather handle poop.

Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses. 

The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.

I wonder how long a blood bank takes to cut you off.

She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.

Liver failure is one hell of a way to go.

Week 2 Shift 3

Today I worked at my other facility, where I used to be a full-time night-shift ICU RN and am now working per diem shifts on days. This hospital and I have some bad blood because their method of handling conflict and "incident reports" involves a lot of stewing and poor communication. Like I might be a bitch to that CNA I chewed out, but by fucking god I talked to her about it, and after this I plan to discuss it again after a few more shifts with her (to see if our initial agreements smooth things over) and if necessary seek mediation from a higher-up. ICUs have too much shit going on to let drama grout up the corners.

This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.

Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.

Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.

One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.

Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.

Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”

The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside). 

Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies. 

While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.

The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.

"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."

I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.

Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.

I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.

Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.

Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.

The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.

A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.

This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.

Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.

Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.