The new crop of ICU nurses is coming on this month. We’ve
recruited our usual blend of experienced RNs from other facilities across the
country, pre-trained travel RNs who’ve been seduced onto full-time jobs after
finishing their contracts (I was one of these), and PCU/PACU/telemetry RNs who
are excited to move to the ICU and learn the ropes. The latter group requires a
hell of a lot of attention before they’re ready to be turned loose on patients.
When I entered the world of the ICU, I was a new grad, fresh
off the NCLEX. I knew I wanted to work ICU, and I had done a lot of high-focus
work in school to get there, but I was in absolutely no way prepared to
actually provide critical care. I don’t know why they hired me—I probably
smelled like amniotic fluid and fresh hay, sitting across the desk from the
manager with my incisors clamped together and my lips peeled back.
As it turned out, they were desperate. A mass exodus of
nurses from their MICU had made conditions very tight there, and I suppose
everyone figured it would be easier to foist off the low-acuity pts on a
clueless tottering foal of a nurse who probably
wouldn’t kill them than it would be to suffer through another month of catastrophic
short-staffing. And, I mean, I’m pretty good at making competent faces.
Fortunately, I had excellent preceptors. I sat through two
weeks of class, then another week of computer training, then started two weeks
of precepting—following an experienced nurse through the care of a single pt,
slowly learning the ropes and getting used to all the drips and rhythms and
schedules and reports. At this facility, new nurses are precepted for up to
three months; at my initial facility, I had two weeks on days, one week on
nights, and then a full pt load. I don’t know how I managed not to kill
anybody.
I probably did kill some people. Not immediately, but by
providing less-than-competent care that didn’t give them the foundation they
needed to heal. I over-sedated my pts—to be fair, we all did this—and I often
ended my shifts completely confused and with so many chores left to do that I was
the terror of the day nurses who had to follow me. I was Not A Good Nurse.
So precepting is really important to me, and I came to work
early because I knew I would be teaching someone how to ICU today.
Her name is Maycee*; she is tiny and energetic and has the
cute kind of freckles that speckle the bridge of her nose (unlike my all-over
sepia dapple that looks like an old-fashioned Instagram filter of a nasty crime
scene under blacklight). She has only ever worked telemetry until now. She’s
quite smart and used to hard work (tele/progressive care nurses are some of the
hardest workers in the hospital), and so I didn’t feel too overwhelmed when
they told me we’d be caring for two pts instead of the traditional precepting
one.
This is actually an intense load. You can’t just do anything—you’re explaining all of it,
the principles behind it, the rationales for your actions, the processes you
used to arrive at your decisions, the whole time. You have to ask leading
questions and see if your preceptee can follow those routes on their own, which
means setting up a decision situation, prompting the preceptee with a question,
and taking the time to gently prod and guide them until they answer the
question on their own. It basically doubles the time anything takes, which
means that taking two pts is an absolutely mind-blasting time-management
gauntlet.
One pt was a desperately ill pt with liver failure and
sepsis who had, before being intubated, said that he didn’t want to be
intubated for more than four days, and who was now on his fifth day with no
family members to follow up on his wishes. The other had chronic worsening
respiratory issues and hadn’t wanted to be intubated at all, but had been found
down by a neighbor who didn’t know his end-of-life wishes, so he’d been tubed
and brought in by the EMTs and was now in full-code hell waiting for some
family members to get back to us and let us put him on comfort-only care.
This has been somewhat of a theme on our ICU lately. It’s
discouraging. I hate to imagine being chronically ill, having no chance of
recovery, and being forced to stick around and suffer because nobody can speak
for me.
By the way, DNR tattoos don’t count. DNR papers, signed by a
physician, are good for something if they’re posted where the EMTs can see them
before they get the tube in and start CPR… but they aren’t allowed to pull the
tube out or, in many cases, stop the CPR once it’s started. If you really don’t
want to get beat up before you die, it’s a good idea to get the signed papers
and put them just inside the front door, and maybe to get a med-alert bracelet
instructing any rescuers to look at your papers and/or call your POA (power of
attorney) person.
Our pt was on levophed, which meant his pressure was okay,
but his arms and legs were enormously swollen. He was up by nineteen liters of
fluid from his admit weight. We diuresed him as much as possible, using albumin
between rounds of lasix to suck the fluid back into his bloodstream from his
tissues. An hour into the shift, we started a lasix drip. We also had to keep
him on a continuous potassium drip, as lasix works by dumping potassium to
force the kidneys to dump water as well (in simplified terms, anyway).
At max rate, the lasix got his kidneys up to a break-even
point where he was peeing about as much as we gave him every hour, except hours
where we gave him antibiotics or literally any other fluid above and beyond his
continual IV drips.
Meanwhile, the guy next door required frequent bolus doses
of sedatives to keep him comfortable, and was shitting more or less
continuously. He weighed a fucking ton, so we were relieved to discover that
his room was one of the two-thirds on our unit that has an overhead lift by
which we could turn and haul and move him. It didn’t really help a lot with cleanups,
since it lifts pts by hoisting the corner-straps of a mesh hammock the pt is
lying on… so if you need to clean the pt’s butt, you have to move the hammock
out of the way. But it made turns a thousand times easier.
Our liver failure/sepsis guy was really not doing well. His
PEEP had to be cranked up; he was so fluid-overloaded his lungs were flooding,
and the high doses of levophed provided even more systemic resistance that
backed up into the left side of his heart. I’m not actually sure if this is
true, as I haven’t fully researched it, but I’ve heard that levophed and
phenylephrine in particular contribute to pulmonary hypertension by squeezing
the lung capillaries, which causes the same swelling in the lungs that happens
in the hands and feet with those drugs.
Either way, I can tell you that a pt on a high dose of
levophed isn’t going to be breathing on their own for long.
(The hand and foot swelling comes from the way levophed
closes up your peripheral blood vessels, resisting blood flow to those areas so
that the blood is redirected to critical organ circulation… but also impeding
the return flow of fluid that actually makes it out that far.)
So we had him on a whalloping fourteen of PEEP. I can’t remember if I’ve explained PEEP before,
but I am the kind of person who precepts well because I can’t stop myself from
ranting, so buckle the hell in.
PEEP stands for Post-End Expiratory Pressure. If you just
breathe all the way out at the end of each breath, the little air sacs in your
lungs—the alveoli—can collapse at the end of expiration. And because the inside
of each alveolus has to be wet and gooey with lung-mucus to allow oxygen to
diffuse across the membranes, the walls of those little sacs stick together
when they close—especially if there’s lots and lots of goop, ie lung boogers or
edematous flooding.. It takes a shit-ton of work to force those stuck-shut
alveoli open again, and until they pop open again, they aren’t exchanging any
air. It’s better to keep them open in the first place… but how?
As a bonus, if your alveoli are swollen up with too much
water, they might stop working properly—in which case you gotta bring that
swelling down. Diuretics might work if it’s a systemic overload problem, but if
your lungs are just irritated and inflamed, you need to find another way to
squeeze the fluid out. If you’ve ever had a sports injury, you know that
compression helps a lot… but how are you going to squeeze your lung tissue?
The answer to both of these questions is PEEP. At the end of
each breath, a sharp puff of air forced into the lung keeps the interior
pressure of the lung juuuuuust high enough to prop open the alveoli, and maybe
even force a few closed ones to reopen. And by maintaining pressure on the
alveolar tissue, PEEP compresses the swelling, forcing fluid back into the
bloodstream so your heart can pump it and your kidneys can dump it.
There’s a problem with PEEP though. And we ran into it
almost immediately, as our pt suddenly bombed his pressures and had to be given
albumin, then cranked up on his levophed even further. Why was this happening,
I asked Maycee?
She pondered this for a while. It’s not an easy concept to
grasp, and I was asking her to piece it together on her own. I hinted that it
had to do with pressures and pressure imbalances in the thorax, and she worked
on that until I could see her brain sweating. At last she ventured: is his
heart not making enough pressure?
Yeah, I said. There are three reasons why the ratio of
pressure involving the heart might be off. The heart itself might be having
trouble generating pressure; the pressure beyond the heart (either in the body
or in the lungs, the two areas the heart empties into) might have spiked,
making the heart’s normal pressure insufficient compared to the new resistance;
or the heart might not be getting enough pressure supplying blood to it. Or a blend of these things—it’s
rarely just one.
Had we recently changed any pressures in his body?
Any post-end expiratory
pressures?
At that point she got it, and it was amazing to watch the
string of lights behind her eyes igniting a trail from one concept to the
other. “More pressure in his lungs from PEEP,” she said. “More pressure for his
his heart to push against; more pressure to resist the flow of blood back to
his heart from his body. We changed the pressure! So can we fix that?”
The answer is complicated. More fluid in his bloodstream
would increase the return pressure to his heart, but stood a good chance of
never making it back to his veins after the pressure in his arteries petered
out, and he was already desperately fluid-overloaded. He had run out of places
to put extra fluid; his arms and legs were weeping and taut, his scrotum had
inflated to the size of a basketball, and his belly was a distended, thumpable
tank of fluid that had oozed from his liver into his abdominal cavity.
And honestly, you can only give someone so much levophed.
So we called the charge nurse and asked if we could hand off
the other guy at 1500—the answer was yes—and then called the pulmonologist/intensivist,
our brilliant and beloved Dr. Padma, and asked if she felt like tapping this
guy’s abdomen.
She agreed with us: we needed to get some fluid off this
guy, and a quick bedside ultrasound showed that he had too much fluid in his
belly to measure easily just by looking at it. She said she would go finish her
rounds, then come back after shift change.
I sent Maycee on an extended lunch break. It’s hard to
absorb all the things you’ll see in an afternoon on the ICU if you’re not used
to it, and I firmly believe that part of the learning process involves time
spent staring at the wall, trying to piece all the memories and ideas together.
By the time she got back, it was ten minutes after shift change, and I had the
room more or less prepared for the paracentesis.
Dr. Padma set up a paracentesis kit at the bedside, and we
watched as she used the ultrasound machine to guide a needle into a
fluid-filled pocket of his abdomen, thread a hollow plastic catheter over it,
then withdraw the needle and leave the catheter to drain.
The bag that came with the kit filled to its total—a liter—almost
immediately. We emptied it, then drained some more, then realized that this was
going to continue for some time. So we hooked the catheter up to a wall suction
canister, turned it to low suck, and changed the canister every time it filled
up.
The fluid was thick and gooey and wheat-colored with a pink
tinge. It also foamed as it poured into the canister, forming a thick layer of
bubbles at the top that forced us to empty the one-liter canisters whenever
they hit 800mL. I explained to Maycee that the foaming came from protein
dissolved in the fluid, a common finding in ascites runoff. Albumin—yes, the
same protein that we give intravenously to thicken up the blood and draw in
fluid from the third space—is essentially the same thing that you get in egg
whites, albumen, which means it foams up nicely when agitated.
I pointed this out to Maycee, and added that you could
probably make a decent meringue out of the stuff. She tripped over a gratifying
dry-heave and then spat in the sink. “That’s fucking gross,” she said, the
first time I’d heard any real language out of her, but her tone of voice was
not one of censure.
I mean, you probably couldn’t make meringue out of it. Any
decent cook can tell you that any kind of lipid or protein impurity in the albumen
can keep the foam from locking; additionally, the acid-base balance of ascitic
fluid is more likely to be alkaline than acidic, which means you’d need a lot
of cream of tartar to make the foam stable.
Either way, the gates of gross stories had now been
unlocked. As we removed liter after liter of fluid from his abdomen—we totaled
at nine and a half liters—she told me about a pt she’d had once with severe
osteomyelitis in a leg-bone exposed by rotten diabetic flesh, who refused
amputation until the doctor reached into the wound and squished the bone
audibly, pointing out that it felt like soggy Triscuits.
I told her that one story about the guy and his mother and
all the cats, and she called bullshit, which is an appropriate reaction to a
story that grim (I will probably never have another story to rival it), but I
texted my coworker from that night: “Hey, remember that one guy and his mom?”
Thirty minutes later she responded: “FUCK YOU WHYD YOU BRING
THAT SHIT UP AGAIN”
“But you remember it, right?”
“Uh I’m carrying that smell to my grave. How’s your week
going, stinky oatmeal?”
The weird thing is that we actually do talk about this
almost every time we hang out. We get a bloody mary each and order a thing of
garlic cheese fries and sit there picking at the gooey stuff, talking about
that guy intermittently between gossiping about coworkers and bitching about
administration. I don’t know what we hope to unearth about it, or what draws us
back, but in some ways our friendship is about
that guy. We’re still working on it.
We finished the paracentesis and Dr. Padma retrieved the
catheter. In its wake the insertion site continued to ooze copiously. His blood
pressure gained by twenty points within thirty minutes, and we started
titrating the levophed down. We administered intravenous albumin again, and shortly
after that deep wrinkles appeared in his feet as the swelling started to
recede.
A short-term fix. We’d just reclaimed his abdomen as a
reservoir for extra fluid; he was still weeping internally. But it felt nice,
and it gave Maycee some visible indicator of the pt’s improvement.
The charge nurse appeared in the hallway and beckoned to
Maycee. “We’re putting in a trach and PEG down the hall,” she said. “You should
come see this.” I waved her off and wrapped up the shift while she and the
other preceptees crowded around my abd guy’s bed, watching the doctors attempt
to open a hole in his neck and one in his belly for breathing and feeding on a
long-term ventilator in a care facility.
He’s actually getting… not well, exactly, but better. His
hemorrhagic necrotizing pancreatitis seems to have turned around, and while I’m
sure he’ll never have full pancreatic function—or, at this point, full
neurological function, as he barely responds to questions and commands—he doesn’t
look like he’s going to die of this anymore.
At this point, it’ll probably be pneumonia that gets him.
That’s what usually gets people on long-term vents.
They did not have much luck with the trach, although the PEG
went in easily enough. He just has weird anatomy. It will need to be done
surgically.
I barely recognized him when I poked my head in. His hair
has grown a lot, and he’s grown a full beard and then had it shaved. The
distribution of weight in his face is really different. You can tell, now that
the swelling is down, that he’s not a tall man. As they cleaned him up after
the trach attempt and let him come back around, his eyes opened and he looked
around the room: a human expression of bewilderment, a hint of comprehension, a
glimpse… I regret, now, that I hoped he would die. He didn’t seem to be in much
pain, despite someone having just literally slit his throat. He looked uncomfortable,
but who knows what discomfort and pain mean to him now?
I wonder what his life is going to be like from this point
on. I wonder if he’ll ever really wake up. I wonder how much brain damage he
sustained during his intense illness, and whether the dialysis and the tube
feeding and the tracheostomy will give him some quality of life. It’s entirely
possible. It’s also possible that I’ll never know.
When the night nurse came on, he flipped his shit because we
had forgotten to change the propofol tubing at 1600. Because propofol is
suspended in a lipid solution, we change the tubing every twelve hours to keep
it from getting goopy; I had completely forgotten. I didn’t feel like the
flipout was completely appropriate, though. He browbeat Maycee when I left the
room and told her it was unacceptable to forget to change the tubing, which is
a bit much considering that she didn’t know the rules on propofol tubing—it was
entirely my fault—and that we were now three hours late on a non-critical task
with a pt we’d spent all day struggling to keep alive. Then he cornered her
into performing a full bed bath on
the pt with him before she left.
Well, part of a bed bath. He’s notorious for this: you give
report to him, and he’ll try to keep you until 2030 as his own private CNA,
bitching at you the whole time. I hooked Maycee by the elbow, gave the night
nurse a frosty look, and dragged my preceptee off to the break room to clock
out.
She looked exhausted, excited, ready for a few hours of
sleep and another shift tomorrow. She doesn’t even seem upset at the prospect
of spending another day in my tutelage.
I think she’ll do well.
