Crowbarrens, chest tubes, and death on the ICU

People die on the ICU.

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

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

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

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

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

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

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

A young stroke pt, a bit of fetal physiology, and some pettiness on my part

I genuinely wasn’t prepared for the popularity of this blog, or for some of the sequelae that followed it. I thought a few people might read it, get a chuckle, and glide on by. So I wrote like the blog would be gone in a month, a forgotten vanity, an echo chamber for my rambling thoughts.

Instead, you liked it. Which is alien and bizarre to me, like discovering that other people really do like the smell of your farts. Are you guys… okay?

Anyway, a lot of things happened while I was on hiatus.

I launched my kid sister at the end of the summer. It was not easy and I spent virtually all my downtime helping her fill out paperwork, set up and attend interviews, and move into her own tiny room in a house where girls rent rooms to sleep in between classes. She has a job now, and passed her GED. I am so proud.

Also, I am so glad that I can flop on my sofa in my underwear when I get home from a shift.

Aside from all that, I also went to Yellowstone for five days because I was losing my mind and my first response to stress is to go camping, and I went to a cheese festival and got constipated and drunk, and I had a shitty run-in with a pt family who heard only what they wanted to hear and reported to my manager that I had lied to them. Fortunately, my manager knows that I am a thousand percent more likely to overshare than I am to conceal, and has been my facebook friend long enough to know that withholding information about medications is not something I am physically capable of doing.

Week 5 Shift 3

Day three with Tiberius. I showed up at work a little early, caught up with the night nurse, then headed to the charge nurse station and insisted that he MUST be made 1:1. They asked if I could take a telemetry overflow admit on the side, and I gently but firmly reminded them that I regularly balance absolutely unreal workloads and am very good at handling high-acuity spreads, and that the last time I insisted on a 1:1 the guy ended up with an open abdomen that afternoon. I got Tiberius 1:1.

Which is a good thing. His sedation was cranked way the hell up, which was appropriate-- even his breathing impulse was completely knocked out on 250mcg of fentanyl per hour + precedex at an obscenely high dosage (got an MD order to double the hourly dosage if necessary, rounded out about 150% of the normal max). And yet he was still waking up from time to time, glaring rings of white around his irises, the expression of puzzled horror that comes with sudden sharp agony. I've had my share of dental work done-- consequences of growing up without owning a toothbrush-- and I recognize the expression well enough, although I'm sure nothing that's happened to my mouth even comes close to the torture of two chest tubes, a partially-closed thoracotomy, a pneumonectomy, and multiple bronchoscopies per day. I dosed him with fentanyl until his blood pressure bombed, and his pressure was still labile for the rest of the morning, dumping whenever he dozed off and soaring whenever he awakened to stabbing pain.

The intensivists had switched out; Dr Sunny was covering him today, and I pitched my case for a new sedative. Given that he was still periodically vomiting, even though we weren't giving him anything by mouth/feeding tube except for a few ground-up pills every day, I was slinging antiemetics at him left and right, and the night nurse had reported a significant prolongation of the QT interval-- the time it takes for the heart to recover from each beat. (The risk being that his heart would try to start the next beat before his ventricles were fully recovered, which could cause his ventricles to freak out and fibrillate, a deadly arrhythmia.) I did some crazy ECG analysis and research and determined that his T wave-- the marker of repolarization, or post-beat recovery-- wasn't prolonged, but he did have a U wave, which is not uncommon for a pt on amiodarone (an antiarrhythmic we were giving him to control atrial fibrillation). The U wave is an extra little bump after the big T bump (after the jagged QRS complex), and apparently it represents the post-beat recovery of the papillary muscles, the little muscle-fingers that anchor and pull your heartstrings to stabilize and open your heart valves. The night nurse had measured from the beginning of the QRS to the end of the U, which made for an incredibly prolonged QT interval, but after a little fishing around on the internet (hey, we google stuff all the time on the ICU!) I found that most cardiologists recommend a slightly different approach.

You measure from the beginning of Q to the end of U only if the U wave is conjoined to the T wave, obscuring the end of the T. If the line returns to its baseline before the U starts, you only measure to the end of the T. Measured this way, he had a perfectly normal QT interval, and I was able to hand Dr Sunny a spittle-flecked piece of paper covered in deranged scribbling and caliper scratch marks and walk away five minutes later with an order for propofol.

It worked beautifully. Thirty mcg/hr of propofol later and Tiberius was sleeping like a baby. 

His wife, Amanda*, was finally joined by a bunch of family from around the country. They have a pretty large family, with various health issues and other things delaying their travels, but the trickling-in of relatives became a steady influx. They are a delightful family, some of them members of a very conservative religion, but free with their affection and bright in their humor and generous with their love. I am not a religious person-- I have some deep and intense spiritual drives that are still bleeding where they were severed, and I still dream of something more satisfyingly divine than the mannequin-god behind the curtain of my milk-faith, but I also have some major bones to pick with organized religion-- but if I had to live in a church faith, I would want one that let me laugh and gossip and cry with my husband's sister and her wife, one that made his grandmother's travel-induced diarrhea an affectionate family joke instead of an unclean shame, one that gave me stories and hope and peace with either life or death, whatever pain or loss followed in its wake.

Good people. Dear people. I wish I could give them the miracle they're hoping for.

While all this was happening, there was a code blue in the ER, followed by a rapid transfer of the pt to the room two doors down, where the horrible family had been before. (They were moved last night because the workstation-computer-cart caught on fire, shortly after which the grandfather had another hypoglycemic episode because the family paused his tube feeds again while they were trying to turn him WHILE THE STAFF WERE TRYING TO EVACUATE THEM FROM THE ROOM. Security was called and the family was limited to one member in the room at a time, with a warning that whichever of them was present next time he had an episode would be banned from hospital grounds.)

This new pt was an older man with a medical-condition necklace on: heart failure, diabetes, etc. It didn't matter much to me, since I didn't get report on him and didn't have any part in his actual care. Except that, ten minutes after arrival, he coded again, and because I was close by I jumped in to help. There wasn't much to do, as everyone else had their hands on the code stations: med nurse, push nurse, chart nurse, resp therapist, and shock nurse. However, from the door I could see that the two-man rotation on chest compressions was having a hard time, mostly because the pt had nothing hard under his back and had to be compressed deeply into the bed to get enough smash to move his ventricles. So I dove in, spiderwebbed through the lines and tubes to the head of the bed, ripped off the CPR board, and shoved it under him at the next compression switch, put the bed on max inflate for a harder surface, and jumped in at the next round to be the third man in the compression chain. Three is a good number; otherwise your arms get really tired.

I am relatively new at this facility, and we are pretty good at preventing codes, which means that I haven't been in a full-bore code in a major role yet. I've carried flushes and even pushed meds, but codes are fast and wild and require strong communication, which means that I'm still at the stage where chest compressions are an appropriate role for me to fill-- a role I share with CNAs and even housekeeping staff in a pinch. I don't mind-- compressions are a workout, and good compressions can make all the difference.

However, this dude was completely fucked. Flash pulmonary edema filled his breathing tube with bubbling red at every compression. His heart wobbled through ventricular fibrillation with the kind of half-assed exhaustion that doesn't respond to shocks. Med after med failed to get a response; shocks and compressions were like rocks thrown down a well. In the hall, his family wailed and collapsed against the wall, and shouted for us to save him. A nurse from down the hall gently guarded the door to keep the more frantic family members from seeing the bloody wreck of a corpse that we were preparing to stop beating.

We called it after twenty minutes. His chest was the texture of new banana pudding, before the cookies have a chance to get soggy-- bone fragments scraping the sternum, muscle and fiber pounded to a pulp. 

CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest.

The family burst into the room, still screaming, still demanding that we bring him back. "Keep going," they said, "he's strong, he'll be fine."

The RT popped the ambu bag off his breathing tube, and blood flecked my left elbow where I stood, wringing the numbness from my fingers over his demolished chest. Someone had thrown a pillowcase over his genitals. His skin was the mottled color and temperature of cheap cotto salami. "Wake him up," his son shouted at me from the door.

Instead I leaned over him and closed his eyes. "I'm so sorry," I said. I don't think his son heard me over the post-code chatter in the room, but he fell silent and white. There's a finality to that gesture that speaks more to our sense of gone, lost, dead than any words or blood or broken bones. They retreated into the hallway and sobbed there until the chaplain ushered them away to a private room. I scrubbed my bloody elbow in the sink and slipped out among the other staff, back to Tiberius, back to smile and offer support to Amanda while she and her family told stories about his childhood.

That disconnect is like a ringing in the ears. Death is touch and go: it touches you, and you go. If you're the lucky asshole in scrubs, you go into a different room, and think about it later. If you're the unlucky asshole in the gown, you go where we all go, eventually.

Anyway, after that I insulted the living hell of out an RT by accident, calling her a "respiratory technician" instead of a "respiratory therapist." I actually am shit at terminology like that sometimes and I felt terrible, but I think she understood my ignorance. Any RTs reading this probably just bared their teeth at me a little. Sorry, dudes, I couldn't do a quarter of my job without you. My apologies for fucking with your fiO2.

After that, I spent the evening fine-tuning Tiberius. He needs another surgery, a repeat thoracotomy to finish closing the stump and properly close his back, which looks like fucking hell. Before we can do that, we need every possible advantage to keep him alive, which means crazy tuning up and blood pressure management and cardiac output optimization. I can't describe to you how boring this process is, or how riveting. It's a game; manipulating numbers, one up one down, tightening your margins and leaving wiggle room; it's also a slog, poking this button and that button and making puckered mouths at the monitor while you try to decide whether this is a fluke or a trend. Overall, though, he trended upward. 

By the time night shift arrived, I was beyond exhausted, and worried sick because I knew I would have a day off tomorrow. I wrote up an extensive report sheet on him to be handed off to night shift, complete with goals, responses to titration on each drip, and precipitating events associated with each previous destabilization. I think the night nurse was a little insulted when I handed it to her, until she started looking over it and asking questions. By the time I left she was making a few addenda of her own to the list, and running off copies. I wished her good luck and godspeed, said goodbye to Amanda, and staggered to the breakroom to clock out and take a fifteen-minute nap before trying to drive home.

I called in the next day and asked how he was doing. Fine, they said. Stable and gaining. Still in ARDS, still on pressors, still requiring extensive sedation, but still alive.

Week (actually) 5 Shift 1

This facility starts its weeks on Mondays. So I typically work Fri, Sat, Sun, Mon; have Tues off; work Wed & Thurs; then have seven days off in a row. It's a pretty rad schedule.

Report this morning: one charming lady with restless leg syndrome and chronic GERD, who had come into the ER after the most severe heartburn of her life, only to discover that she was having a STEMI.

The term “heart attack” is kind of tricky. We picture a guy grabbing his chest and keeling over, or if the TV writers are extra clever, maybe the guy has some left shoulder pain and starts sweating. The medics hook the actor up to a monitor and we see a flat line—his heart stopped! OH MY VERY FUCK, WE HAVE TO SHOCK. The nurse and doctor make eyes at each other as they paddle one million kilojoules into the patient’s nipples.

This may shock you: heart attacks on television are not usually accurately portrayed. For one thing, if your heart has stopped, you are generally not gonna have the energy to clutch your chest and manfully pretend that you’re just a little out of breath. Heart attacks—we call them myocardial infarctions because that sounds more professional and cool—may often end with cardiac arrest, but kind of in the same way that digestion ends with pooping.

“Myocardial” breaks down into two words: cardiac, which I’m sure you can figure out, and myo, which just means ‘muscle tissue’. Infarct is not a word we use often in the civilian world, although we fucking should, because it means that something has necrosed from oxygen starvation. “What happened to your boss?” “He has been… infarcted.” So myocardial infarction, MI, means that blood flow to part of the heart has been cut off, and some of the tissue has died.

The surrounding tissue is typically ischemic, which is another great metaphor word that should totally be used to describe shit like traffic jams, social isolation, and wi-fi shortage. Ischemia means that the tissue is being starved for oxygen, but hasn’t actually died yet. So in any MI, there’s usually an area of ischemia that can be rescued if you get blood flow going again.

Ischemia is responsible for the pain. Dead tissue doesn’t feel like anything much, but injured and starving tissue does. If you’ve ever sat on your leg wrong and cut off blood flow to your foot, you know how much that shit hurts. Or if you’ve attempted to run a mile because you heard it’s a good thing to do, and ended up a block and a half later throwing up into your neighbor’s hydrangeas while your diaphragm insists that it’s been stabbed in the dick—which is absolutely not something I would do of course—you know what muscle feels like when it’s pushed past its ability to gather oxygen.

Weirdly enough, biologically female bodies have different symptoms. I’ve heard various rationales for this, ranging from “smaller blood vessels” to “different enervation” to “estrogen causes clotting changes” to “uhhhh lady parts are weird.” Fact is, if you were born with a vagina, chances are good your heart attack will feel more like back pain, indigestion, fatigue, and shortness of breath than the “classic” heart attack. (This scares me, because I don’t know about you ladies, but I just call that Wednesday evening.)

I would like to see some more research done on heart disease and MI symptoms in FTM transgendered people undergoing testosterone therapy, by the way. I feel like we could learn a hell of a lot about the effect of androgens on the cardiovascular system.

But I digress. The area of ischemia and infarction is really important. If there’s just ischemia, no infarct, you get angina—transient (or not so transient) chest pain that isn’t a heart attack, but should warn you that you’re in danger. If there is infarct, but only some unimportant corner of your heart muscle dies, you can still have some nasty side effects (any dead tissue, for instance, is at risk of rupturing), but you’ll probably be okay except for the loss of heart flexibility and contraction power.

If you have a chunk of dead heart in the middle of a crucial conduction path or an area responsible for a lot of fluid-pushing, you are in serious, serious shit. The bigger the MI, the more likely you are to kill off a really critical section of your heart, and the more vital it is that you get the clots dug out of your heart , like, stat.

One of the ways we tell the gravity of the dead-heart-chunk situation is by classifying MIs as NSTE-MIs or STE-MIs. A Non ST Elevation MI typically has an area, the ST segment, in the EKG—the wavy line that represents electrical activity in the heart—that is depressed, rather than elevated. The depressed line tells us that the electricity is moving slower in that area of the heart, because the cells are stressed out and can’t exchange ions quickly (remember how some ions, like potassium, belong inside the cell, where they provide electrical impulse?). If the cells die, however, they stop being machines and become dead lumps of cell-wreckage, with ions floating around their battered husks freely. And this means that transmission of electrical impulses through that area is extremely fast, because nothing is regulating the flow, because everything is dead and therefore isn’t accessing (or even delaying) that electrical signal before it’s passed on to the next glob of cells.

This is expressed on the EKG as an area of ST elevation. An ST Elevation MI is bad, bad news, and requires immediate intervention and clotbusting. An NSTEMI can often be medically managed for a while with oxygen and anti-clotting medications and vasodilators to increase blood flow, allowing the body a chance to fix its shit without having holes punched in it. A STEMI is do or die—punch a hole in the pt’s crotch, jam a long tube up their femoral artery and aorta into their heart, dig out the clot, and put in a stent to hold the chewed-up cardiac artery open before any more heart-chunks die.

The weird thing is that, after a cardiac cath procedure, pts often don’t realize how big of a deal this is. They were moderately sedated during the procedure, and there wasn’t a lot of visible cutting, and their chest pain is all better and they’re annoyed because they have to keep their leg perfectly straight while their femoral artery heals for a few hours. All the cousins visit and bring flowers and See’s Candies. They’ll be headed home tomorrow or the day after, gotta pick up a few new prescriptions on the way, remember to call 911 for chest pain or shortness of breath, back on their feet in time to make that baseball game on Friday. It’s not like they were dying.

And yet… they did almost die. Twenty years or so ago, before we had cardiac catheterization as an option, people keeled over and died all the damn time, and even if they made it to the hospital there wasn’t a thing we could do. STEMI or NSTEMI, we dumped medications into them and crossed our fingers that enough heart muscle would survive to keep them going. They would lie in hospital beds, pale and sweating and gasping for breath, gagging on ten-out-of-ten crushing chest pain, until the MI had run its course and they could either go home and wait to die slowly of heart failure, or half their heart turned black and gooey and they died. For days.

Modern medicine is nothing short of a fucking miracle.

Anyway. All that was to say: this pt was absolutely just fine, headed for home by noon the next day, eating and walking around. She was a good pairing for the other pt I picked up.

My other pt was incredibly sick. He had been some kind of college athlete once upon a time, headed for the big leagues, scouts bothering him while he and his brand-new wife tried to move into their brand-new home. Then he was diagnosed with non-Hodgkins lymphoma, dosed with chemo, nuked with radiation, sliced open to remove his spleen, and finally proclaimed cancer-free. He played his sport the entire time, but after college his health—while fairly acceptable— wouldn’t permit professional athleticism. He still holds several records at his prestigious university.

Fast-forward a couple of decades and a couple dozen hospital stays. The radiation tore him up. His esophagus was burned and scarred, and where his spleen had been removed to stop the spread of lymphoma, he now has a hiatal hernia—a weak spot in his diaphragm—and his stomach has adhered to his belly wall. He’s had a couple of heart attacks, as his coronary arteries were so damaged by the radiation that they’re all scarred up and tear and clot easily. And recently, he started coughing up blood.

A biopsy revealed adenocarcinoma—cancer, from the radiation that once cured him of cancer. His left lung was eaten up with it.

About a week ago, he had surgery to remove the cancer. They ended up removing his entire left lung and pieces of the pericardium, the fluid sac around the heart. The tumor had grown to wrap around the pulmonary artery, which made the procedure a terrifying ordeal—a millimeter off, and the pt would exsanguinate like the Black Knight. While they were removing his lung, he suffered another MI intraoperatively, and because of the severity of the surgery and the danger of fucking up his precariously snipped-and-scraped pulmonary artery, they weren’t able to perform a cardiac cath for three days.

It was a STEMI. The right side of his heart, the side that pumps blood into the lungs (or, in his case, lung), has lost some of its function permanently.

But after the cath, he started to come around. He was extubated, and managed to talk and sit up in a chair and even have a few sips of water, although his esophageal scarring had acted up again and he had developed stenosis—narrowing—which prevented him from eating.

A few days later, he vomited. He inhaled the vomit. Things went downhill from there.

A lot of people who vomit while already weak or ill accidentally inhale it. This is incredibly bad for the lungs and can cause severe pneumonia, both from the germ content of the gut juices and from the irritation of stomach acid in the lung’s air sacs. For him, the combination of slow gut movement (after anesthesia and opioid administration, a very common effect), esophageal scarring, and adhesion of the stomach caused vomiting, and his body’s weakness combined with his scarred-up throat kept him from protecting his airway. Within twelve hours, he was reintubated.

Attempts to give him a feeding tube failed. Even in Interventional Radiology, where live-action xray imaging is used to do delicate internal work, the tube wouldn’t go the right way. Important medications, like the Plavix he takes to keep his cardiac stents open, went unadministered; other drugs, like heparin, provided some protection but still left him at uncomfortably high risk. His depression medication levels lagged.

I picked him up, noted that he was pouring gross green-gray chunky secretions from his remaining lung, and alerted the pulmonologist. I’ve seen pts cough up some outrageous things, but this looked like some kind of dead flesh liquefaction business, and smelled like fish sauce. The pulmonologist grabbed a bronchoscope and a respiratory tech, and we did a bedside swish-and-slurp of his airway, sending the results off to be examined by the lab.

There really wasn’t much down there, reported the pulmonologist, just a big chunk of sticky gray shit—which came up through suction in pieces, a chunk maybe the size of a cherry pit all told, reeking like an Icelandic delicacy—and a lot of very irritated lung tissue. We did a chest x-ray, and revealed patchy white spots that indicated fluid buildup in the lungs. The pulmonologist suspected pulmonary edema, and ordered a diuretic to see if that helped his lungs clear out… but I suspected something grimmer.

Pulmonary edema—backed-up fluid in the lung tissues—typically happens because the left side of the heart is sick and can’t pump fluid away from the lungs effectively. It’s not uncommon after a left-sided MI. But this guy had a right-sided MI, so if there was a fluid back-up issue from the heart, it should be backing up into the tissues themselves, not into the lungs.

There is another condition that looks like pulmonary edema, and is, in a way, fluid swelling in the lungs. It’s called ARDS—acute respiratory distress syndrome—and instead of fluid pooling in the air sacs, the lung tissues themselves become inflamed and brittle and start to weep. The cardboard-stiff tissues are too swollen to allow blood to flow easily, and fluid backs up into the right side of the heart, blowing it up like a balloon, and causing atrial fibrillation as the nerve fibers stretch apart and start panicking and firing at random intervals.

ARDS is not a thing you want to have with only one lung.

By midmorning we performed another bronchoscopy, this one attempting to advance his breathing tube past the split between his airway branch, the place where the left and right mainstem bronchi split, called the carina. If we could get the inflatable balloon cuff down into the right mainstem, totally cutting off the left, we could increase his PEEP, forcing some of the fluid back into his circulatory system and protecting his air sacs (alveoli) from boogering shut. (Increasing the air pressure against a freshly sewn-up bronchial tube is a bad thing, and can cause rupture, which is basically the worst.)

In the end, we weren’t able to get the cuff secured in the right mainstem, and he continued to struggle to oxygenate and ventilate. Finally, in fear and trembling, we raised his PEEP juuuust a little bit.

And what do you know, he improved! Finally a fucking break for this guy.

He was improved enough that the GI doc felt safe doing a bedside EGD to try and place a PEG tube for feedings. Unfortunately, between his hiatal hernia (stomach not where it should be), his esophageal stricture, and the adhesions, the only place that was available to stick a tube through would have gone through the wall where all the arteries are. You can imagine how excited we were at the prospect of blindly cutting into a forest of arteries on this guy. Instead, the GI doc fed a small-bore feeding tube along the scope, and just like that we had access for his pills again. Not a moment too soon—his anxiety when he woke up was out the roof. I ended up grinding a Xanax into powder and flushing that down his feeding tube.

Oh yeah—this guy is poorly sedated. We have him on a shitload of fentanyl for pain, but his hospital course has been long and ugly, and opioids don’t work as well for him as they used to. We’re also using precedex, a newer sedative that’s not supposed to contribute to delirium or cause hypotension, but which the average ICU nurse will tell you is almost as effective as plain saline at sedating a really agitated pt. I asked if we could start him on some propofol, and got some bullshit about the danger of prolonging his QT interval—the time it takes his heart to repolarize and be ready for the next beat—even though we have him on a kajillion other QT-prolonging meds. I just bolus him a huge dose of fentanyl every time I plan to do anything to him, and dosing him with all the grudgingly-metered benzos and low-level pain control meds (tylenol, toradol) I can scare up by jumping out at doctors from behind the printer.

His nausea issues have been a fucking thorn in my side. With his guts all backed up, he can totally puke around the breathing tube, although his airway will be protected… but a newish surgical incision is not a fun thing to strain against while you’re vomiting. Also, I am not a fan of all the pressure jackery that comes along with dry heaving, especially with that left mainstem all delicate. I’ve been giving him a ball-ton of Zofran, which usually helps with the nausea… but it’s not doing a lot. The docs have me giving him scheduled Reglan, which stimulates gastric movement and reduces nausea, but it doesn’t seem to be very helpful, and has the potential to interact with his SSRI (as would any of the stronger anti-nausea meds). I’m giving him some truly thorough oral care, for the most part, and trying to avoid stimulating his gag reflex any more than I have to.

In the midst of all this, I traded pts at 1500 during afternoon shift change. Somebody else got my lovely STEMI lady, and I picked up a complete train wreck of a family whose grandfather has been treated uselessly for glioblastoma, a brain tumor that has negligible survival rates. They’ve put him through everything anyway—chemo, gamma knife, you name it. He’s slowly losing control of his body. His family is of mixed faith, mostly Farsi speaking, and the faith conflict has been… incredibly tricky. As a result, he’s just lying in the ICU slowly choking on his secretions while the family fusses about him, providing tons of supportive care and love and also fucking with all his equipment and doing batshit crazy things like stuffing his oxygen mask straps with tissue paper to keep the loose elastic from irritating his face. All the air whooshes out over his forehead and he starts gasping, so they plug the edges of the mask with more tissue paper. I walked in there about 1700 and thought that poor fucker had been mummified. They had also poured medicated antifungal powder all over his body, patting it into his thick pelt of body hair until he looked like some kind of gigantic Versailles pompadour or a guinea pig making a nest in a brick of cocaine.

At one point I walked in and found three of them crowded at the foot of the bed, fighting with each other about God and about whose caregiving was the best as they clipped and filed his toenails, which were grisly. I backed out of the room and left them to it.

Their behavior is just fucking bizarre. They fight and snivel and guilt-trip each other and assume martyred postures and heave endless rubbery sighs as they make up new and ever-more-intrusive ways to take care of their grandfather, who looks more and more uncomfortable as they tape towels to his hands and smear vaseline in his eyebrows and fiddle with his foley catheter so that it pulls against this side, then the other side, then this side again, of his urethra.

Apparently a number of nurses have fired them. I am well-accustomed to families from that part of the world being very involved in pt care, distrustful of American doctors, and deeply invested in the possibility of their family member recovering even when chances are slim. That can be challenging, because American medicine is not really set up to accommodate that spectrum of cultural needs, and anybody who’s worked in a hospital can tell you that pts with a thick accent are more likely overall to have their questions and requests ignored. But it’s not really something to fire a pt for—it’s something to learn a new cultural language for.

This is totally different. These people are an unhealthy family of whackjobs with irreconcilable differences who are held together entirely by the tenuous glue of their grandfather’s chronic illness, which they use against each other as a weapon, struggling to maintain control of his condition by being the most caretaker at any given point. His body is a family battleground. Thank goodness he’s mostly zonked and doesn’t have to be awake for this bullshit.

Abd guy has been making tenuous progress. His abdomen is mostly closed except for a wound vac, and he was able to wake up during my camping trip and follow commands. As far as I can tell, nobody has checked him for methanol intoxication yet. I floated a hint to his nurse, although I’m not sure at this point it will make much of a difference. His anion gap acidosis rages unchecked. I’m impressed that he’s alive, let alone progressing; his necrotizing pancreatitis is severe. I’m not exactly holding out a lot of hope for him, but who knows?

If I had to choose only one of them to survive, I'd rather see my pneumonectomy guy live than my abd pt, which makes me feel a little guilty. They both seem like nice people, but the abd guy is a single dude with a distant family—still ignorant of his condition, none of them in contact yet—and a crippling chronic addiction problem that will make his recovery process hell for him, while the pneumo guy is just an unlucky dude who got cancer as a young adult and who has kids and a wife who will be devastated when he’s gone.

But hey, if I could choose who lives or dies, I’d throw Crowbarrens out a window and chuck his wife after him and let both of these guys live. I would be a dread god of capricious benevolence.

Crowbarrens isn’t back yet, and every day he stays gone, I’m a little more antsy. I can’t believe we sent him home last time with his wife—did I mention this? She brought him in on a Friday because all their daytime home health nurses were taking the weekend off and his wife, who performs all care for him at night and while the caretakers are gone, called the police and said that if she had to spend the weekend with him she would murder him and then kill herself. She spent the weekend on our psych unit and he spent the weekend on our ICU. AND THEN WE SENT HIM HOME WITH HER. That will go over really, really well if she actually does murder him. Or if there’s a welfare check and he tells the police what she said last time. Or, basically, if anything happens to him at all, we are getting reamed like half a lemon by Adult Protective Services.

I cornered my manager and delivered a frothy screed about risk management and liability and the extent to which I do not want to lose my job because the ICU got sued down to the baseboards and is now too poor for indoor plumbing. His eyes bugged out a little bit. I think this is the first time he’s seen me in warpaint. It’s good for him, probably. I hope he doesn’t start dodging me behind corners.

Three days on, then one day off, then two more days on. Then I go camping again, because I have a Problem.

God, I hope this one lives. He probably won’t, but I hope he does.

Week 5 How Many Fucking Shifts Jesus

I didn't write the day of this shift because I was too busy sobbing like an open drain at a Sufjan Stevens concert that night, and then afterward my friend dragged me to her house and forced me to watch (okay, fall asleep trying to watch) Tinkerbelle and the Legend of the Neverbeast. (She has a two-and-a-half-year-old and might be going a little crazy.)

Opened the shift with a decent duo: a GI bleeder and a post-laminectomy. The latter was only under my care for a few hours, as her biggest issue was pain-- a lot of pain-- and she had come to the ICU because all the pain meds made her loopy on the medical floor and they wanted to watch her a little closer. We were concerned by how dramatically her neuro status had declined; she wasn't somnolent or respiratory-depressed at all, as you'd expect with someone having an opioid OD, but she was totally hallucinating and paranoid. We don't like to see major mental status changes in a pt who's fresh off a major back surgery and/or had an epidural (as is common with back surgeries), because there's always the chance of infection in the central nervous system.

She cleared up around 0845 and seemed totally fine. I interviewed her a little more closely about what she thought had happened, and she said: "Oh, I just have these episodes. Never really thought they were a big deal." Straight from there to a head CT, where the radiologist noted what could be a lesion-- possibly a tumor-- in her head. From that point the neuro team got involved, and because she wasn't really critical care status they moved her off the ICU.

That interview process, by the way, is one of the more ticklish and annoying aspects of nursing, but one of the most important if you want to catch things before they go south. Most people are hesitant to offer their own opinions about their medical issues to healthcare staff, which means that sometimes valuable bits of information get withheld because the patient doesn't want to look dumb in front of the doctor. Thing is, we aren't mind-readers, we rarely have a truly comprehensive health history, and we don't always connect the dots with the same one-on-one scrutiny that a person can perform on themselves. We might not be able to take a pt's diagnosis at face value, because we can't expect them to have a full medical education (I mean, shit, I can't diagnose anybody either), but we can definitely get a lot of crucial information from a person's opinions about their body.

It's like: you might not know exactly what's wrong, but by god, you know something's wrong. And we don't always know even that much, until your vital signs start to crash.

There's a saying that, when a pt tells you they're dying, you fucking listen. People don't just toss that phrasing around. They might not be able to tell you exactly why they're dying, but they know their body is about to lose its grip. 

That kinda came into play later in the shift. More on that later though.

My other pt, the GI bleeder, was a bit of a weird dude. He'd gone AMA the week before and returned vomiting blood, and in addition to a massive variceal banding, he also needed a TIPS procedure. 

If you need a refresher on liver failure and what it does to your guts, here's my patho lesson from last week.

So this guy, a chronic heavy drinker who regularly mixes Tylenol PM with his vodka (do not fucking do this, alcohol + tylenol/paracetamol = liver-ripping molecular knives), has a liver so blocked that all his esophageal vessels are bubbling up like a teenager's face. All the blood vessels around his liver and intestines are completely blown out and ready to explode. Medical treatment hasn't helped him at all, and eventually we'll run out of chances to catch his bleeds... so the next step is a TIPS.

A transjugular intrahepatic portosystemic shunt, TIPS, is a tube that connects the blood vessels on either side of the liver. Now the intestines can dump straight into the system, bypassing most of the liver. If you're guessing that this can have amazingly nasty side effects, you are absolutely correct-- jizz proteins and brain-pickling nitrogens and straight-up chunks of shit are free to wander. Your liver is still getting a little filtration done, and making what proteins it can, but if it's almost completely cardboarded sometimes blood doesn't even bother and just travels by shunt... which cuts off blood flow to the liver and can kill you. But hey, you won't bleed to death?

As is common with families that involve alcoholism, this guy's family-- him and his wife, his children being estranged-- was extremely enabling and secret-keeping and just weird, with bad ideas about boundaries. He and his wife insisted that his hospital bed be moved closer to the wall sofa, so that he and his wife could hold hands as he slept; his wife refused to leave the room at any time, and spent weird amounts of time in the room "changing" (ie naked for some reason????) so that any entry to the room had to be preceded by lots of knocking and calling out. Super codependent, super enmeshed, super inappropriate, and super terrified of "being caught." When I stumbled across the pt's wall charger plugged in by the sink, a totally normal thing that everyone does, the wife reacted as if I'd caught her slipping her husband booze. Families afflicted with alcoholism run on secret-keeping, and most family members have a hard time telling what's an actual secret and what's normal, because they're so used to keeping the world at bay. I felt really, really bad for them both, because things will never get better for them without help, and they'll never get help because they're so invested in the secret and so locked into the psychological addiction of enabling. 

But he went down for this TIPS at two, and did pretty well, so he's got maybe another year or two's worth of chances to break the secret and get their lives back.

While all this was going on, Rachel went home. She isn't even going to rehab-- she's been totally off vent for a while, even taking a few steps at a time, and she went home in a medicab to her children and her own home. I hope things go well for her.

The exploding poop guy was doing much better. A few days of nonstop diarrhea had loosened his belly up to the point that, when I poked my head in, I could see the droopy skin of his abdomen flopping as his nurse turned him to wipe his ass. 

A couple of people asked me how somebody can live without shitting for six months. (Hopefully tomorrow I can get caught up on replies?) The answer is: you can't live without shitting for six months. You can, however, be massively chronically constipated, and if it starts slowly and doesn't advance too quickly, your body gradually learns to compensate for the increasing blockage. You shit liquid around the blockage, mostly. But eventually even that deteriorates, and soon you're backed up to your neck. Literally. So this guy hadn't pooped in something like a week, but he'd been working on that week of constipation for so long that it damn near killed him.

The last pt I got for the day was an utter clusterfuck. She was an older woman, a marathon runner, who had developed a hiatal hernia and had it repaired via Nissen fundoplication (wrapping the stomach around the esophagus, which I can't describe any better than Wikipedia). Her wife is an RN and had been staying with her since the surgery a couple of days before, and yesterday had started expressing some concerns about the pt's status: requiring more oxygen, having increased pain, unable to advance her diet, and just "looking weird." Overnight the pt's oxygen needs had increased to the point that, when I finally got report, she had been on a non-rebreather mask at 15 liters, satting 89% O2 (you and I probably sit between 96% and 100%), for almost six hours without anybody insisting there was a problem.

Sometimes nurses make the worst pts. This nurse, however, impressed the hell out of me both with her insight and her grace in light of the medical floor staff's failure to recognize her wife's decompensation... though honestly I would have been a lot pushier than she was. I can't nitpick. She's trauma-ortho and I'm ICU and therefore she's a steady time-managing proceduralist while I'm a neurotic compulsive paranoid with control issues.

The transfer was awful. Charge told me I'd be getting a pt shortly, so I asked my break buddy to watch my TIPS guy while I took a fifteen-minute nap, and notified the charge and the unit secretary to call me on break if report came up. Instead, I enjoyed a nice snooze, checked on my TIPS, poured myself a cup of coffee, and walked down the hallway to find the new pt waiting for me-- no RN, no report, just a confused transport guy from CT and a pt who looked like she was about to crash on me.

As we moved her into the new bed, she grabbed my arm and gasped: "I think I'm dying." Then she was too short of breath to say anything else. I keep my hair back in a sloppy french braid, but I'm pretty sure half of it popped out and stuck up straight in the air. Remember what I said earlier? That's not a good thing to hear from any pt.

She had subcutaneous emphysema with crepitus-- crackling bubbles under her skin-- from her shoulders up to her temples. A quick chest x-ray showed that she had a massive pleural effusion, so I got her sitting up on the side of the bed, and the pulmonologist stuck a needle in her back and pulled out a liter of bloody-clear fluid, which improved her breathing but was extremely alarming. Her wife watched the whole procedure and looked increasingly apprehensive, especially when the pulm ordered the fluid checked for amylase-- one of the enzymes secreted by the pancreas, which belongs in the intestines breaking down your food, not in your lung cavities. 

Sure enough, the radiologist showed up twenty minutes later to tell us that her CT showed a giant rip in her esophagus, with communicating fluid and free air between abdomen, thorax, and mediastinum. This is SUPER BAD AND HORRIBLE and requires immediate surgery. Unfortunately, our cardiothoracic surgeon that day had started an open heart an hour before and wouldn't be available to operate for at least another four hours, and the nightmare in her gut was massive enough that she would need a GI surgeon and a thoracic surgeon to perform the surgery. We intubated her immediately to stabilize her, then transferred her to another hospital in the area, a thirty-minute drive at the end of which the op team was already preparing the OR. I hope she's okay, for her wife's sake. I can't imagine being a nurse, knowing what I know, and watching helplessly as my spouse suffered horrible pain and life-threatening health events. I don't know how she wasn't flipping tables and kicking doctors all night, watching her wife go from nasal cannula to mask to non-rebreather without being assessed for critical care status needs, watching her face blow up with subcutaneous air without somebody at least asking for a chest x-ray to rule out pneumothorax. 

This is why nurses make terrible pts. We get all freaked out and controlling about our care. It's just ridiculous. Any time my husband spends in the hospital is time I will spend gnawing my tongue off in the middle so I don't get thrown off the campus.

Let me tell you, though, getting that pt with no report and no prior warning was more of a wake-up than any amount of freshly-poured coffee that I promptly forgot about and left on the station until it got cold and the unit secretary threw it away. A pt with no report AND massive sub-q (uh, that's subcutaneous in nurse jargon) emphysema will give your sphincters a workout. I had to stay a little late just to write up the incident report. Still a little stressed out just thinking about it.

I only worked eight hours though, and after that I went home and washed up and put on something way too shabby and sloppy to wear to a concert, but I guess it didn't matter because I had a blast. Or possibly an emotional breakdown. It's kind of hard to tell. I will write about today's shift tomorrow, after the morning's meeting with my sister's social worker. 

My sister, btw, is doing really well, but she reminds myself a lot of me at that age-- questionable personal hygiene, terrible time management, serious lack of some basic social niceties. The usual rural-religious homeschooled stuff. But she's just as smart and articulate as I remember, and has charmed my friends and responded well to all our conversations about my expectations for her time in my home, and I'm really glad to have her with me as she starts her adult life.

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.

Diabetes 101, or Put Down the Fucking Candy

Edit: This page seems to be getting a lot of traffic, which is unexpected, and I wish now that I'd done a better job of explaining some things about diabetes, both Type I and Type II. I certainly never expected this to be passed around as a PSA!

For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.

So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.


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A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.

So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...

...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)

We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.

That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)

Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.

On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.

But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.

Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?

To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)

So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.

This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.

Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.

Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.


If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.


DKA is a horrible way to die.


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Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.