Dix, Hamm, and Pulmonary Fibrosis

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

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

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

The cure for pulmonary fibrosis is a lung transplant.

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

Whitney the Muslim

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

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

Anyway.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I am glad for him. He earned his rest.

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

Week 8 Shift 3

Day two with Maycee. Somehow she survived her first shift and is back for more, and even looked a little energetic during shift change, which was downright irritating for me because I hadn’t had any coffee yet and felt like a lake of lukewarm shit. Fortunately our unit has free (terrible) coffee in a truck-stop-style machine in the supply rooms, so I was able to get my smack-and-wince dose of caffeine before my ability to feign personhood ran out.

I wasn’t always such a complete caffeine junkie. On nights I rarely ever drank coffee because it fucked up my sleep schedule so badly. Nowadays I can’t get through the morning without my usual half-cup mixed with a stolen mini carton of milk, and I drink the second half-cup cold and kind of stale-milk-tasting later in the afternoon. It’s not much caffeine, but I can’t do without it.

This disturbs me.

Maycee was drinking some sort of sentient green morass out of a Nalgene bottle. It smelled like algae and pineapple. It’s probably some healthy superfood thing I should be drinking instead of a paper cup of two percent and bean tar.

We took report from that one nurse again, the one with the propofol tubing fetish. He was still bitching about the damn tubing. I mean, I have been taken to task by some nurses for stupid things, but by this point I was a little embarrassed for him, especially since the pt we were taking back had been down to almost no levophed at all when we passed him off and now he was cranked up to a stupendous dose, his urine output had been trending downward for three hours with no MD notification, and he looked sweaty and shitty and filthy because apparently that bed bath he’d tried to trick Maycee into was the only bath he got all night.

Night shift nurses do the official bed baths, especially on vented pts. Whatever. I used to be a night nurse and I still have a Thing about my pts being clean. We opened up our shift with a stiff, polite nod to the departing nurse and then a proper bed bath for the pt.

We only had the one this time. Thank goodness—I planned to have Maycee assume all of his care today, and that would be completely impossible if we were running back and forth between pts all day. The neighbor, the humongous guy with diarrhea who was (also) wrongfully intubated, is still doing his thing and I still got to run in every twelve seconds and fix his IV so he could keep getting his sedatives, but we were able to focus mostly on the liver failure/sepsis pt and his increasing needs.

He was not getting at all better, but then again he wasn’t doing anything flashy either. He had high gastric volumes (amount of stomach juice that wasn't moving from stomach to intestine) so we couldn’t start tube feeds; he had lots of fluid in his abdomen so we ended up doing another paracentesis for another 6 liters. Since he weighed in at about 15 liters up this morning, in excess of his base weight, this was less impressive than I could have hoped… but there’s something deeply satisfying about watching all that gooey liquid pour into the suction canister, knowing that we’re cheating the body’s self-destructive excesses and recovering the balance.

A friend of mine observed this recently: a lot of what we do in the ICU is simply keeping your body from killing itself. Many of our natural processes are totally normal and productive at low levels: swelling is an important part of washing out infected or traumatized areas of the body, clotting keeps us from bleeding out, fevers fight infection… but at a critical level of acuity, those same processes become a potential death sentence. Inflammation crushes our bodies, deforms our tissues, drains the liquid from our blood; clots occlude our arteries and contribute to adhesions and use up our platelets where they aren’t needed; fevers cook our brains and organs like gently poached eggs.

Past that threshold, the body can’t heal itself effectively. It’s a last-ditch effort, a forlorn hope: maybe another half a degree will stop the bacteria, and we can rebuild the damage later, maybe, or live without the ruined parts. Maybe a little more swelling will give us the edge against the infection, and maybe we can catch up on blood volume later. Maybe this clot will be the one that heals the damage.

If this one doesn’t work, we die anyway.

But then here comes modern medicine with its antibiotics and other weapons of microbial mass destruction, ready to save the day, if only we can get the body to stand aside and let us do the work. Septicemia? Sure, we have an antibiotic for that—one bug, one drug. Maybe two or three, if we can’t figure out which thing we’re fighting.

But while the vancomycin and piperacillin and ceftriaxone are working perfectly well and the invaders are in fast retreat, the body is still fighting as if it’s alone on the field. So we give drug after drug to support the body through its berkserk phase: liters of fluid to replace losses, pressors to keep the fluid where it belongs, blood-thickening albumin to draw the swelling back in, diuretics to pee it off; steroids to interrupt the cascade of inflammation, blood to counter the dilution and make up for the body’s deficit while it focuses on white blood cells instead of red. Heparin to keep the immobile body from clotting. Bicarb to counteract the acid produced by stressed cells.  Mechanical ventilation to keep the swollen lungs functional and increase available oxygen. Proton pump inhibitors to prevent ulcers and acid reflux while the body is stressed and ventilated. Chlorhexadine mouthwash to keep other germs from crawling down the breathing tube.

It’s insane. If we can naturally produce the antibiotics we need as soon as the germs invade, antibodies with the right markers to identify their enemies immediately instead of mounting a full septic assault, we don’t need any of the other drugs. If we can interrupt the sepsis early, before the inflammation gets out of control and the body’s organs are dying from low blood pressure, we don’t need the ever-increasing volumes of supporting drugs to deal with the consequences of sepsis. And if our bodies can’t control the infection and our doctors can’t keep our bodies in check, we die.

Nothing in nature prepared us to survive things like this. When we save someone in deep sepsis, we are fighting more than germs, more than poisons: we are fighting human history, evolutionary pressure, nature itself.

I have no problem with this. Nature is a bitch. Tumors are natural; epidemics are natural. I am perfectly comfortable fighting nature, as long as we remember that the battle is fought on many fronts and that winning the battle with sepsis doesn’t always mean winning the battle against organ failure, old age, lingering infirmity, and pain. So yes, absolutely, I will fight nature bare-fisted and without shame—but I know better than to gloat over my victories.

All this makes it very hard, emotionally, to care for pts who are doomed. This poor guy never wanted to suffer like we’re making him suffer: he wanted four days, max, on the ventilator, and here we are punching holes in his belly so his weeping, failing liver can get some relief, days beyond his deadline. It’s fucked up and awful and out of my hands. It’s a very American way to die.

Fortunately the ethics committee is involved in this one, and we’re hoping for permission to withdraw pretty soon. Until then, you had better fucking believe I’m blasting him with fentanyl. If he’s got to stick around for this shit, he’s gonna be oped up to the eyelashes the whole time.

Maycee performed most of his care today. I helped with turns and assisted whenever asked, but I let her try things out, make mistakes, and zero out her pressure lines by herself. She did wonderfully, and between chores we exchanged war stories of hospital life.

Having worked on the telemetry unit until now, Maycee’s patient loads have been three and four pts to a nurse, and none of her pts are sedated or on titratable drips. She also worked nights, which means she got to see pts at their weirdest and most whacked-out—a thing I kinda miss, now that I’m days.

She described a group of three sundowning pts whose rooms were unfortunately close to one another, all of whom spent all night yelling at each other. One was a tiny old lady who constantly demanded: “Who’s there? Who’s there?” Another was a little old lady who cursed and screamed for “them” to leave her alone. The third was a developmentally delayed man in his forties who called out for help with almost every breath he took. Two could be redirected temporarily with a bit of soothing company, but the paranoid old lady got worse every time someone came into the room, and the other two responded to her bellowing with a litany of responses: Who’s there? Help! Who’s there? Help me!

All night they kept this up. If one of them fell asleep, the others would wake them back up. Closing the doors increased the screaming—a lot of delirious pts are terrified of being enclosed. Maycee related the charge nurse’s ongoing battle with Bed Control and the shift administrator, as all three pts needed to be close to a nurse station for observation, and breaking them up would involve transferring at least one of them to another floor. Finally the shift admin dropped by to have a face-to-face chat with the charge, observed the noise firsthand, and had transfer orders for two of the three within thirty minutes.

I laughed my ass off, naturally. We’ve all had nights like this, and we’ve all begged distant, uncomprehending administrators for mercy the way prisoners wish upon stars. Any story where someone doesn’t believe a nurse until they see for themselves is a relatable story; any story where the unbeliever is driven mad, splattered with body fluids, or chewed out for their disbelief is a great story. We are nothing if not predictable.

Well. Maybe we’re also bloodthirsty and petty. But we’re predictably bloodthirsty and petty.

I told her about a pt I had in Texas, a woman whose panniculus obscured her legs down to the knee, whose labia majora were distended with edema and obesity to the point that they looked like sagitally aligned panniculi on their own, and whose foley catheter placement was an effort of legend. We used a hammock-style bedsheet hoist to restrain her panniculus and lift it toward the top of the bed—a sheet folded lengthwise, tucked under the hanging gut, threaded through the bed rails on either side and pulled back to achieve a primitive pulley effect.

She had been an uncontrolled diabetic, as I recall, and had a raging raw yeast infection downstairs. I felt fucking terrible for her—she had not been taken care of at all, and was well past the point where she could take care of herself. As we struggled to hold her labia back, she sobbed and hissed with each pressure of a glove against her bleeding, excoriated skin. I had one coworker holding each labe, and I was wearing long gloves and squinting at the bloody, curdled mess of her vaginal vestibule, searching for her urethral meatus—

When one of the coworkers started to lose her grip. “Get out,” she barked, understandably not wanting to grapple with that incredibly painful stretch of skin for a better hold; I got my arm out of the way just in time, as did the other coworker, and the two labia slapped together the way you might clap dust out of a couple of rugs. It sounded like somebody had dropped a fresh brisket on the linoleum. Yeasty effluvium launched from between the folds like taffy thrown from a parade float. All three of us caught a little bit of the splash; I was spackled from my right elbow all the way up to my left ear.

And man, what do you do with something like that? I mean, you can’t really laugh that shit off until you’ve had a chlorhexidine shower and a glass of gin. You sure as fuck can’t freak out and gag and cry and curse, because your pt is right there and no matter how gnarly her vagina is you don’t want to be the dick humiliating a sick woman for being half-eaten by yeast. You can’t even really process it. You assess the damage—did any of it get on my mucus membranes? Do I need to control any secondary drippage? Will I need to get some fresh sterile gloves?—and if you’re not in immediate danger, you just take a deep breath and get back at it.

I do remember reassuring her that I would get her a topical treatment to help with the pain and itching, and that she was extremely relieved once the foley was in and she wasn’t trickling hot urine over her raw, infected skin.

She actually ended up doing pretty well, as I recall. She came back to the MICU three weeks later after a panniculectomy and double knee replacement, and was able to walk a few steps on her second post-op day. I hope that gave her a chance to turn her life around.

After our second-to-last turn, I was tapped to watch a pt down the hall while his sitter was on break. Fifteen minutes of watching a little old guy scratch his balls and ask whose garage he was sitting in? Sweet. We had a great conversation about carburetors, mostly consisting of me having no idea what the fuck a carburetor does and him explaining it to me four times without making much sense, and then he looked me in the eye, lifted his wrist to his mouth to cover a yawn, and pulled out his IV with his teeth. Blood went everywhere. I stanched the flood, paged IV team, and apologized to his nurse for my utter failure as a sitter.

Turned out this was his fourth IV that day. I hadn’t known, when I started sitting him, that his IVs were supposed to be wrapped in an obscuring bandage at all times, and apparently while the sitter was handing off to me he’d unwrapped his line and thrown the bandage on the floor all sneaky-like. Some pts are crafty lil fuckers, I don’t care how confused they are. It’s kind of impressive, really. I don’t know if I could come up with a plan that effective, and I’m not even tripping Haldol-pickled balls on the ICU.

Toward the end of the shift, the abd guy started having a lot of trouble. He had gone down for surgical placement of a tracheostomy and PEG, and I guess he’d been fine for most of the day. During the PEG placement, it seemed, they had insufflated his abdomen—pumped it full of air to allow free movement—and the leftover air was causing pressure issues. He ended up having what I can only describe as an abdominal needle decompression, the way you decompress a tension pneumothorax, and the catheter in his belly farted as they rolled him back and forth to work out all the air.

He nearly coded, apparently. I have never seen anybody react that harshly to insufflation. It’s not like they leave you all blown up. I guess he was just hoarding air—his abdomen is probably a maze of adhesions and scar-pockets by now. Once they decompressed him he was perfectly fine, and even came to enough to open his eyes and move his mouth in voiceless ba ba ba syllables, singing to the ceiling.

Today they started talking to rehab facilities to see if we can get him a bed with Kindred or one of the other long-term care places.

We wrapped up the shift without any more remarkable occurrences, and after running over the day’s events with Maycee, I signed off as her preceptor and gave her full marks for work well done. She will work with a couple other nurses before they start giving her pts of her own. I look forward to seeing how she grows as a nurse. She’s pretty cool.

Regarding the story I mentioned last time, the man and his mother and the cats: I honestly didn’t think this blog would be popular at all outside of the people who already read my forum posts, and they already know that story. I might post it here at some point this weekend, but I want to give a couple of disclaimers:

--It’s definitely the worst thing I’ve ever experienced as a nurse, and hopefully the worst thing I ever will. It’s not the kind of cool story you want to gross your friends out with; I still find it distressing and disturbing and almost sacred in its awfulness, like retelling it is some kind of violation. But I also know that it’s a real thing that happened, and that storytelling is one of the ways we give awful things meaning beyond tragedy, and that some of the things we should fear most are simply hidden from us because they’re too awful to discuss. So I might post it anyway.

--I will definitely have to figure out how to hide it behind a read-more link first.

Week 2 Shift 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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