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.
Showing posts with label liver failure. Show all posts
Showing posts with label liver failure. Show all posts
Friday, July 17, 2015
Thursday, July 16, 2015
Week 3 Shift 3
Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Wednesday, July 15, 2015
Liver Failure 101, or How That One Family Member Will Actually Die
Why do alcoholics bleed to death?
In order to explain this, I'm gonna have to get a little pathophysiological, as I promised in an earlier post.
Most chronic alcoholics die shitting or vomiting blood. It seems like a weird connection, especially if (like most people in a non-medical arena) you're not totally clear on what the liver does exactly. Something to do with poisons, right?
Well, yeah, but not just poison. A lot of things come into your body through your mouth, and you can feel free to insert your own dick jokes here, in much the same way that you insert dicks into your mouth. That shit ranges from "inadvisable and kind of sweaty-tasting" to "straight-up block of pesticides" and your stomach and intestines give no shits about this. If you swallow a mouthful of jizz, as far as your stomach is concerned, you just had a teaspoon or two of protein supplement, and your pancreas will happily bathe it in flesh-dissolving enzymes so your intestinal bacteria can chew it up and shit it all over the absorptive walls of your intestines. Directly outside of those gut walls, blood vessels happily pump away the acid-bathed, pancreas-liquefied, bacteria-digested jizz protein for your body to make into more of itself.
Hold the fucking phone, you say. That jizz was probably nontoxic, but what about the other nasty things we eat every day without realizing it? The 2.5 spiders you swallow in your sleep every night-- where does their venom go? That waxy shit on the outside of cucumbers that tastes like Raid? The shampoo you got in your mouth last time you showered? (I know I'm not the only person who has this problem.)
And worse, even if you assume that the intestinal walls have some pretty strong filtration powers to separate the shit from the food, what happens when you get horrific diarrhea and your insides get raw? What if you eat too much corn and you scrape up your gut? What if you have hemorrhoids and your body is constantly insisting that you have to squeeze fist-sized turds directly over the open wound that your asshole has become? Oh my god, you are going to have shit blood poisoning and die.
So here's the trick: your body has two separate blood-circulating systems. One of them is systemic, and full of delicious clean blood with lots of carefully sterilized proteins and freely-available sugars floating happily through it, ready to feed your heart and brain and other assorted bits without subjecting them to anything gross at all. The other is intestinal, and it's a fucking junkyard of sloppy proteins that still look a little like the sperm you chugged to begin with, plus all the other poisonous chemicals you've splashed in your mouth recently, plus all the perfectly natural nitrogen waste that comes with living and is incredibly disruptive to brain activity, plus any traces of shit that are scraping their way into your bulging assgrapes. Fortunately, this complete wasteland of trash is outfitted with a couple of critical defenses.
First, you have tons of lymphatic drainage in your intestines. I'll cover the lymph system later sometime, but it's like an alternate circulatory system, a set of loose-mouthed leaky veins that pick up extra water and trash and scour it with macrophages that live in the nodes.
Second, the intestinal system is on a closed circuit that only returns to the rest of the body through, you guessed it, the liver. Inside the liver, the jizz proteins are reduced and converted to more usable proteins; chemicals are scrubbed and pumped back into the shit chute for dumping. The hepatic portal (literally the "liver door") refers to the tiny straw-like filters through which all your blood has to squeeze on its way in and out of the intestinal circuit. All of your blood goes through here, and the pressure gets pretty high.
Alcohol and other liver toxins scar up these tubes and make them stiff and tight, forcing your blood to squeeze through smaller and smaller spaces. Healthy liver tubes are flexible and have a little bit of give; scarred tubes are about as flexible as particleboard. Cirrhosis-- liver scarring-- results in portal hypertension, or excessive pressure on either side of the liver-door. On the systemic side of the door, backed-up blood bloats into hemorrhoids in the esophagus, which eventually burst and bleed, often catastrophically. On the intestinal side, so much blood builds up that the extra fluid is forced to ooze out into the abdominal cavity, forming that stretched-out, water-filled liver-failure belly you see in liver pts and chronic alcoholics. This is in addition to similar ready-to-pop situations in your intestines, which can blow out at any time.
Adding insult to injury, the liver takes all these proteins and food particles and makes all your blood clotting factors out of them. A failing liver, or one continually taxed by alcohol or tylenol/paracetamol, is too busy struggling to filter and repair to be effective at making clotting factors. And, being in a prime position to monitor your nutrition status, your liver has control of your body's access to its food stores-- control that's mediated largely through proteins.
The thing about proteins is that they're basically specialized wrenches, low-tech thing-grabbers designed to grab the thing they're made to grab and move it however it needs to be moved. They CAN be broken down for energy, but they're terrible energy sources, and the more protein your body has, the more wrenches it can build. And what builds your wrenches? Yeah, it's totally your liver.
And while you probably know about platelets, and with a little brain-poking you can probably figure out that those are blood cells and come from inside your bones, you should also know that platelets don't do much more than grab broken areas and then group-hug. They really aren't a fix for a torn blood vessel. Fortunately, once they're group-hugging your wound, they can secrete chemicals that activate the wrenches around them-- things like fibrin, which helps you heal and build scar tissue, and which forms the bulk of a dry scab.
Platelets by themselves don't last all that long and can't make a decent scab. But if they have the tools, they can build huge structures to protect your blood from wandering off. And what are these hammers and wrenches?
Proteins.
And what makes your proteins?
Yeah, you get the idea.
So if you start bleeding and your liver is shot to shit, good luck. Your body is going to forget how to clot very quickly. And that is why alcoholics die bleeding from the throat.
In order to explain this, I'm gonna have to get a little pathophysiological, as I promised in an earlier post.
Most chronic alcoholics die shitting or vomiting blood. It seems like a weird connection, especially if (like most people in a non-medical arena) you're not totally clear on what the liver does exactly. Something to do with poisons, right?
Well, yeah, but not just poison. A lot of things come into your body through your mouth, and you can feel free to insert your own dick jokes here, in much the same way that you insert dicks into your mouth. That shit ranges from "inadvisable and kind of sweaty-tasting" to "straight-up block of pesticides" and your stomach and intestines give no shits about this. If you swallow a mouthful of jizz, as far as your stomach is concerned, you just had a teaspoon or two of protein supplement, and your pancreas will happily bathe it in flesh-dissolving enzymes so your intestinal bacteria can chew it up and shit it all over the absorptive walls of your intestines. Directly outside of those gut walls, blood vessels happily pump away the acid-bathed, pancreas-liquefied, bacteria-digested jizz protein for your body to make into more of itself.
Hold the fucking phone, you say. That jizz was probably nontoxic, but what about the other nasty things we eat every day without realizing it? The 2.5 spiders you swallow in your sleep every night-- where does their venom go? That waxy shit on the outside of cucumbers that tastes like Raid? The shampoo you got in your mouth last time you showered? (I know I'm not the only person who has this problem.)
And worse, even if you assume that the intestinal walls have some pretty strong filtration powers to separate the shit from the food, what happens when you get horrific diarrhea and your insides get raw? What if you eat too much corn and you scrape up your gut? What if you have hemorrhoids and your body is constantly insisting that you have to squeeze fist-sized turds directly over the open wound that your asshole has become? Oh my god, you are going to have shit blood poisoning and die.
So here's the trick: your body has two separate blood-circulating systems. One of them is systemic, and full of delicious clean blood with lots of carefully sterilized proteins and freely-available sugars floating happily through it, ready to feed your heart and brain and other assorted bits without subjecting them to anything gross at all. The other is intestinal, and it's a fucking junkyard of sloppy proteins that still look a little like the sperm you chugged to begin with, plus all the other poisonous chemicals you've splashed in your mouth recently, plus all the perfectly natural nitrogen waste that comes with living and is incredibly disruptive to brain activity, plus any traces of shit that are scraping their way into your bulging assgrapes. Fortunately, this complete wasteland of trash is outfitted with a couple of critical defenses.
First, you have tons of lymphatic drainage in your intestines. I'll cover the lymph system later sometime, but it's like an alternate circulatory system, a set of loose-mouthed leaky veins that pick up extra water and trash and scour it with macrophages that live in the nodes.
Second, the intestinal system is on a closed circuit that only returns to the rest of the body through, you guessed it, the liver. Inside the liver, the jizz proteins are reduced and converted to more usable proteins; chemicals are scrubbed and pumped back into the shit chute for dumping. The hepatic portal (literally the "liver door") refers to the tiny straw-like filters through which all your blood has to squeeze on its way in and out of the intestinal circuit. All of your blood goes through here, and the pressure gets pretty high.
Alcohol and other liver toxins scar up these tubes and make them stiff and tight, forcing your blood to squeeze through smaller and smaller spaces. Healthy liver tubes are flexible and have a little bit of give; scarred tubes are about as flexible as particleboard. Cirrhosis-- liver scarring-- results in portal hypertension, or excessive pressure on either side of the liver-door. On the systemic side of the door, backed-up blood bloats into hemorrhoids in the esophagus, which eventually burst and bleed, often catastrophically. On the intestinal side, so much blood builds up that the extra fluid is forced to ooze out into the abdominal cavity, forming that stretched-out, water-filled liver-failure belly you see in liver pts and chronic alcoholics. This is in addition to similar ready-to-pop situations in your intestines, which can blow out at any time.
Adding insult to injury, the liver takes all these proteins and food particles and makes all your blood clotting factors out of them. A failing liver, or one continually taxed by alcohol or tylenol/paracetamol, is too busy struggling to filter and repair to be effective at making clotting factors. And, being in a prime position to monitor your nutrition status, your liver has control of your body's access to its food stores-- control that's mediated largely through proteins.
The thing about proteins is that they're basically specialized wrenches, low-tech thing-grabbers designed to grab the thing they're made to grab and move it however it needs to be moved. They CAN be broken down for energy, but they're terrible energy sources, and the more protein your body has, the more wrenches it can build. And what builds your wrenches? Yeah, it's totally your liver.
And while you probably know about platelets, and with a little brain-poking you can probably figure out that those are blood cells and come from inside your bones, you should also know that platelets don't do much more than grab broken areas and then group-hug. They really aren't a fix for a torn blood vessel. Fortunately, once they're group-hugging your wound, they can secrete chemicals that activate the wrenches around them-- things like fibrin, which helps you heal and build scar tissue, and which forms the bulk of a dry scab.
Platelets by themselves don't last all that long and can't make a decent scab. But if they have the tools, they can build huge structures to protect your blood from wandering off. And what are these hammers and wrenches?
Proteins.
And what makes your proteins?
Yeah, you get the idea.
So if you start bleeding and your liver is shot to shit, good luck. Your body is going to forget how to clot very quickly. And that is why alcoholics die bleeding from the throat.
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