I had Friday off. I spent it on meaningless bullshit and faffery, for the most part; my sister and I had a meeting with her new guidance counselor to schedule some aptitude testing and discuss tutoring/counseling options for the next week. She’s settling in well—learning things like “how to make a sandwich” and “how to use a bus.” I feel like I’ve been working almost every day since she arrived.
Saturday morning I assumed the role of first admit nurse, then took report on one pt, a frequent flyer who has been notorious for her poor adherence to heart failure medications and home bipap use. She is cared for almost entirely by her devoted son, who does a fine job except that she refuses a lot of care, and hits. Or did. Last time she was here we put her on a horse-tranquilizing dose of Paxil, and this time around she’s been fairly pleasant and cooperative.
Her son is a very gentle sort, a little bit Bob Ross and a little bit hapless victim, so I was quite surprised to hear him call the Paxil her “anti-bitch pills.” He said it in such a self-deprecating way that it took me a moment to realize he was making a joke. I suspect that his life has changed a lot for the better since we started her on the meds.
She hadn’t been handling her bipap well lately, though, so not only had she collected lots of carbon dioxide, but her heart failure was really acting up. Explaining this will take a little bit of pathophysiology, so buckle in.
The old ICU saying goes: if you ain’t got pressure, you ain’t got shit. Blood pressure is so crucial to survival that we’ve even changed our CPR methods to emphasize compressions—pressing on the heart to maintain some blood pressure—and decreased the whole rescue-breathing thing to “meh, if you have time, but don’t stop compressions.” Oxygenation and ventilation (remember, ventilation refers to airing out the carbon dioxide in your blood) are important, but without pressure, you can’t get the oxygen to the tissues or return CO2-laden blood from the tissues. And your body can deal with a little low oxygen or high CO2 (your blood keeps a huge amount of oxygen after its first pump-through!), but not with a loss of pressure.
But what if you have too much pressure? High blood pressure makes tiny tears in your veins, which scab and scar and become susceptible to clots. Not as damaging as high blood sugar, which is like knives in your blood, but it will definitely tear you up inside. And if your blood pressure gets too high, you might blow a blood vessel in your brain—you will typically feel a headache only once it’s too late to do more than contain the bleed. High blood pressure is a silent killer.
What about if you have a pressure imbalance? That’s what’s happening to this lady. She has an obstructive breathing disease, with nasty sleep apnea that traps air in her lungs while she sleeps. The pressure in her lungs grows and grows as her body struggles to overcome her collapsed airways, until finally the air escapes with a whoosh and she can start the process of gasping for more air. There’s a reason people with sleep apnea are always tired and shitty-feeling: they spend their nights suffocating.
Meanwhile, the right side of the heart, which pumps blood into the lungs to be oxygenated, has to pump against a huge amount of pressure. As the pressure grows in the lungs, the blood has to be squeeeeeezed in with incredible force, and eventually the right side of the heart blows out like a stepped-on water balloon, becoming weak and floppy, and struggling to empty itself so more blood can return from the body. So blood backs up in the body, and the water that would normally be peed away by the kidneys just squeezes out into your tissues instead. Usually the lower part of your body first. People with right-sided heart failure get giant, swollen ogre legs, which get so stretched out they form big bubbly scars where water is tucked away, never to be returned to the bloodstream again.
One of the most crucial treatments for this is a diuretic, a water pill that convinces the kidneys to pee extra water away while it has the chance, since it’ll take a lot more work for the body to get water all the way back around to the kidneys again. So if you are, say, a grouchy old lady who hits nurses and doesn’t believe in taking her pills, pretty soon you’re retaining more water than New Orleans in hurricane season. And if your bipap is lying in a drawer while you sleep, your CO2 rises, and you become too groggy from CO2 poisoning to wake up and breathe.
CPAP and BiPAP can help a lot with this too. CPAP gives a little boost of air pressure to keep the airways open; BiPAP uses two different pressure levels, one for inspiration and the other for expiration. The increase in pressure is absolutely minimal compared to the whole “lungs stuck shut” pressure differential, and the overall result is that the lungs stay open, the volume of air (and thus the ventilation of CO2) is maximized, and the pt is wildly uncomfortable for the first little bit and then suddenly realizes they can breathe again. Nobody wants to wear a mask over their face… until they realize they can finally sleep like a real human with the mask on.
So she came in to the hospital nearly comatose, swollen up like a marshmallow in the microwave, smelling like the inside of a hobo’s shoe. I have a personal thing about stinky pts: I want them to be clean. I will make them clean if it kills me. Under no circumstances short of immediate, life-threatening danger will I allow my pts to lie in their filth with a baguette’s worth of yeasty crust on their scalp and a gunt-tuck full of smegma the texture and color of butterscotch pudding. If you come into my merciful care and your vagina is oozing all-natural Cheez Wiz, you had better get ready to spread.
I shoved a bedpan under her head and shoulders and soaked her in warm soapy water up to the ears, periodically sloshing more over her scalp and dumping the detritus in the toilet to be replaced with more. Once the water started clearing up, I emptied half a bottle of chlorhexadine mouthwash into the next round, and let that seep through the microbial rainforest of her ratty hair until the tectonic plates of yeast-plaque gave up and let go. The scalp underneath was raw and pink and looked like a fresh pork chop with a little incidental gray hair growing out of it.
All her folds I scrubbed, with the help of the long-suffering CNA, lashing the creases with antifungal powder and lining them with folded absorbent pads. The less said about her lady parts the better, but I can’t imagine how anyone could have dustflaps that yeast-eaten and not cry like a kicked dog every time they took a piss.
Her son came in near the end of the scrub-a-thon and gaped. “She never lets me wash her,” he said. “The last time I tried, she hit me and said she’d be dead before anybody washed her hair again.”
“Well, unconscious,” I said, and added that if she really wanted to stay filthy she was going to have to make sure she took her medicine so she wouldn’t become unconscious and be at the mercy of nurses again.
Then I got a call from the charge nurse: a rapid response from upstairs would be my admit, an alcoholic gentleman who had come in with pancreatitis three days before, gone into massive withdrawal, and then become so short of breath that he was being emergently intubated upstairs.
I knew right away it was going to be a clusterfuck. The intensivist was up to his neck in the drowned kid’s case, and was in the middle of a chest tube insertion that would need to be followed by a bronchoscopy. His acute lung injury was reaching the point where he couldn’t maintain decent oxygen levels, let alone ventilate effectively. Worse, he’d started to show signs of severe brain injury, small seizures that ramped up throughout the day until (right around the time I left) he was in status epilepticus, a massive seizure storm that we couldn’t seem to get under control. Needless to say, if my guy was going to be trouble, he was going to be my trouble.
Naturally, he showed up looking like yesterday’s shit. Blood pressure tanking, legs cold and mottled, foley catheter having drained less than 5mL of urine per hour (we start worrying at 30mL/hr) for the last six hours, nostrils flaring to suck in more air even while the ventilator forced each breath in. His anion gap—a measure of his energy status on the cellular level—was incredibly elevated, along with his blood glucose, which suggested that his sugar was staying in his blood rather than being eaten by his cells. His body was acidotic, which supported that idea—starving cells shit out torrents of lactic acid—but, weirdly, his potassium levels were low.
Those of you who have been following this blog for a bit have already been bashed over the head with the relationship between insulin, sugar, and potassium, but I will explain it again for the new admits. Insulin isn’t a magic anti-sugar substance—it’s just the key that opens your cells’ mouths so they can eat the sugar out of your blood. It also lets them eat potassium, which is a positive anion that keeps the inside of the cell electrically imbalanced against the outside (where negative sodium ions and other such things float around). Between the potassium, which is the electricity that powers the cells’ pumps, and the sugar, which is the gasoline that powers their engines, insulin keeps your cells purring along like that Nissan 240Z pignose you had in college and will never forget.
(I did not have that car. I barely know what that car is. My husband had that car and still obsessively draws pictures of it, rhapsodizes about it, and laments its demise to this day. He likes engines a lot and likes to stay up late at night and look at pictures of old Soviet planes until three in the morning, hurriedly switching windows back to wholesome Miata portraiture when I stumble to the kitchen for a glass of water. This is a dumb derail and I will stop.)
If there’s not enough insulin, or if your cells have become resistant to insulin, your blood sugar will soar as your cells starve. Potassium lingers in the blood, slowly throwing off the balance of positive and negative until muscle cells—especially heart muscle cells—can’t function properly. As your cells rip themselves to pieces, looking for anything they can burn for energy, pouring out lactic acid diarrhea from eating their own garbage, your heart begins to short out and beat erratically.
So it was really weird that he was hypokalemic—LOW on potassium. Especially since his kidneys had started failing, and thus weren’t able to dump any potassium. Even weirder, his lactic acid levels were still fairly low. (I can tell you now, days and days later, that even nephrology was never quite able to pin down the reason behind the rhyme with this one. Actual quote, with warning for medical blather: “Anion gap acidosis. The large anion gap is unexplained by the minimally elevated lactate or phosphorus level. The acidosis is larger than the ABG or serum bicarb suggests since he is currently receiving 180 mEq per day of sodium bicarbonate. Doubt ketosis. Doubt salicylate at this point in hospitalization. Because of ileus, could possiblly have d lacate. No heavy lorazepam (he did have several doses IV) or other propylene glycol ingestion.”)
But all this weirdness aside, I can tell you he was sicker than shit. His abdomen was HUGELY distended and hard to the touch. It’s not uncommon for people with pancreatitis to have swollen, painful bellies—really, that’s usually what brings them in—but this was just out of control. I laid him flat to turn him, and his blood pressure bombed. His ice-cold, mottled legs had no pulses. I sat him back up and he recovered his blood pressure, and I developed a hunch.
Low blood pressure from sepsis isn’t positional. Positional hypotension usually means that either the aorta is so scarred up (usually from smoking) that the heart can’t push blood hard enough to reach the brain when you stand up, or that something is crushing your heart in one position and not in another position. I suspected abdominal compartment syndrome.
Compartment syndrome is what happens when some part of your body is so swollen that it fills up its entire "compartment" and crushes itself, preventing blood from circulating to the tissue. Compartment syndrome in an arm or a leg can result in losing the limb, and the primary treatment is a fasciotomy: a deep slash that opens the muscle sheath-- the fascia-- so the swollen tissue has somewhere to expand to.
But what if you have massive pancreatitis, and your intestines are so swollen they're crushing all your internal organs, blocking your aorta, preventing blood from returning to your heart, and blocking any blood flow to themselves at all?
One carefully worded discussion with the intensivist-- who was moving the drowned boy into a rotoprone bed, which would rock him gently face-down to help drain his lungs and keep them open-- I got permission to put in a consult by a GI surgeon. "If he's pissed," said the intensivist, "I'm gonna tell him it was the pushy nurse that put in that order." We get along well and are facebook friends, but he's testy when pressed and haaaates being told what to do.
Whatever. Put in the consult with a note of my own-- STAT PLEASE SUSPECT ABD COMPARTMENT SYNDROME-- and within an hour the GI surgeon had cleared his slate and called in the team for an open abdomen washout.
He returned three hours later with his guts still open. A plastic bag contained his bright-red, massively swollen small intestine, sutured to the edges of his incision. Gooey abdominal fluid poured from every crease and seam. His urine output picked up a little, but to this date he hasn't recovered kidney function yet. His legs turned pink again, and his breathing eased. His guts had been crushing him to death.
I had him almost stable by the time night shift arrived. I gave report, helped clean and turn and mop his juices out of the bed, and staggered out of the hospital. I was so tired I slept in my car for an hour before I could drive home.
I will tell you all more about his care and progress tomorrow, and hopefully get caught up completely, as I finally DON'T work tomorrow. For now, I will tell you that there is an actual photograph of his guts posted on my Patreon, and that shit only gets crazier.
Rachel was readmitted that day. She was having sharp pleural pains in her side, and she has a pneumothorax. She's getting another chest tube, but isn't expected to stay long. She's gained ten pounds since discharge and is as sweet as ever.
A forty-five-year-old woman died that day of sudden-onset pneumonia with hypoxia. We are all a little stressed over all these young, incredibly sick pts.
Showing posts with label kid sister. Show all posts
Showing posts with label kid sister. Show all posts
Saturday, July 18, 2015
Friday, July 17, 2015
Week 5 How Many Fucking Shifts Jesus
I didn't write the day of this shift because I was too busy sobbing like an open drain at a Sufjan Stevens concert that night, and then afterward my friend dragged me to her house and forced me to watch (okay, fall asleep trying to watch) Tinkerbelle and the Legend of the Neverbeast. (She has a two-and-a-half-year-old and might be going a little crazy.)
Opened the shift with a decent duo: a GI bleeder and a post-laminectomy. The latter was only under my care for a few hours, as her biggest issue was pain-- a lot of pain-- and she had come to the ICU because all the pain meds made her loopy on the medical floor and they wanted to watch her a little closer. We were concerned by how dramatically her neuro status had declined; she wasn't somnolent or respiratory-depressed at all, as you'd expect with someone having an opioid OD, but she was totally hallucinating and paranoid. We don't like to see major mental status changes in a pt who's fresh off a major back surgery and/or had an epidural (as is common with back surgeries), because there's always the chance of infection in the central nervous system.
She cleared up around 0845 and seemed totally fine. I interviewed her a little more closely about what she thought had happened, and she said: "Oh, I just have these episodes. Never really thought they were a big deal." Straight from there to a head CT, where the radiologist noted what could be a lesion-- possibly a tumor-- in her head. From that point the neuro team got involved, and because she wasn't really critical care status they moved her off the ICU.
That interview process, by the way, is one of the more ticklish and annoying aspects of nursing, but one of the most important if you want to catch things before they go south. Most people are hesitant to offer their own opinions about their medical issues to healthcare staff, which means that sometimes valuable bits of information get withheld because the patient doesn't want to look dumb in front of the doctor. Thing is, we aren't mind-readers, we rarely have a truly comprehensive health history, and we don't always connect the dots with the same one-on-one scrutiny that a person can perform on themselves. We might not be able to take a pt's diagnosis at face value, because we can't expect them to have a full medical education (I mean, shit, I can't diagnose anybody either), but we can definitely get a lot of crucial information from a person's opinions about their body.
It's like: you might not know exactly what's wrong, but by god, you know something's wrong. And we don't always know even that much, until your vital signs start to crash.
There's a saying that, when a pt tells you they're dying, you fucking listen. People don't just toss that phrasing around. They might not be able to tell you exactly why they're dying, but they know their body is about to lose its grip.
That kinda came into play later in the shift. More on that later though.
My other pt, the GI bleeder, was a bit of a weird dude. He'd gone AMA the week before and returned vomiting blood, and in addition to a massive variceal banding, he also needed a TIPS procedure.
If you need a refresher on liver failure and what it does to your guts, here's my patho lesson from last week.
So this guy, a chronic heavy drinker who regularly mixes Tylenol PM with his vodka (do not fucking do this, alcohol + tylenol/paracetamol = liver-ripping molecular knives), has a liver so blocked that all his esophageal vessels are bubbling up like a teenager's face. All the blood vessels around his liver and intestines are completely blown out and ready to explode. Medical treatment hasn't helped him at all, and eventually we'll run out of chances to catch his bleeds... so the next step is a TIPS.
A transjugular intrahepatic portosystemic shunt, TIPS, is a tube that connects the blood vessels on either side of the liver. Now the intestines can dump straight into the system, bypassing most of the liver. If you're guessing that this can have amazingly nasty side effects, you are absolutely correct-- jizz proteins and brain-pickling nitrogens and straight-up chunks of shit are free to wander. Your liver is still getting a little filtration done, and making what proteins it can, but if it's almost completely cardboarded sometimes blood doesn't even bother and just travels by shunt... which cuts off blood flow to the liver and can kill you. But hey, you won't bleed to death?
As is common with families that involve alcoholism, this guy's family-- him and his wife, his children being estranged-- was extremely enabling and secret-keeping and just weird, with bad ideas about boundaries. He and his wife insisted that his hospital bed be moved closer to the wall sofa, so that he and his wife could hold hands as he slept; his wife refused to leave the room at any time, and spent weird amounts of time in the room "changing" (ie naked for some reason????) so that any entry to the room had to be preceded by lots of knocking and calling out. Super codependent, super enmeshed, super inappropriate, and super terrified of "being caught." When I stumbled across the pt's wall charger plugged in by the sink, a totally normal thing that everyone does, the wife reacted as if I'd caught her slipping her husband booze. Families afflicted with alcoholism run on secret-keeping, and most family members have a hard time telling what's an actual secret and what's normal, because they're so used to keeping the world at bay. I felt really, really bad for them both, because things will never get better for them without help, and they'll never get help because they're so invested in the secret and so locked into the psychological addiction of enabling.
But he went down for this TIPS at two, and did pretty well, so he's got maybe another year or two's worth of chances to break the secret and get their lives back.
While all this was going on, Rachel went home. She isn't even going to rehab-- she's been totally off vent for a while, even taking a few steps at a time, and she went home in a medicab to her children and her own home. I hope things go well for her.
The exploding poop guy was doing much better. A few days of nonstop diarrhea had loosened his belly up to the point that, when I poked my head in, I could see the droopy skin of his abdomen flopping as his nurse turned him to wipe his ass.
A couple of people asked me how somebody can live without shitting for six months. (Hopefully tomorrow I can get caught up on replies?) The answer is: you can't live without shitting for six months. You can, however, be massively chronically constipated, and if it starts slowly and doesn't advance too quickly, your body gradually learns to compensate for the increasing blockage. You shit liquid around the blockage, mostly. But eventually even that deteriorates, and soon you're backed up to your neck. Literally. So this guy hadn't pooped in something like a week, but he'd been working on that week of constipation for so long that it damn near killed him.
The last pt I got for the day was an utter clusterfuck. She was an older woman, a marathon runner, who had developed a hiatal hernia and had it repaired via Nissen fundoplication (wrapping the stomach around the esophagus, which I can't describe any better than Wikipedia). Her wife is an RN and had been staying with her since the surgery a couple of days before, and yesterday had started expressing some concerns about the pt's status: requiring more oxygen, having increased pain, unable to advance her diet, and just "looking weird." Overnight the pt's oxygen needs had increased to the point that, when I finally got report, she had been on a non-rebreather mask at 15 liters, satting 89% O2 (you and I probably sit between 96% and 100%), for almost six hours without anybody insisting there was a problem.
Sometimes nurses make the worst pts. This nurse, however, impressed the hell out of me both with her insight and her grace in light of the medical floor staff's failure to recognize her wife's decompensation... though honestly I would have been a lot pushier than she was. I can't nitpick. She's trauma-ortho and I'm ICU and therefore she's a steady time-managing proceduralist while I'm a neurotic compulsive paranoid with control issues.
The transfer was awful. Charge told me I'd be getting a pt shortly, so I asked my break buddy to watch my TIPS guy while I took a fifteen-minute nap, and notified the charge and the unit secretary to call me on break if report came up. Instead, I enjoyed a nice snooze, checked on my TIPS, poured myself a cup of coffee, and walked down the hallway to find the new pt waiting for me-- no RN, no report, just a confused transport guy from CT and a pt who looked like she was about to crash on me.
As we moved her into the new bed, she grabbed my arm and gasped: "I think I'm dying." Then she was too short of breath to say anything else. I keep my hair back in a sloppy french braid, but I'm pretty sure half of it popped out and stuck up straight in the air. Remember what I said earlier? That's not a good thing to hear from any pt.
She had subcutaneous emphysema with crepitus-- crackling bubbles under her skin-- from her shoulders up to her temples. A quick chest x-ray showed that she had a massive pleural effusion, so I got her sitting up on the side of the bed, and the pulmonologist stuck a needle in her back and pulled out a liter of bloody-clear fluid, which improved her breathing but was extremely alarming. Her wife watched the whole procedure and looked increasingly apprehensive, especially when the pulm ordered the fluid checked for amylase-- one of the enzymes secreted by the pancreas, which belongs in the intestines breaking down your food, not in your lung cavities.
Sure enough, the radiologist showed up twenty minutes later to tell us that her CT showed a giant rip in her esophagus, with communicating fluid and free air between abdomen, thorax, and mediastinum. This is SUPER BAD AND HORRIBLE and requires immediate surgery. Unfortunately, our cardiothoracic surgeon that day had started an open heart an hour before and wouldn't be available to operate for at least another four hours, and the nightmare in her gut was massive enough that she would need a GI surgeon and a thoracic surgeon to perform the surgery. We intubated her immediately to stabilize her, then transferred her to another hospital in the area, a thirty-minute drive at the end of which the op team was already preparing the OR. I hope she's okay, for her wife's sake. I can't imagine being a nurse, knowing what I know, and watching helplessly as my spouse suffered horrible pain and life-threatening health events. I don't know how she wasn't flipping tables and kicking doctors all night, watching her wife go from nasal cannula to mask to non-rebreather without being assessed for critical care status needs, watching her face blow up with subcutaneous air without somebody at least asking for a chest x-ray to rule out pneumothorax.
This is why nurses make terrible pts. We get all freaked out and controlling about our care. It's just ridiculous. Any time my husband spends in the hospital is time I will spend gnawing my tongue off in the middle so I don't get thrown off the campus.
Let me tell you, though, getting that pt with no report and no prior warning was more of a wake-up than any amount of freshly-poured coffee that I promptly forgot about and left on the station until it got cold and the unit secretary threw it away. A pt with no report AND massive sub-q (uh, that's subcutaneous in nurse jargon) emphysema will give your sphincters a workout. I had to stay a little late just to write up the incident report. Still a little stressed out just thinking about it.
I only worked eight hours though, and after that I went home and washed up and put on something way too shabby and sloppy to wear to a concert, but I guess it didn't matter because I had a blast. Or possibly an emotional breakdown. It's kind of hard to tell. I will write about today's shift tomorrow, after the morning's meeting with my sister's social worker.
My sister, btw, is doing really well, but she reminds myself a lot of me at that age-- questionable personal hygiene, terrible time management, serious lack of some basic social niceties. The usual rural-religious homeschooled stuff. But she's just as smart and articulate as I remember, and has charmed my friends and responded well to all our conversations about my expectations for her time in my home, and I'm really glad to have her with me as she starts her adult life.
Opened the shift with a decent duo: a GI bleeder and a post-laminectomy. The latter was only under my care for a few hours, as her biggest issue was pain-- a lot of pain-- and she had come to the ICU because all the pain meds made her loopy on the medical floor and they wanted to watch her a little closer. We were concerned by how dramatically her neuro status had declined; she wasn't somnolent or respiratory-depressed at all, as you'd expect with someone having an opioid OD, but she was totally hallucinating and paranoid. We don't like to see major mental status changes in a pt who's fresh off a major back surgery and/or had an epidural (as is common with back surgeries), because there's always the chance of infection in the central nervous system.
She cleared up around 0845 and seemed totally fine. I interviewed her a little more closely about what she thought had happened, and she said: "Oh, I just have these episodes. Never really thought they were a big deal." Straight from there to a head CT, where the radiologist noted what could be a lesion-- possibly a tumor-- in her head. From that point the neuro team got involved, and because she wasn't really critical care status they moved her off the ICU.
That interview process, by the way, is one of the more ticklish and annoying aspects of nursing, but one of the most important if you want to catch things before they go south. Most people are hesitant to offer their own opinions about their medical issues to healthcare staff, which means that sometimes valuable bits of information get withheld because the patient doesn't want to look dumb in front of the doctor. Thing is, we aren't mind-readers, we rarely have a truly comprehensive health history, and we don't always connect the dots with the same one-on-one scrutiny that a person can perform on themselves. We might not be able to take a pt's diagnosis at face value, because we can't expect them to have a full medical education (I mean, shit, I can't diagnose anybody either), but we can definitely get a lot of crucial information from a person's opinions about their body.
It's like: you might not know exactly what's wrong, but by god, you know something's wrong. And we don't always know even that much, until your vital signs start to crash.
There's a saying that, when a pt tells you they're dying, you fucking listen. People don't just toss that phrasing around. They might not be able to tell you exactly why they're dying, but they know their body is about to lose its grip.
That kinda came into play later in the shift. More on that later though.
My other pt, the GI bleeder, was a bit of a weird dude. He'd gone AMA the week before and returned vomiting blood, and in addition to a massive variceal banding, he also needed a TIPS procedure.
If you need a refresher on liver failure and what it does to your guts, here's my patho lesson from last week.
So this guy, a chronic heavy drinker who regularly mixes Tylenol PM with his vodka (do not fucking do this, alcohol + tylenol/paracetamol = liver-ripping molecular knives), has a liver so blocked that all his esophageal vessels are bubbling up like a teenager's face. All the blood vessels around his liver and intestines are completely blown out and ready to explode. Medical treatment hasn't helped him at all, and eventually we'll run out of chances to catch his bleeds... so the next step is a TIPS.
A transjugular intrahepatic portosystemic shunt, TIPS, is a tube that connects the blood vessels on either side of the liver. Now the intestines can dump straight into the system, bypassing most of the liver. If you're guessing that this can have amazingly nasty side effects, you are absolutely correct-- jizz proteins and brain-pickling nitrogens and straight-up chunks of shit are free to wander. Your liver is still getting a little filtration done, and making what proteins it can, but if it's almost completely cardboarded sometimes blood doesn't even bother and just travels by shunt... which cuts off blood flow to the liver and can kill you. But hey, you won't bleed to death?
As is common with families that involve alcoholism, this guy's family-- him and his wife, his children being estranged-- was extremely enabling and secret-keeping and just weird, with bad ideas about boundaries. He and his wife insisted that his hospital bed be moved closer to the wall sofa, so that he and his wife could hold hands as he slept; his wife refused to leave the room at any time, and spent weird amounts of time in the room "changing" (ie naked for some reason????) so that any entry to the room had to be preceded by lots of knocking and calling out. Super codependent, super enmeshed, super inappropriate, and super terrified of "being caught." When I stumbled across the pt's wall charger plugged in by the sink, a totally normal thing that everyone does, the wife reacted as if I'd caught her slipping her husband booze. Families afflicted with alcoholism run on secret-keeping, and most family members have a hard time telling what's an actual secret and what's normal, because they're so used to keeping the world at bay. I felt really, really bad for them both, because things will never get better for them without help, and they'll never get help because they're so invested in the secret and so locked into the psychological addiction of enabling.
But he went down for this TIPS at two, and did pretty well, so he's got maybe another year or two's worth of chances to break the secret and get their lives back.
While all this was going on, Rachel went home. She isn't even going to rehab-- she's been totally off vent for a while, even taking a few steps at a time, and she went home in a medicab to her children and her own home. I hope things go well for her.
The exploding poop guy was doing much better. A few days of nonstop diarrhea had loosened his belly up to the point that, when I poked my head in, I could see the droopy skin of his abdomen flopping as his nurse turned him to wipe his ass.
A couple of people asked me how somebody can live without shitting for six months. (Hopefully tomorrow I can get caught up on replies?) The answer is: you can't live without shitting for six months. You can, however, be massively chronically constipated, and if it starts slowly and doesn't advance too quickly, your body gradually learns to compensate for the increasing blockage. You shit liquid around the blockage, mostly. But eventually even that deteriorates, and soon you're backed up to your neck. Literally. So this guy hadn't pooped in something like a week, but he'd been working on that week of constipation for so long that it damn near killed him.
The last pt I got for the day was an utter clusterfuck. She was an older woman, a marathon runner, who had developed a hiatal hernia and had it repaired via Nissen fundoplication (wrapping the stomach around the esophagus, which I can't describe any better than Wikipedia). Her wife is an RN and had been staying with her since the surgery a couple of days before, and yesterday had started expressing some concerns about the pt's status: requiring more oxygen, having increased pain, unable to advance her diet, and just "looking weird." Overnight the pt's oxygen needs had increased to the point that, when I finally got report, she had been on a non-rebreather mask at 15 liters, satting 89% O2 (you and I probably sit between 96% and 100%), for almost six hours without anybody insisting there was a problem.
Sometimes nurses make the worst pts. This nurse, however, impressed the hell out of me both with her insight and her grace in light of the medical floor staff's failure to recognize her wife's decompensation... though honestly I would have been a lot pushier than she was. I can't nitpick. She's trauma-ortho and I'm ICU and therefore she's a steady time-managing proceduralist while I'm a neurotic compulsive paranoid with control issues.
The transfer was awful. Charge told me I'd be getting a pt shortly, so I asked my break buddy to watch my TIPS guy while I took a fifteen-minute nap, and notified the charge and the unit secretary to call me on break if report came up. Instead, I enjoyed a nice snooze, checked on my TIPS, poured myself a cup of coffee, and walked down the hallway to find the new pt waiting for me-- no RN, no report, just a confused transport guy from CT and a pt who looked like she was about to crash on me.
As we moved her into the new bed, she grabbed my arm and gasped: "I think I'm dying." Then she was too short of breath to say anything else. I keep my hair back in a sloppy french braid, but I'm pretty sure half of it popped out and stuck up straight in the air. Remember what I said earlier? That's not a good thing to hear from any pt.
She had subcutaneous emphysema with crepitus-- crackling bubbles under her skin-- from her shoulders up to her temples. A quick chest x-ray showed that she had a massive pleural effusion, so I got her sitting up on the side of the bed, and the pulmonologist stuck a needle in her back and pulled out a liter of bloody-clear fluid, which improved her breathing but was extremely alarming. Her wife watched the whole procedure and looked increasingly apprehensive, especially when the pulm ordered the fluid checked for amylase-- one of the enzymes secreted by the pancreas, which belongs in the intestines breaking down your food, not in your lung cavities.
Sure enough, the radiologist showed up twenty minutes later to tell us that her CT showed a giant rip in her esophagus, with communicating fluid and free air between abdomen, thorax, and mediastinum. This is SUPER BAD AND HORRIBLE and requires immediate surgery. Unfortunately, our cardiothoracic surgeon that day had started an open heart an hour before and wouldn't be available to operate for at least another four hours, and the nightmare in her gut was massive enough that she would need a GI surgeon and a thoracic surgeon to perform the surgery. We intubated her immediately to stabilize her, then transferred her to another hospital in the area, a thirty-minute drive at the end of which the op team was already preparing the OR. I hope she's okay, for her wife's sake. I can't imagine being a nurse, knowing what I know, and watching helplessly as my spouse suffered horrible pain and life-threatening health events. I don't know how she wasn't flipping tables and kicking doctors all night, watching her wife go from nasal cannula to mask to non-rebreather without being assessed for critical care status needs, watching her face blow up with subcutaneous air without somebody at least asking for a chest x-ray to rule out pneumothorax.
This is why nurses make terrible pts. We get all freaked out and controlling about our care. It's just ridiculous. Any time my husband spends in the hospital is time I will spend gnawing my tongue off in the middle so I don't get thrown off the campus.
Let me tell you, though, getting that pt with no report and no prior warning was more of a wake-up than any amount of freshly-poured coffee that I promptly forgot about and left on the station until it got cold and the unit secretary threw it away. A pt with no report AND massive sub-q (uh, that's subcutaneous in nurse jargon) emphysema will give your sphincters a workout. I had to stay a little late just to write up the incident report. Still a little stressed out just thinking about it.
I only worked eight hours though, and after that I went home and washed up and put on something way too shabby and sloppy to wear to a concert, but I guess it didn't matter because I had a blast. Or possibly an emotional breakdown. It's kind of hard to tell. I will write about today's shift tomorrow, after the morning's meeting with my sister's social worker.
My sister, btw, is doing really well, but she reminds myself a lot of me at that age-- questionable personal hygiene, terrible time management, serious lack of some basic social niceties. The usual rural-religious homeschooled stuff. But she's just as smart and articulate as I remember, and has charmed my friends and responded well to all our conversations about my expectations for her time in my home, and I'm really glad to have her with me as she starts her adult life.
Thursday, July 16, 2015
Week 3 Shift 4
My splenic rupture pt had a rough night. It’s not uncommon for people over the age of 70 to get confused at night when they’re in a strange place, sick, covered in tape and wires, and this can lead to some really risky situations. In her case, she pulled out her PICC line, which was put in yesterday to replace the internal-jugular central line she pulled out the night before. I came in to find her wrists strapped down and her nurse sitting at the bedside, gently talking to her to keep her occupied and soothed.
Used to be, as soon as you started acting like you might pull something out, you got your wrists strapped down with restraints. These days, we pay a lot more attention to delirium, and restraints dramatically increase both the incidence and severity of delirium. The night nurse who cared for her while I was sleeping is a damn good one and I trust him, so when I saw the soft bracelets on her wrists I knew things had gone to shit.
She’d pulled her PICC while making eye contact with him, holding his hand with her free hand, and saying that she felt pretty good. Grab and rip. After this she pulled two peripheral IVs, removed her oxygen a dozen times, and tried to pull out her foley catheter. The night nurse felt that restraints were the only way to keep her IV access in, so he sat beside her for the rest of the night, talking to her to keep her from going completely crazy.
Sunlight is the usual cure for this kind of delirium, which is so common we call it “sundowning” and expect it with certain age groups. Once the sun comes up, you can usually transition the pt from wrist restraints to puffy mittens, then open the fingertip part of the mittens, and finally free their hands entirely. Sometimes it’s even quicker than that.
Delirium is very different from dementia. Often, severe acute illness will combine with other factors like dehydration, sleep deprivation, and unfamiliar medications to make a patient forget where they are and what day it is, possibly even thinking they’re in a different country or it’s 1970 or that I’m a Nazi captor in a WWII prison. (This is depressingly common in older folks from Europe, many of whom were terrified as children that they would be captured and tortured by enemies of war.) We call that confusion, initially, but if confusion has an acute onset (they aren’t like this at home), the pt can’t focus long enough to follow a brief set of instructions (“I’m going to spell a few words, and I want you to squeeze my hand whenever I say ‘A’.”), and they can’t get their bearings enough to answer simple questions (“Will a stone float on water?”), they’ve moved past mere confusion and are delirious.
In a state of delirium, a pt is likely to hurt themselves—falling, pulling out tubes, etc—and is at very high risk of having weird delusions and hallucinations. These are a big deal because, in the delirious state, your mind can’t really differentiate between reality and the bizarre ideas that come with confusion and delirium, and it processes these as if they’re fact. You can end up having intense, vivid PTSD flashbacks to things like being smothered by aliens, raped and tortured by Nazis, shoved into a box and left there for hours, and burned alive—even though none of these things actually happened. The flashbacks and mental fuckery can last for literal years afterward. People who become delirious in the ICU generally have cognitive issues for a long time after discharge. (We see this a lot in re-admits, who aren’t quite themselves when they leave and return a month later completely whacked out.)
Perhaps most immediately worrying, delirium can disguise other major signs of danger, like altered level of consciousness, pain, and feelings of impending doom.
So I progressed her pretty quickly from restraints to mittens to open mittens. Too quickly—she pulled out one of her IVs. She has another, though, so I stopped the bleeding and let it rest. I feel like her mental status is one of the most vulnerable aspects of her health right now, and it would be awful if she (an independent woman who teaches music) ended up in a nursing home when she leaves here.
Anyway, as the shift progressed her lethargy continued, and she had trouble articulating almost anything she said. Head CT from yesterday was totally clean, neuro checks negative except for lethargy and verbal difficulty, blood sugar and hematocrit stable, abdomen stable, and finally we just settled in to “watch and wait.” I asked her son if she wears glasses, because although she claimed not to, she also didn’t know what state she lived in… Son brought in glasses and a novel she’d been reading, and a little later in the afternoon she came around just fine.
Still a little worried about her. Drowsiness after a splenic rupture is usually a sign that the pt is about to take a turn for the worse. But she had plenty of time to make that turn, and instead finished up my shift with a quick trip to the bedside commode and a bit of worrying-aloud about whether she would be able to get up the stairs at home. (She will be strong enough to get up the stairs by the time we send her home-- physical therapy opens almost every intial interview with, believe this or not: "Do you have stairs in your house?" This is a goon joke.)
As for my pt with the GI bleed, she was quite thoroughly recovered. She was downgraded to medical status halfway through the day, and after a bit of consultation with the blood bank, the doctor decided to go ahead and top her off with the last unit of matching, prewashed blood they had on hand, then send her home in the morning. Her family came in to visit during the afternoon, and her kids were so excited to see her that they literally jumped up and down, in place, for almost thirty minutes. One of them would settle down, and the other would kind of chill out, and then the first one would start bouncing again, and pretty soon they'd just be hopping in place, talking three hundred mph in their weird little shrieking voices. Kids are basically insects, is what I'm saying.
At three, afternoon shift change time, I traded out-- GI bleed passed off to a nurse with a group of other medical/telemetry overflow pts, new pt picked up. This guy was still critical care status, having been extubated around 1030, and he had a very distinct set of challenges to present me.
He is a developmentally delayed man, about forty, mentality between six and eight years old. Very polite-- turned his face and covered his mouth when he coughed, waved at everyone-- but easily frustrated and, for obvious reasons, very stressed out. He had been at his adult family home, eaten a bunch of dinner, aspirated it somehow, and gone into respiratory-cardiac arrest. 911, CPR, intubation, bronchoscopy with washout, extubation the next day. Really good outcome, no neuro deficit from baseline.
His lungs were still pouring sputum in response to the dinner invasion. Listening to his chest was like sticking your stethoscope into a washing machine full of shoes. Every few minutes he would cough up huge rippling mountains of sputum, which he had a very hard time managing and would suck back down his windpipe maybe one out of three times, causing another coughing fit. He did NOT like having the suction catheter in his mouth. He also wanted dinner, and some soda, and the speech therapist unsurprisingly made him strict NPO (nil per os, aka nothing by mouth) because he genuinely couldn't swallow his own spit without choking.
He'll probably get that functionality back, to a degree, but we still have to assess what made him aspirate in the first place.
In the short term, I got a packet of honey from the condiment drawer, smeared a trace of it on the suction cath (also called a yankauer, a plastic wand for sucking things out of the mouth and upper throat), and offered it to him as a "honey straw." He loved it. There wasn't enough honey to cause any trouble, and honey doesn't come off easily, so I wasn't worried about choking... and it encouraged him to keep it in his mouth almost constantly, coughing up crap and immediately jamming the "honey straw" back in his mouth. I refreshed it every hour or so and he cleared his airway wonderfully the whole time.
The real challenge came from his severe chronic constipation. An abdominal CT performed yesterday on admit, for his hugely distended belly, revealed that his colon was PACKED with shit. Cecum to rectum, dilated to a terrifying degree, crammed full of poop that hadn't seen the light of day in months. They loaded him with a truly amazing volume of bowel meds, and the night before he had started out with a few semi-liquid stools-- the kind of thing that manages to seep through the shit tunnel gridlock and keep you from backing up so hard that you die.
And he was backed WAY up. He kept burping and it smelled distinctly of shit. His OG tube, pulled out with the breathing tube when he was extubated, had been pulling something that the doc initially worried about because it looked a little like coffee grounds (a sign of gastric bleeding)... but which, when the OG tube came out, was pretty clearly just backed-up shit. Shit from his STOMACH. That is not supposed to happen and is a very bad sign.
Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets.
As I sloshed through that cleanup, trying not to breathe more than strictly necessary, I realized that this shit had been inside him for one hell of a long time. The smell had that intense death-rot odor you get when you've been hoarding that particular nugget for quite a while. That corn wasn't last week's veggie side at the cafeteria, dude. I bet you a dollar he gnawed that shit off the cob at his grandma's house for Christmas.
The fecal journey continued with inspiring diversity. One delicately-jointed, bubble-textured oblong came out looking like a Baby Ruth bar. One delivery was thick and slushy, but contained crumbly elements that glued themselves to everything they touched and pilled up like a hoodie in the dryer.
We attempted to get him up to the bedside commode at one point, hoping to catch the bounty in a bucket rather than the bed, but as he prepared to sit down he suddenly decided that there was a better potty out in the hall somewhere, and took off running with his gown flapping behind him. Two steps into his flight, his sphincter lost control. Spatters and ribbons festooned the tile in a pseudo-Farsi calligraphic scrawl. The CNA and I caught him before he could open the room door; she guided him by the shoulders back to his plastic throne, and I cupped my hands under a washcloth to form a towel-cup that I clamped to his backside, catching the steaming runoff to prevent any more modern art.
After a while, he exhausted himself on the bucket, and we got him back into bed. Five minutes after that he had another coughing fit and ripped a gargantuan chunky fart right into his disposable bed-liner. I heard the expulsion lap up against his thighs like the bubbles popping in a pot of boiling oatmeal. The pulmonologist came up to ask me a question and started coughing at the smell.
Some days are just like this. I passed that guy off to night shift with sincere condolences and warnings.
It occurs to me that I would not want to eat anything honey-flavored while in the room with a smell like that. But this pt happily smacked away on his "honey straw" even while his gut was blasting out everything he'd eaten this year, not so much as blinking. You know what? Whatever makes him happy. That's what.
The only real upside is that, being developmentally delayed, he could be convinced that this shit was hilarious, and wasn't really offended when we acknowledged that his shit stank. Some people get really upset if you don't manage to keep a straight face as you clean up their poop; some people just get incredibly embarrassed and feel horrible, and my heart goes out to those people, because I can't take a dump if anyone in the building knows I'm taking a dump and I would rather pretend at all times that I don't actually have bowel movements. (This is probably a leftover of my upbringing somehow, but I don't care to examine it too closely.)
You just gotta be really good at keeping your poker face strapped on. Gross wound? Learn to smile through it. Gallons of liquid shit? Reassure the pt that you've seen so much worse. (You have.) Crusty vadge plopping out cheese curds the size of thumb joints while you're trying to scrub the area for a catheter? Keep your face pleasantly neutral and talk about something else.
This job is allllll about winning people's confidence. It's much harder to care for someone whose guard is up, who distrusts you, or who feels awkward when you walk into the room. If they can relax and feel comfortable, if they can trust you, they have a much better experience and will tolerate a lot more of the pain and indignity that comes with a hospital stay, knowing that you're not doing this shit for fun either and that you won't judge them for anything that happens.
A particularly weird aspect of this is the importance of not reacting to anything with shock, panic, or visible distress. Like if you stub your toe and they see you wince and hop around, they're going to be wondering: is she gonna hurt me by accident too? Is she really in control of the situation? Can she be distracted at a critical moment, and possibly let me die because she just jammed her thumb in a drawer? These aren't conscious assessments, they're just part of the natural human reaction to being powerless and needing a team member you can trust. So one of the reflexes I've cultivated as a nurse is keeping a straight face when I bang my elbow, stub my toe, or otherwise remind myself that my body is pretty vulnerable and these hospital rooms are fucking crowded. If I drop something on my foot, I'm gonna politely excuse myself to another room before I descend into hissing and cursing.
I don't want my pts to ever feel like they have to comfort or protect me. I don't want to seem physically or professionally vulnerable to a person whose life may depend on my capability and strength. I want questions to be surface-level, where I can encourage my pts to articulate them and have them answered. I want to avoid situations in which my pts have to assess the situation without full access to relevant information, which means that even if my toe-stubbing happens because I'm focused on their cardiac output, I don't expect them to be able to explain my priorities of attention to themselves and decide that I must have been looking at something more important.
I am probably a fucking nutjob. I overthink things. I am paranoid and obsessive. This might make me a better nurse, or it just might make me a crazy person thinly disguised as a medical professional. Either way, I am probably the only person most people will ever meet who can make them feel safer just by smiling noncommittally as I wipe their ass.
Three days off after that shift. My kid sister moves in this evening, and will probably absorb most of my time for a couple of days.
Thank you guys so much for the encouraging messages and stuff. I get really shy sometimes when people praise my writing and I have to sit in a quiet place and squeak and drink tea, and eventually I muster up enough resistance to reply en masse while turning red and occasionally pausing to mash my hands against my mouth. You are all way too nice to me.
Used to be, as soon as you started acting like you might pull something out, you got your wrists strapped down with restraints. These days, we pay a lot more attention to delirium, and restraints dramatically increase both the incidence and severity of delirium. The night nurse who cared for her while I was sleeping is a damn good one and I trust him, so when I saw the soft bracelets on her wrists I knew things had gone to shit.
She’d pulled her PICC while making eye contact with him, holding his hand with her free hand, and saying that she felt pretty good. Grab and rip. After this she pulled two peripheral IVs, removed her oxygen a dozen times, and tried to pull out her foley catheter. The night nurse felt that restraints were the only way to keep her IV access in, so he sat beside her for the rest of the night, talking to her to keep her from going completely crazy.
Sunlight is the usual cure for this kind of delirium, which is so common we call it “sundowning” and expect it with certain age groups. Once the sun comes up, you can usually transition the pt from wrist restraints to puffy mittens, then open the fingertip part of the mittens, and finally free their hands entirely. Sometimes it’s even quicker than that.
Delirium is very different from dementia. Often, severe acute illness will combine with other factors like dehydration, sleep deprivation, and unfamiliar medications to make a patient forget where they are and what day it is, possibly even thinking they’re in a different country or it’s 1970 or that I’m a Nazi captor in a WWII prison. (This is depressingly common in older folks from Europe, many of whom were terrified as children that they would be captured and tortured by enemies of war.) We call that confusion, initially, but if confusion has an acute onset (they aren’t like this at home), the pt can’t focus long enough to follow a brief set of instructions (“I’m going to spell a few words, and I want you to squeeze my hand whenever I say ‘A’.”), and they can’t get their bearings enough to answer simple questions (“Will a stone float on water?”), they’ve moved past mere confusion and are delirious.
In a state of delirium, a pt is likely to hurt themselves—falling, pulling out tubes, etc—and is at very high risk of having weird delusions and hallucinations. These are a big deal because, in the delirious state, your mind can’t really differentiate between reality and the bizarre ideas that come with confusion and delirium, and it processes these as if they’re fact. You can end up having intense, vivid PTSD flashbacks to things like being smothered by aliens, raped and tortured by Nazis, shoved into a box and left there for hours, and burned alive—even though none of these things actually happened. The flashbacks and mental fuckery can last for literal years afterward. People who become delirious in the ICU generally have cognitive issues for a long time after discharge. (We see this a lot in re-admits, who aren’t quite themselves when they leave and return a month later completely whacked out.)
Perhaps most immediately worrying, delirium can disguise other major signs of danger, like altered level of consciousness, pain, and feelings of impending doom.
So I progressed her pretty quickly from restraints to mittens to open mittens. Too quickly—she pulled out one of her IVs. She has another, though, so I stopped the bleeding and let it rest. I feel like her mental status is one of the most vulnerable aspects of her health right now, and it would be awful if she (an independent woman who teaches music) ended up in a nursing home when she leaves here.
Anyway, as the shift progressed her lethargy continued, and she had trouble articulating almost anything she said. Head CT from yesterday was totally clean, neuro checks negative except for lethargy and verbal difficulty, blood sugar and hematocrit stable, abdomen stable, and finally we just settled in to “watch and wait.” I asked her son if she wears glasses, because although she claimed not to, she also didn’t know what state she lived in… Son brought in glasses and a novel she’d been reading, and a little later in the afternoon she came around just fine.
Still a little worried about her. Drowsiness after a splenic rupture is usually a sign that the pt is about to take a turn for the worse. But she had plenty of time to make that turn, and instead finished up my shift with a quick trip to the bedside commode and a bit of worrying-aloud about whether she would be able to get up the stairs at home. (She will be strong enough to get up the stairs by the time we send her home-- physical therapy opens almost every intial interview with, believe this or not: "Do you have stairs in your house?" This is a goon joke.)
As for my pt with the GI bleed, she was quite thoroughly recovered. She was downgraded to medical status halfway through the day, and after a bit of consultation with the blood bank, the doctor decided to go ahead and top her off with the last unit of matching, prewashed blood they had on hand, then send her home in the morning. Her family came in to visit during the afternoon, and her kids were so excited to see her that they literally jumped up and down, in place, for almost thirty minutes. One of them would settle down, and the other would kind of chill out, and then the first one would start bouncing again, and pretty soon they'd just be hopping in place, talking three hundred mph in their weird little shrieking voices. Kids are basically insects, is what I'm saying.
At three, afternoon shift change time, I traded out-- GI bleed passed off to a nurse with a group of other medical/telemetry overflow pts, new pt picked up. This guy was still critical care status, having been extubated around 1030, and he had a very distinct set of challenges to present me.
He is a developmentally delayed man, about forty, mentality between six and eight years old. Very polite-- turned his face and covered his mouth when he coughed, waved at everyone-- but easily frustrated and, for obvious reasons, very stressed out. He had been at his adult family home, eaten a bunch of dinner, aspirated it somehow, and gone into respiratory-cardiac arrest. 911, CPR, intubation, bronchoscopy with washout, extubation the next day. Really good outcome, no neuro deficit from baseline.
His lungs were still pouring sputum in response to the dinner invasion. Listening to his chest was like sticking your stethoscope into a washing machine full of shoes. Every few minutes he would cough up huge rippling mountains of sputum, which he had a very hard time managing and would suck back down his windpipe maybe one out of three times, causing another coughing fit. He did NOT like having the suction catheter in his mouth. He also wanted dinner, and some soda, and the speech therapist unsurprisingly made him strict NPO (nil per os, aka nothing by mouth) because he genuinely couldn't swallow his own spit without choking.
He'll probably get that functionality back, to a degree, but we still have to assess what made him aspirate in the first place.
In the short term, I got a packet of honey from the condiment drawer, smeared a trace of it on the suction cath (also called a yankauer, a plastic wand for sucking things out of the mouth and upper throat), and offered it to him as a "honey straw." He loved it. There wasn't enough honey to cause any trouble, and honey doesn't come off easily, so I wasn't worried about choking... and it encouraged him to keep it in his mouth almost constantly, coughing up crap and immediately jamming the "honey straw" back in his mouth. I refreshed it every hour or so and he cleared his airway wonderfully the whole time.
The real challenge came from his severe chronic constipation. An abdominal CT performed yesterday on admit, for his hugely distended belly, revealed that his colon was PACKED with shit. Cecum to rectum, dilated to a terrifying degree, crammed full of poop that hadn't seen the light of day in months. They loaded him with a truly amazing volume of bowel meds, and the night before he had started out with a few semi-liquid stools-- the kind of thing that manages to seep through the shit tunnel gridlock and keep you from backing up so hard that you die.
And he was backed WAY up. He kept burping and it smelled distinctly of shit. His OG tube, pulled out with the breathing tube when he was extubated, had been pulling something that the doc initially worried about because it looked a little like coffee grounds (a sign of gastric bleeding)... but which, when the OG tube came out, was pretty clearly just backed-up shit. Shit from his STOMACH. That is not supposed to happen and is a very bad sign.
Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets.
As I sloshed through that cleanup, trying not to breathe more than strictly necessary, I realized that this shit had been inside him for one hell of a long time. The smell had that intense death-rot odor you get when you've been hoarding that particular nugget for quite a while. That corn wasn't last week's veggie side at the cafeteria, dude. I bet you a dollar he gnawed that shit off the cob at his grandma's house for Christmas.
The fecal journey continued with inspiring diversity. One delicately-jointed, bubble-textured oblong came out looking like a Baby Ruth bar. One delivery was thick and slushy, but contained crumbly elements that glued themselves to everything they touched and pilled up like a hoodie in the dryer.
We attempted to get him up to the bedside commode at one point, hoping to catch the bounty in a bucket rather than the bed, but as he prepared to sit down he suddenly decided that there was a better potty out in the hall somewhere, and took off running with his gown flapping behind him. Two steps into his flight, his sphincter lost control. Spatters and ribbons festooned the tile in a pseudo-Farsi calligraphic scrawl. The CNA and I caught him before he could open the room door; she guided him by the shoulders back to his plastic throne, and I cupped my hands under a washcloth to form a towel-cup that I clamped to his backside, catching the steaming runoff to prevent any more modern art.
After a while, he exhausted himself on the bucket, and we got him back into bed. Five minutes after that he had another coughing fit and ripped a gargantuan chunky fart right into his disposable bed-liner. I heard the expulsion lap up against his thighs like the bubbles popping in a pot of boiling oatmeal. The pulmonologist came up to ask me a question and started coughing at the smell.
Some days are just like this. I passed that guy off to night shift with sincere condolences and warnings.
It occurs to me that I would not want to eat anything honey-flavored while in the room with a smell like that. But this pt happily smacked away on his "honey straw" even while his gut was blasting out everything he'd eaten this year, not so much as blinking. You know what? Whatever makes him happy. That's what.
The only real upside is that, being developmentally delayed, he could be convinced that this shit was hilarious, and wasn't really offended when we acknowledged that his shit stank. Some people get really upset if you don't manage to keep a straight face as you clean up their poop; some people just get incredibly embarrassed and feel horrible, and my heart goes out to those people, because I can't take a dump if anyone in the building knows I'm taking a dump and I would rather pretend at all times that I don't actually have bowel movements. (This is probably a leftover of my upbringing somehow, but I don't care to examine it too closely.)
You just gotta be really good at keeping your poker face strapped on. Gross wound? Learn to smile through it. Gallons of liquid shit? Reassure the pt that you've seen so much worse. (You have.) Crusty vadge plopping out cheese curds the size of thumb joints while you're trying to scrub the area for a catheter? Keep your face pleasantly neutral and talk about something else.
This job is allllll about winning people's confidence. It's much harder to care for someone whose guard is up, who distrusts you, or who feels awkward when you walk into the room. If they can relax and feel comfortable, if they can trust you, they have a much better experience and will tolerate a lot more of the pain and indignity that comes with a hospital stay, knowing that you're not doing this shit for fun either and that you won't judge them for anything that happens.
A particularly weird aspect of this is the importance of not reacting to anything with shock, panic, or visible distress. Like if you stub your toe and they see you wince and hop around, they're going to be wondering: is she gonna hurt me by accident too? Is she really in control of the situation? Can she be distracted at a critical moment, and possibly let me die because she just jammed her thumb in a drawer? These aren't conscious assessments, they're just part of the natural human reaction to being powerless and needing a team member you can trust. So one of the reflexes I've cultivated as a nurse is keeping a straight face when I bang my elbow, stub my toe, or otherwise remind myself that my body is pretty vulnerable and these hospital rooms are fucking crowded. If I drop something on my foot, I'm gonna politely excuse myself to another room before I descend into hissing and cursing.
I don't want my pts to ever feel like they have to comfort or protect me. I don't want to seem physically or professionally vulnerable to a person whose life may depend on my capability and strength. I want questions to be surface-level, where I can encourage my pts to articulate them and have them answered. I want to avoid situations in which my pts have to assess the situation without full access to relevant information, which means that even if my toe-stubbing happens because I'm focused on their cardiac output, I don't expect them to be able to explain my priorities of attention to themselves and decide that I must have been looking at something more important.
I am probably a fucking nutjob. I overthink things. I am paranoid and obsessive. This might make me a better nurse, or it just might make me a crazy person thinly disguised as a medical professional. Either way, I am probably the only person most people will ever meet who can make them feel safer just by smiling noncommittally as I wipe their ass.
Three days off after that shift. My kid sister moves in this evening, and will probably absorb most of my time for a couple of days.
Thank you guys so much for the encouraging messages and stuff. I get really shy sometimes when people praise my writing and I have to sit in a quiet place and squeak and drink tea, and eventually I muster up enough resistance to reply en masse while turning red and occasionally pausing to mash my hands against my mouth. You are all way too nice to me.
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