Wishbone, Leah, and the Return of Crowbarrens

Every shift, we introduce ourselves to our pts, explain how long we’ll be there today, and talk about our goals for the day. Some people have very simple goals: don’t die is popular, as are things like control pain and get out of bed. Some people will have procedures during the day, endoscopies or central line placements or dialysis.

Occasionally, the most important goals aren’t things we can cheerfully schedule with our pts: come to peace with impending death, or manage not to shit directly on anyone’s scrubs. In those cases, we find simpler goals: order breakfast and lunch early so they don’t have to wait, take a walk and get some sunlight, that kind of thing.

Then we do our assessments, because nothing helps your day get moving like peering at some guy’s butt and hoping that pink spot on his tailbone isn’t turning into a pressure ulcer.

Week Five Please Send Help Too Much Work

Thursday I rolled into work around 1045, having juggled my hours to accommodate the concert. Getting out at 1500 on Wed was just enough time to let me stagger home, wash my gross self, nap for an hour, and put on some real-people clothes before the festivities commenced. Coming back in at 1100 on Thurs let me sleep in, which I desperately needed (and still need, and will always need even when I don’t get it). So I was well-rested, well-fed, and wearing my best work pajamas when I showed up at the nurses’ station and asked about my assignment.

Charge nurse put on a very serious face and asked if I would be comfortable getting oriented to hearts at this facility today.

Open hearts are a big deal, the moneymaker of any ICU that does them. Nurses that take fresh open heart recoveries are rigorously trained, tested, precepted, and even given classroom time on the unit’s dollar to make sure they’re fully equipped. Heart pts are delicate, touchy, and heavily regulated, but a really sharp RN with lots of training can keep everything moving smoothly despite the inevitable hiccups. I had not taken a fresh open heart in something like nine months, because even a few months before I left my last facility, the open-heart program became a dangerous place for a relatively inexperienced nurse.

A second-day heart pt had been assigned to a non-heart night nurse due to understaffing, with the idea that the heart-certified charge nurse would be able to back her up and keep things running smoothly. Instead, the pt lost conduction (valve replacements often do, though it’s less common for this to happen on the second or third days) and dropped their heartbeat completely. They ended up coding her for almost thirty minutes before someone thought to hook up her pacemaker, and after thirty more minutes without success they called the code.

The charge nurse was hung out to dry, and retired to PACU a few months later. The unfortunate unit nurse assigned to the pt was scapegoated roundly, despite having never been trained on hearts and therefore lacking the reflex to hook up the pacer to the V-wires sticking out of the pt’s chest. Every hiccup in every recovery for the next six months was scrutinized, written up, and presented “in a meeting” between managerial staff and the heart nurse in question. Everyone on the unit was trained in temporary pacer management, but when the heart RNs requested additional training to address the hiccups that were obviously such a big problem now, they were given no more education—just stripped of autonomy and grilled after every case.

I voluntarily removed myself from the heart list. Which is sad, because I fucking love hearts. They are a huge rush and the detail and precision and reflex required is a serious, galvanizing challenge. There’s also an element of prestige to the open heart program, which I like because I am a bit shallow and vain. Succeeding at the challenge makes me feel like a Real Nurse instead of the secret imposter I usually feel like I am.

The imposter thing is a huge deal in my life. Even writing this diary is kind of terrifying to me, because I know that I’m getting some things wrong and there are probably people shaking their heads and wondering why I suck so bad. I’ve worked ICU since 2008 and I still regularly encounter things that make me feel like a clueless kid wearing borrowed scrubs, things I should have known but didn’t, moments of dumb that make me cringe for months. I am deeply afraid of appearing stupid or uneducated or incompetent. One of the hardest things in my practice is recovering rusty skills—things I used to do well, but which I haven’t done for a while, and which I might be expected to perform competently but will probably make mistakes with. I am constantly ashamed of myself, and sometimes this makes me defensive or aggressive when I really shouldn’t be.

Mostly I channel it into fighting my innate laziness. I don’t want to look like a piece of shit nurse who can’t do anything without her hand being held, so I constantly educate myself, refresh my skills, pay attention to the details, and attend to the shitty boring jobs as well as the exciting flashy ones.

So taking this heart pt was very important to me, and although my shamepanic drive geared up for a beating, I accepted the assignment. As a psychological incentive, there was also an element of the unit really needing a few more heart nurses—my other great fear is abandonment, which means that I am at my most comfortable and secure when I feel necessary. It’s vital that I keep that impulse in check, because a hospital will chew you up and spit you out if you can’t resist the phrase “we really need you.” And nobody in a hospital is truly indispensable, so at some point in every work situation I will inevitably encounter the truth that I will never be perfect and that perfection is not required for me to be valuable. But I allow myself a few smug moments sometimes to enjoy my employers’ gratitude and/or relief, just as I occasionally remind myself that if I don’t get my job done right, I will get in just as much trouble as the next nurse down the hall.

My value is earned, and if I fuck around and make messes, other people are entitled to avoid me—which means that the approval and security I crave is a predictable resource I can expect if I fulfill certain realistic expectations, and am entitled to demand if it’s inappropriately withheld.

There was a time when I handled things with much less self-awareness. Approval and love were like an endless series of rocks thrown into the emotional well of my insecurity, each little splash a momentary fix, while the whole time I acted like a crazy person, trying to drive the source of approval away to “prove” that my fears were legitimate and that the splashes would stop coming. I was an incredibly challenging person to care about. I think the only reason I finally escaped that personality hellhole was that I got into nursing, where my value was measured in life and death and hourly wage. It’s hard to lie to yourself about patient outcomes.

I’m pretty sure nursing saved my life.

I’m also pretty sure this diary is not at its best when I’m navel-gazing in it. Lo siento, my friends.

Anyway, Mavi*, one of the best heart nurses on the unit, offered to be my second/preceptor for the day. She is a tiny Filipina woman with beastly skills, ice-cold reflexes, and the kind of gentle, humorous nursing style that makes everyone around her comfortable and happy.

We prepared the room and sat down to get me oriented to the paperwork and charting. Every fresh heart has a primary nurse (in this case, me) and a second (Mavi), with distinct roles in the recovery process—there is a hell of a lot of work to do during those first few hours. Every facility documents its hearts a little differently, and every surgeon has their own preferences and quirks, and every heart nurse needs to get familiar with the details very quickly so they can be second nature by the time they’re making decisions about which medication to start.

This surgeon doesn’t like SCDs (leg massager pumps used to prevent blood clots from forming), prefers to be texted rather than paged, dislikes high doses of epinephrine used as a pressor, and is blazing fast at his job. He also plays jazz guitar, was once an aerospace engineer (his first career), and is in active military duty through some branch or other. I was a little intimidated, to be honest. Mavi put the surgeon’s number in my phone while we looked over the procedural chart for landing a fresh heart, which she wrote a while back and which has become official paperwork because it rocks.

Off-pump call came about four hours after surgery started, which was incredible, considering that the guy had a valve replaced (requires cutting into the heart itself), a coronary artery bypass graft (CABG, requires harvesting a vein or artery from somewhere else in the body), and a double MAZE procedure (a labyrinth of burn scars in both atria to prevent atrial fibrillation). This is a whole lot of stuff to have done in a single surgery, let alone in a mere four hours of surgery.

Elevator call is typically an hour after off-pump call. Once the pt is taken off the bypass pump and their heart is restarted, the team still needs to close the chest and perform a few other little tune-ups, then watch the pt until they’re satisfied that he’s stable. Then they give one last notification to the ICU and load the whole crew into the elevator. So the pt arrived, intubated and still working off the anesthesia, with a churning nest of OR nurses, techs, and anesthetologists squirming all over him. Mavi hooked him up to monitors while I checked on his chest tubes; Mavi drew up his initial labs while I charted until my eyes started to sweat. Mavi performed foley care; I ran hemodynamics through his swann catheter, checking on the function of his various cardiac components. I listened to his heart and lungs—this is especially important in valve surgeries, since a valve problem will usually be audible as a murmur—and Mavi examined his pacer wires and vent settings.

He was atrially paced. Many valve pts come back with their pacer wires hooked up and firing, either by directly stimulating the ventricles (the big chambers at the bottom of the heart, the ones with all the kick) or by starting the electric cascade in the atria (the little chambers whose job is mostly to pack extra blood into the big chambers and stretch them out bigger so they can beat harder). Some surgeons prefer to let the ventricles fill on their own and just pace from the ventricles themselves. In valve surgery, the actual heart itself is cut and the nerves are very unhappy, especially the nerves responsible for relaying messages from the atria (where each beat starts) down to the ventricles (where the beat ends with a big push). Angry, swollen, shocky nerves don’t relay impulses well, and thus any beat that starts at the top of the heart—whether natural or atrially paced—may not get conducted all the way to the bottom.

But that atrial kick gets a lot more mileage out of each beat. Imagine holding a water balloon in your fist, and squeezing it until it pops. If the balloon was filled just by dunking the empty balloon into a bucket of water, it won’t have much water inside, and your fist will have to squeeze really hard to pop the balloon. But if you hooked the same balloon up to a water hose and filled it until it was ready to pop in the first place, the balloon itself wants to return to its original shape—it has mechanical elasticity, and your fist only has to work a little to make it pop. In this case, the ‘pop’ is the force of perfusing your entire body with blood, and the water hose is the atrial kick that forces extra blood into your ventricles. So atrial pacing is a great place to start a cardiac pt. If you lose conduction, you can always hook up the ventricular pacer wires and stimulate beats that way.

His blood pressure and cardiac output, of course, started to drop very quickly. The recently-cut heart is stiff and shocky and stressed out, and its walls don’t want to move very well. Plus, the body is reacting to the insult of being cut up and partially exsanguinated by shifting fluid around its various spaces, pulling water out of the blood into the tissues where it’s mostly useless except to swell up and make you look puffy. So we administer fluids, to replenish the thirsty bloodstream, and we administer albumin, which thickens up the blood (increases its osmolarity) to suck water back out of the tissues into the blood vessels.

To support the blood pressure, we use several different medications by steady drip. I am pretty used to using dobutamine as a front-line inotrope—that is, the first drug I turn to when I need to stimulate the heart to squeeze harder instead of faster. This surgeon, however, prefers epinephrine, aka adrenaline, which both speeds the heart (a chronotrope) and increases its contractility (an inotrope). As the pt’s recovery continued, we shifted from the fluid-moving phase to the vasodilation phase, in which the body really wants to relax its veins and dump all its fluid into the tissues. Here we started using phenylephrine, also known as neosynephrine, which is a pure vasopressor—that is, it tightens up your blood vessels, and doesn’t affect the workings of your heart. In the same way that you get higher pressure by squirting water through a straw than through a hose with the same force, tighter blood vessels increase pressure… although they resist the heart’s beats a little harder.

One of the other big bad pressors, norepinephrine/noradrenaline, is also known as Levophed… or, in ICU parlance, leave-‘em-dead. It will squeeze the living shit out of your blood vessels until your toes drop off, which is what happened to my CRRT lady a while back. If you find yourself using norepi on a cardiac surgery pt, something has gone extremely wrong. The other two pressors, vasopressin and dopamine, I will probably talk about later, when I have a pt I’m using them on.

Within about two hours of his arrival on the unit, he awakened enough from general anesthesia that he could open his eyes, lift his head, and follow commands, so we pulled out his breathing tube and let him breathe on his own. A little morphine for pain, a few ice chips for his dry throat, and he was happy as a clam in sauce.

He was also convinced that I spoke exclusively German, and was courteous enough to speak exclusively German to me. I do not speak German at all, so occasionally I would rattle back at him in hospital Spanish (I cut my ICU teeth in Texas) and he would recoil, startled. He is a world traveler and historian and as he came back to his senses throughout the afternoon he and I had many wonderful conversations in English. Any time he drifted off though, he would wake up, look at me, and start speaking German again.

Man, I don’t know. I don’t even look German. I have enormous bushy brown hair, a prominent forehead, freckles, glasses, and the kind of sloppily-assembled facial features you get from slightly inbred trailer trash that grew up in the river bottom. I look like leftover tax dodger and piney-woods moonshiner and hastily concealed ancestor ethnicity back when Irish was considered ‘ethnic’. I am white as shit, but not in the classy-lookin’ European way, is what I’m saying. Four years ago, before suffering my way through braces, I had buck teeth.

I’m not exactly pretty, but fuckin hell man, I don’t have to be. I am the apocalyptic definition of ‘personality hot’. I’m the lady equivalent of that weird-lookin fucker on TV that’s sixty years old and worryingly asymmetrical in the face parts and could bang your girlfriend in the bathroom at your favorite bar after five minutes of conversation. I am also incredibly arrogant and don’t speak a word of German. It’s quite possible that he was just telling me how my face is so gnarly it’s giving him flashbacks to WWII.

We joked a little about our respective experiences with foreign languages, and he taught me a little about the ways in which Italian deviates from Spanish. I taught him to say “qapla’.” I can’t help but feel that I got the better end of that deal.

Anyway, linguistic barriers aside, by the time we had this guy settled down and feeling pretty good, I had an imperial shit-ton of charting to get done, so Mavi watched him for a bit while I had lunch and then tore into the paperwork. The surgeon came by to see how the guy was doing, and I noticed that he was wearing an honest-to-god Starfleet insignia badge on his white coat, which after my earlier Klingon language lesson seemed like a much stranger coincidence than it probably was. We ended up having a nice chat about Star Trek, after which a couple of the RTs came up and started reminiscing about Jimmy Doohan, who apparently used to come to this hospital for pulmonary fibrosis because he lived nearby. (I would consider this HIPPA material except that it’s freely available information from Wikipedia.) He was apparently funny and personable, hated being called “Scotty,” and once left AMA because he hadn’t had any alone time with his wife in a week.

The RTs apparently thought very highly of his wife, who was much younger than him but who genuinely seemed to care about him and connect with him on a personal level. “They were great people,” said the surgeon. “I was always a little intimidated by him though.” Then he started talking about how his engineering career was spurred by his love of Star Trek, and how he missed NASA because he had felt like a member of a modern-day Starfleet there. I turned into a brick of shy-terror and finished my charting in record time.

After that, we got my pt sitting up on the edge of the bed so his feet could dangle, reminding him to hug his heart-shaped splint pillow tightly to relieve tension on his chest, then popped him back into bed and tidied up the room for the next shift. He was scheduled for at least one more major exercise activity, probably an hour sitting in a recliner, before bedtime. Exercise is critical to the early recovery phase; a pt who lies in bed the whole time will have nasty consequences. Lungs collapse and close up and fill with fluid; chest tubes clot off, and fluid builds up around the heart; blood clots up in the legs and causes pain and swelling, with a huge risk of pulmonary embolism; and the whole body misses the opportunity to tune itself up after the surgery, leading to increased swelling, decreased cardiac output, and severe constipation.

Tomorrow he’ll walk around the unit four times, and spend at least half the day in a chair. After that we’ll really start pushing. His case will be a smooth one, barring any major unanticipated events, and he’ll probably go home in a week or two. Before the surgery he couldn’t walk without collapsing because his heart was too starved for oxygen and too backed up from his scarred-up valve; when he gets home, lord willin’ and the creek don’t rise, he’ll be able to stroll around the park and even do some gentle gardening.

Other things that happened today…

The screaming lady died. Her ammonia poisoning—hepatic encephalopathy—became so intense that she could no longer speak or make eye contact, and she laid in bed thrashing and groaning in horrible garbled sentences of fragmented non-words as if demons had crawled into her skull and were eating everything inside it. Her family stopped going into the room at all, and huddled outside in knots of two and three, weeping. Palliative care approached gingerly, having been rebuffed many times before, and her closest relative made the decision without even having to be asked.

“Let her go,” he said. “She’s not even really alive anymore.”

We took the fem-stop pressure dressing off her leg, and she bled out and died within five minutes. The absence of her screams was sickening for the first half-hour; then hospital silence seeped into the cracks, a weird relief.

In the car on the way home from a shift, you forget to turn on the radio, you forget that you were going to make that phone call—you soak in the lack of alarms, the lack of dinging and beeping and chiming and clanging. It’s like breathing after you resurface from the water, at first. Your eardrums feel like somebody is pressing on them, blunting out the constant bells you know must still be ringing. Then, as other small daily sounds creep in at the edges, you forget what it was that you were supposed to be hearing. The white hum of road noise, the whoosh and rumble, disappears beneath the sounds of the car passing you in the other lane, the click of your blinker, the subvocalization of the gearshift, the creak of your knee as you depress the clutch and wonder why the fuck you can’t just give up your dignity and buy an automatic for the commute. You remember that you downloaded the new episode of that podcast, and hook your phone up with one hand, and dig that last Kit-Kat bar out of your purse to devour while you drive. By the time you reach your home, the endless litany of alarms is not only missing but forgotten.

That’s how it was with her screaming. An hour after she died, we were all cursing under our breath about the one guy whose monitor kept false-alarming. I almost forgot she had been alive just that afternoon.

We also got in two pediatric cases. Okay, teenagers. One was in a car wreck and had mashed up his legs, but was expected to recover, although his entire family was shaken and white-faced. The other was involved in a drowning incident; his mother had seen him go underwater and not come up, and although there was a nurse nearby who started CPR as soon as they could pull him up, he had inhaled a fuck-ton of lake water. His mother was a complete wreck, and understandably so, but very optimistic and desperately hopeful that he would wake up soon.

We’ve had a few drowning cases. Everyone is keeping a politely neutral face, and of course we’re doing everything we can, but (because I’m writing this a few days later) I can tell you that on Friday he had his first code blue as his lungs succumbed to the inevitable damage of lake aspiration, and that today he’s in a rotoprone bed, seizing.

He might yet make it. Maybe. It’s a long shot. Either way, I’ll be here every day through Wednesday, so if he dies I have about a 50% chance of being here for it.

Week 3 Shift 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Frankly, I'd rather handle poop.

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

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

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

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

Liver failure is one hell of a way to go.