Dix, Hamm, and Pulmonary Fibrosis

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

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

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

The cure for pulmonary fibrosis is a lung transplant.

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

Ketamine

Somebody tried to tell me today that we aren't allowed to ride around dangling from the elbows on the cardiac walkers, making TIE fighter noises. Fortunately I was on a cardiac walker at the time so I just screeched away with my toes dangling over the linoleum, faster than they could shuffle after me in their Dansko mules.

We’ve had some extra-special pts on the ICU lately. Things seem to come in waves, a month at a time, and this month’s theme seems to be a tie between “exhausting psych” and “heartbreaking pulmonary fibrosis.” April started out with a seemingly straightforward admit: a woman with a fresh spinal fusion, history of chronic pain, and osteoporosis.

Ellen Hamm* was the first pt I took with my latest preceptee, Lizzie, who comes to us fresh from a psych hospital-- sharp and bright and already jaded as hell. “I hope my experience is useful on the ICU,” she said, and sighed when I toppled into chair-spinning gales of laughter.

Whitney the Muslim

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

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

Anyway.

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

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

Lucy, Ed, and Carl Hamilton Park

First impressions, outside the hospital, are predictable. Height, weight, color of skin, expression; handshake, attention span, first and last name. Maybe you find out what their laugh sounds like, or you notice how everyone else in the room watches them with wary admiration, or you discover that they spit when they pronounce their sibilants.

Inside the hospital, first impressions are just as predictable, but in different ways. Every shift begins and ends with report, and every report follows the same structure, a whole unit reciting the history and status of each patient every eight to twelve hours, in unison.

This is an anxious fifty-year-old woman, the night nurse told me, patient of Dr. Ling, here for hyperkalemia and possible sepsis secondary to C.diff superinfection. Here is her entire medical history: bowel cancer, diarrhea, multiple intestinal fistulae to both internal and external abdomen, repeated surgical revisions, perineal remodeling with multiple additional fistulae, urinary tract infections, incontinence. Here, look at these reports: learn all about her rectum, her vagina, her most private processes.

Here is a picture of her chest, a scan of her abdomen. Look at her body, right down to the bones. Look inside her. Here are all the molecules we’ve found in her blood, in their rightful and wrongful proportions. Here is a transcription of her heartbeat from twelve separate axes.

Oh, her name is Lucita. She goes by Lucy. Want to go in and meet her now?

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 7, Shift 1

Well, I definitely got the crazy little lady this morning, and no, my attempt at jinxing her didn’t work. But more on that in a bit.

My adorable pt with the screaming hearing aids had really bad sundowners last night, and spent all morning groggy and slow to communicate. Even after I put in her hearing aids, she mostly just lay in bed napping, drifting off mid-sentence every time I tried to have a conversation with her. Somebody had given her a bump of dilaudid last night for an episode of back pain, and she apparently processes opioids slower than I process an entire brick of cheddar cheese, so she was completely zorked most of the morning.

Her family came in and stood around the bed, morose, watching her mutter in her sleep. “She’s really gone downhill,” said her son. “Yesterday she was so bright and awake, and she was up in the chair for hours… Today she barely wakes up to say hello. What happened?”

I explained about the pain medicine and our plan to closely limit her opioid administration from here on out, and added that her labs were all improving and her vital signs were solid, and that I was recommending to the MD for her to be transferred to a unit with a lower level of acuity. The family was uneasy, and I don’t blame them—I was keeping a weather eye out for weirdness myself, because while I had a pretty good explanation for her behavior (or lack of behavior), any time family says their loved one is different, I pay attention. I can’t tell you how many times I’ve caught something that would have gone unrecognized—a heart attack, a stroke, a major status change—just because I pay attention when family is worried.

(Sometimes I have to completely ignore worried family, when their worry is pathological and they’re doing themselves and their families no favors… more on that later. And yet, if the family is worried, even if it’s just because they’re always worried, I stay at a higher level of worry all day. Not necessarily about the pt, especially if I can look at them and tell that they’re doing fine, but I have plenty of my own shit to worry about and if we’re having a party anyway, heeeey!)

In this case, I was definitely watching her closely, especially when family brought in some edible and drinkable treats to try and coax her into eating. I was concerned that, despite her passing her swallow eval earlier, she would (in her current groggy state) fall asleep while chewing and end up with a hamburger in her lung. I hovered by the bed while her daughter leaned over and bellowed in her ear: “MOM. DO YOU WANT SOME DIET DR. PEPPER.”

And man, her face lit up like Mardi Gras in Las Vegas. Her eyes popped wide open and she levered herself upright in bed like a vampire popping out of the coffin. “Do you have any?”

After that, she was still prone to drifting off, but now she had a vested interest in staying awake. Family? Pssshhh, you can see them anytime. Diet Dr. Pepper? Now that is worth feigning alertness.

Fortunately, she really wasn’t in need of a lot of care, and the doc agreed around 0900 to downgrade her acuity to telemetry. I say ‘fortunately’ because my other pt Martha*, the crazy lady from last night, demanded almost all of my time.

Her history of bipolar disorder has provided her with a history of lithium use, and last year she attempted suicide by taking all of her lithium pills at once. The ways in which people attempt to kill themselves just horrify me. Taking two bottles of Tylenol? Finishing off your Wellbutrin in a single go? Jesus, are you trying to make sure you suffer on your way out? I mean, I sincerely hate the idea that anyone has to deal with the utter bleakness of chronic depression and the spiral that leads down to suicide, and I wish to god nobody killed themselves at all, and I hate that our society makes mental illness such a hush-hush no-funding issue that people can reach that point of suffering without having the resources they need to escape… But the shit that people do to themselves trying to kill themselves, that shit is like an Eli Roth porno. Even handguns fail frequently enough; it’s not uncommon for a person to attempt suicide, fail, and have an entire lifetime of medical fallout to deal with… or six weeks of pure torture in the ICU before they finally manage to actually die.

And of those who succeed in slow motion… they all want to live by the time they die. It’s awful.

Please don’t fucking kill yourself. Entirely aside from the fact that you’ll miss all the movies of the next few decades, that you’ll miss the chance to fake your own death and escape to a South American country and become the mysterious foreigner who lives in the jungle, that you’ll leave behind a body that somebody has to clean up… you have a pretty significant chance of ending up in a nursing home, just conscious enough to feel pain and humiliation, for the rest of your life.

Give it another year. Do something different. Talk to somebody about it. Don’t end up on my unit with ARDS from inhaling your own vomit when the pills kick in. If the Huntington’s is closing in and you really gotta go before you turn into a slack-lipped veggie on a vent, plan that shit out and have your family by your bed. If you don’t think you could convince someone to sit by your bedside while you die, it’s not time for you to die yet.

Anyway, that’s a grim little side note. The point is, this lady took all her lithium pills, and after a major round of dialysis, she ended up with a seizure disorder, diabetes insipidus, and maybe about two-thirds of her original IQ. This time around, she’s in the hospital because a week ago she tripped and fell at home, broke most of her ribs on the left side, and ended up with a hemothorax—a big pool of blood in the space her left lung was trying to occupy—plus pneumonia from her immobility and from being unable to breathe deeply and cough without pain, plus dehydration from the DI, plus a UTI.

Diabetes insipidus is a totally different animal from what we usually refer to as ‘diabetes’. Diabetes mellitus—those of you with some base in languages may recognize the root of ‘mellitus’ to mean ‘honey’—is sugar diabetes, which I have ranted about at length here. Type 1 diabetes mellitus means all the insulin cells in your pancreas were devoured by your immune system in a bizarre childhood autocannibalistic orgy, and you probably need an insulin pump; Type 2 diabetes mellitus means your body is growing resistant to insulin and your pancreas is maybe not pumping out as much as you need, often because you have a genetic predisposition or (more likely) your fat cells are overstuffed and trying to tell you to lay off the cheesecake.

It’s called ‘mellitus’ because your kidneys are dumping sugar, and your piss turns sweet. Doctors used to have to taste their pts’ urine to see if they were diabetic. It’s never been a good career for the mentally well.

Diabetes insipidus, therefore, means that your urine is insipid instead of sweet—it’s bland and watery. Lucky doctor. The problem here is that, inside your braincase, your pituitary gland (yes, the gland responsible for dragging you through puberty) has become fucked up somehow. In addition to hairy-armpit hormones, your pituitary gland regulates your water balance, secreting a hormone called vasopressin to remind your body that it actually needs water to survive. (In higher doses, vasopressin also causes your vasculature, your blood vessels, to constrict and increase your blood pressure… thus the name ‘vasopressin’. We use a synthetic version of this regularly on the ICU to raise blood pressure in septic pts.) So if you have a pituitary tumor, or massive brain trauma, or certain types of toxicity like lithium… you will constantly gush gallons of dilute watery fifteenth-beer piss, even though you’re dehydrated and dying of thirst and could really, really use all that water you’re filling your Depends with.

So this woman was constantly in desperate need of a trip to the ladies’ room, which is hard to manage when you’re completely deranged from a urinary tract infection, your entire left chest is hamburger on the inside, and you aren’t firing on all cylinders to begin with. She couldn’t bring herself to use a bedpan, and initially she was too dizzy and sick to get up to a bedside commode, so she would try to hold it until she just couldn’t, then fill the bed with a liter of water-pee and start screaming. Nothing we said to her made any sense to her. She hit and kicked and screamed, and it took her daughter and a sitter to keep her in bed and safe and calm.

Her daughter looked familiar. I’d seen her last night in the hallway, but now that I was in the room with her, she looked really familiar. After the first ten minutes of introductions, I recognized her with a start—she’d been the caretaker for a pt I cared for at my last facility, and she’d been an absolute nightmare. A few delicate questions confirmed my suspicion, and she recognized me too.

She had been enormously controlling, extremely anxious, convinced that we were neglecting her ward even though her nurse could never even get out of the room. She would regularly decide that the pt needed something—a breathing treatment, a new medication, a very specific positioning, an aggressive round of nasotracheal suctioning—and she would insist on it until the doc either gave in or had a stern, invariably ugly talk with her about appropriate care. She was absolutely unable to manage her stress, and this led to her ward being absolutely punished with unnecessary and uncomfortable turns every time she got comfortable.

But this just meant I’d had time to establish a rapport and a set of boundaries with her, and thank living fuck, I was able to get those back into place pretty quickly. I promised to genuinely consider any request she made, but told her I wouldn’t sugarcoat anything or perform any kind of care that I felt endangered her mother, and that if she got stressed out I would stay in the room for fifteen minutes at a time while she went to the waiting room to collect herself.

It worked pretty well.

Then she fired the sitter. The new guy who’d come in for the morning shift is this super sweet CNA I’ve worked with several times, a tall black guy with a genuine smile and dimples to boot, who spent thirty minutes with me last time he floated to our floor while we scrubbed a massive Code Brown off the walls even though he could by rights have ducked out halfway through. He is a wonderful, compassionate human being whose bedside manner is gentle as a lamb and soothing as a fifth of whiskey, and within thirty minutes of his assuming sitter duty, the daughter fired him for being ‘intimidating’.

“My mom is kind of old-school,” she said, clutching her elbows and speaking in low tones, trying her damnedest not to sound racist as hell. “She gets really scared if there’s anyone… intimidating around.” Inside the room, my pt was holding the CNA’s hand and smiling at him while he asked her about her grandchildren.

I told her I would see what I could do, and dove into the chart. Turns out, this cute little old lady with the crazy thrashing etc had not received any pain medication during her stay besides her scheduled toradol, which seemed unrealistic to me considering that she had six broken ribs and regularly freaked out like somebody had filled her bed with bees. She had PRN dilaudid IV available, and I drew it up and headed into the room.

“Are you having pain,” I asked her.

“No,” she said. “I want to go home.”

“Are you hurting?” Sometimes it helps to ask again a different way. “Maybe just a little bit?”

“Yeeeeeah. But I want to go home. So I’m not hurting.”

“We’re gonna get you home as fast as I can,” I said, and pushed the dilaudid. Pts with dementia often have trouble recognizing and expressing pain, and sometimes they think that if they tell you they’re not hurting, they can go home faster. Sure enough, five minutes later she was sleeping like a baby, had peed another liter without freaking out, and had gone from shallow rapid breathing to deeper, regular breathing.

So I sent the CNA off to the charge nurse to be reassigned, and gave her round-the-clock dilaudid coverage. She woke up nicely between doses, no thrashing, coughed on command, and gradually improved to the point that she could get up to the bedside commode.

Pain control is a big deal. And it amazes me that, with all her WebMD recommendations for care, her daughter hadn’t seemed to pick up on her pain. She didn’t need a sitter for the rest of the day.

Her two other daughters dropped by that afternoon. One was even more anxious than the first, terrified of the hospital, terrified of her mother’s condition, not wanting to talk about any of it. The other was fairly laid-back, having worked for a nursing home for a long time, and was mostly stressed out because her sisters were stressed out.

The pt did have a seizure. It started with her eyes jerking to the left, which apparently is her characteristic onset symptom; her daughter called me in, and I gave her Ativan to break the seizure as it kicked in, so she ended up having a few seconds of genuine tonic-clonic seizing before lapsing into post-ictal grogginess.

About 1300, just after my hastily-shoveled lunch of microwave burrito and cottage cheese, the charge nurse cornered me. “I hate to do this,” she said, “but we have a new pt coming in and nobody to admit them. Can you give your tele lady to this other nurse, and admit?”

Charge just seems like a position where you have to constantly deliver bad news and ask people for huge favors. I will definitely want to train for charge someday, but I also dread the thought of having to tell someone that I’m screwing them over because their assignment is too easy and I need somebody to land a clusterfuck and you’re it.

So I gave report and handed off my cute little lady, who was chugging her fifth Diet Dr. Pepper, and took report from the emergency room on a frequent flier.

This poor guy has been in the hospital five times already this year, and god knows how many times last year. He has some kind of GI bleed, probably in his small intestine, which recurs regularly for no reason anybody can pin down—no history of alcohol, no NSAID use, no fucking idea. Last year he had what our GI docs call the “million-dollar workup,” a cascade of diagnostic tests culminating in a literal swallowed camera capsule that films your entire gut as it passes through. No results.

This time his hematocrit was really, really low. I gave him several blood products and wiped his ass a few times while he shit out the last of the blood, and his GI bleed was over—just a couple days of blood transfusion and crit checks, and he’d be back home with his mystery bleed, happy as you please. He’s been here so often that the docs ordered him a full meal plan as soon as his crit stabilized, recognizing his telltale signs of recovery. Usually GI bleeders have to wait a while to eat… we just know that this poor guy is done bleeding once he starts getting hungry, and there’s no use in keeping him ravenous all the way up to discharge.

We did an EGD though, because we kind of have to, because it would be shitty to miss a bleeding ulcer just because he’s never had one before, and have him perf his stomach and die. It was a five-minute affair and he was damn near awake for the whole thing—he said he was used to it by now. That is not a thing I can imagine getting used to. He had a beautiful pink happy stomach lining though. His breakfast of scrambled eggs was still intact and recognizable and made me extremely hungry. I really need to start bringing multiple freezer burritos per shift.

I got hiccups toward the end of shift. I used to get them all the time on nights, usually between three and four in the morning, big whooping hiccups that sounded like some kind of lost stork wandering the darkened hallways calling for its young. My coworkers used to make relentless fun of me. Well, guess what, these coworkers also make fun of me when I start yelling HOOP uncontrollably in the middle of shift.

I could close my mouth and kind of muffle them, but that hurts. So fuck you, I’m gonna contribute to noise pollution, and you can all suck it and/or wear earplugs.

I hope this doesn’t become a regular thing.

At 1500 shift change, the new charge nurse dropped by and poked her head into the room. The pt’s daughter gasped. “Oh my god, I didn’t know you worked here now!” Turns out, this particular charge nurse once directed the adult family care center where my pt’s mother spent her declining years, had known my pt since she was a teenager, and had held all three anxious daughters while they were all still in diapers.  There was a distinct change in the dynamic after that—they seemed to trust us more, now that their old friend was in charge, and I didn’t have to enforce boundaries quite so stringently.

It’s a small fucking world, my friends. I never met this charge nurse before I started working here, and now here I am, taking care of a pt she practically raised, whose daughter I knew from another facility as a pt caregiver. This isn’t a huge city/region (technically the two facilities are in different cities, part of the sprawl of the central metro), but I am always amazed at how often I run into nurses I know from other places, pts I took care of years ago, and people I have to pretend not to recognize lest I violate HIPAA or make shit awkward.

Been checking up on my abd guy. Yeah, he’s still alive. Why, how, I’m not sure. His hemorrhagic necrotizing pancreatitis and total kidney failure have reduced his quality of life to “constant torture when he’s not in a coma.” Lots of legal pushing later, and they’ve assigned him a guardian ad litem… who now has to jump through a million legal hoops and decide whether or not to let him just die.

It’s not an easy choice. He’s very far removed from anyone who could speak for him. His roommate, who only realized he was hospitalized because nobody was using the toilet paper for three days, says he has a daughter somewhere…. But he’s never said her name, just called her ‘my daughter’. He left no living will, no advance directive, nobody with a durable power of attorney.

His coworkers keep coming by to check on him. They’ve all shelled out to get a rental storage unit for his belongings; they show up in their work uniforms, still sweaty and obviously exhausted from their shifts, to stand by his bedside for a few moments and tell him what’s going on at work. We can’t tell if he understands any of it. He opens his eyes sometimes to painful stimuli.

They obviously care about him a lot, and to me this means something. Most people who suffer from major addictions don’t have a lot of people who care about them; they sever their ties, drive away their families, and are slowly devoured by whatever chemical owns them, alone. Even recovering addicts usually spend a little while with their only friends being fellow recovering addicts, if they’ve been addicted for some time. At least that’s what it feels like.

But it’s telling that this guy, despite being a profound alcoholic, separated from family and friends, struggling with addiction, is still someone that his coworkers care about. They’ve worked with him for a long time. Some of them know that he had big issues with alcohol, and have delicately made the awkward effort to inform his nurses so we can “make sure that gets taken care of too.” They really miss him, and that means something to me—even feeling isolated, even in the throes of addiction, even sweating on his deathbed… he (like many other addicts) is still loved. And they are so glad to see him get help that they’re holding out hope he’ll recover, even though he’s long past the point where his death can be more than delayed.

It breaks my heart. I wish he’d got help sooner. He would have been surrounded with love.

In the meantime, all I can really hope for him is that he dies soon, and quickly. Maybe somebody will show up for him that has some legal authority.

Fucking depressing, man. On a bright note, today one of the consulting MDs accidentally locked himself into the staff bathroom, jamming the doorknob somehow. While the environmental services guys scrambled to try and get him out, he kept up a steady litany of exhortations and pleas: “You guys have to hurry, I gotta get out of here. I took a power dump in here. You gotta get me out, guys. Take off the hinges…”

I’d laugh harder if I didn’t occasionally get locked in a room with a pt who’s shitting uncontrollably. The aftermath of a three-pounder is nothing you wanna breathe in a closed space.

I have no idea what week this is but it's Friday

I had Friday off. I spent it on meaningless bullshit and faffery, for the most part; my sister and I had a meeting with her new guidance counselor to schedule some aptitude testing and discuss tutoring/counseling options for the next week. She’s settling in well—learning things like “how to make a sandwich” and “how to use a bus.” I feel like I’ve been working almost every day since she arrived.

Saturday morning I assumed the role of first admit nurse, then took report on one pt, a frequent flyer who has been notorious for her poor adherence to heart failure medications and home bipap use. She is cared for almost entirely by her devoted son, who does a fine job except that she refuses a lot of care, and hits. Or did. Last time she was here we put her on a horse-tranquilizing dose of Paxil, and this time around she’s been fairly pleasant and cooperative.

Her son is a very gentle sort, a little bit Bob Ross and a little bit hapless victim, so I was quite surprised to hear him call the Paxil her “anti-bitch pills.” He said it in such a self-deprecating way that it took me a moment to realize he was making a joke. I suspect that his life has changed a lot for the better since we started her on the meds.

She hadn’t been handling her bipap well lately, though, so not only had she collected lots of carbon dioxide, but her heart failure was really acting up. Explaining this will take a little bit of pathophysiology, so buckle in.

The old ICU saying goes: if you ain’t got pressure, you ain’t got shit. Blood pressure is so crucial to survival that we’ve even changed our CPR methods to emphasize compressions—pressing on the heart to maintain some blood pressure—and decreased the whole rescue-breathing thing to “meh, if you have time, but don’t stop compressions.” Oxygenation and ventilation (remember, ventilation refers to airing out the carbon dioxide in your blood) are important, but without pressure, you can’t get the oxygen to the tissues or return CO2-laden blood from the tissues. And your body can deal with a little low oxygen or high CO2 (your blood keeps a huge amount of oxygen after its first pump-through!), but not with a loss of pressure.

But what if you have too much pressure? High blood pressure makes tiny tears in your veins, which scab and scar and become susceptible to clots. Not as damaging as high blood sugar, which is like knives in your blood, but it will definitely tear you up inside. And if your blood pressure gets too high, you might blow a blood vessel in your brain—you will typically feel a headache only once it’s too late to do more than contain the bleed. High blood pressure is a silent killer.

What about if you have a pressure imbalance? That’s what’s happening to this lady. She has an obstructive breathing disease, with nasty sleep apnea that traps air in her lungs while she sleeps. The pressure in her lungs grows and grows as her body struggles to overcome her collapsed airways, until finally the air escapes with a whoosh and she can start the process of gasping for more air. There’s a reason people with sleep apnea are always tired and shitty-feeling: they spend their nights suffocating.

Meanwhile, the right side of the heart, which pumps blood into the lungs to be oxygenated, has to pump against a huge amount of pressure. As the pressure grows in the lungs, the blood has to be squeeeeeezed in with incredible force, and eventually the right side of the heart blows out like a stepped-on water balloon, becoming weak and floppy, and struggling to empty itself so more blood can return from the body. So blood backs up in the body, and the water that would normally be peed away by the kidneys just squeezes out into your tissues instead. Usually the lower part of your body first. People with right-sided heart failure get giant, swollen ogre legs, which get so stretched out they form big bubbly scars where water is tucked away, never to be returned to the bloodstream again.

One of the most crucial treatments for this is a diuretic, a water pill that convinces the kidneys to pee extra water away while it has the chance, since it’ll take a lot more work for the body to get water all the way back around to the kidneys again. So if you are, say, a grouchy old lady who hits nurses and doesn’t believe in taking her pills, pretty soon you’re retaining more water than New Orleans in hurricane season. And if your bipap is lying in a drawer while you sleep, your CO2 rises, and you become too groggy from CO2 poisoning to wake up and breathe.

CPAP and BiPAP can help a lot with this too. CPAP gives a little boost of air pressure to keep the airways open; BiPAP uses two different pressure levels, one for inspiration and the other for expiration. The increase in pressure is absolutely minimal compared to the whole “lungs stuck shut” pressure differential, and the overall result is that the lungs stay open, the volume of air (and thus the ventilation of CO2) is maximized, and the pt is wildly uncomfortable for the first little bit and then suddenly realizes they can breathe again. Nobody wants to wear a mask over their face… until they realize they can finally sleep like a real human with the mask on.

So she came in to the hospital nearly comatose, swollen up like a marshmallow in the microwave, smelling like the inside of a hobo’s shoe. I have a personal thing about stinky pts: I want them to be clean. I will make them clean if it kills me. Under no circumstances short of immediate, life-threatening danger will I allow my pts to lie in their filth with a baguette’s worth of yeasty crust on their scalp and a gunt-tuck full of smegma the texture and color of butterscotch pudding. If you come into my merciful care and your vagina is oozing all-natural Cheez Wiz, you had better get ready to spread.

I shoved a bedpan under her head and shoulders and soaked her in warm soapy water up to the ears, periodically sloshing more over her scalp and dumping the detritus in the toilet to be replaced with more. Once the water started clearing up, I emptied half a bottle of chlorhexadine mouthwash into the next round, and let that seep through the microbial rainforest of her ratty hair until the tectonic plates of yeast-plaque gave up and let go. The scalp underneath was raw and pink and looked like a fresh pork chop with a little incidental gray hair growing out of it.

All her folds I scrubbed, with the help of the long-suffering CNA, lashing the creases with antifungal powder and lining them with folded absorbent pads. The less said about her lady parts the better, but I can’t imagine how anyone could have dustflaps that yeast-eaten and not cry like a kicked dog every time they took a piss.

Her son came in near the end of the scrub-a-thon and gaped. “She never lets me wash her,” he said. “The last time I tried, she hit me and said she’d be dead before anybody washed her hair again.”

“Well, unconscious,” I said, and added that if she really wanted to stay filthy she was going to have to make sure she took her medicine so she wouldn’t become unconscious and be at the mercy of nurses again.

Then I got a call from the charge nurse: a rapid response from upstairs would be my admit, an alcoholic gentleman who had come in with pancreatitis three days before, gone into massive withdrawal, and then become so short of breath that he was being emergently intubated upstairs.

I knew right away it was going to be a clusterfuck. The intensivist was up to his neck in the drowned kid’s case, and was in the middle of a chest tube insertion that would need to be followed by a bronchoscopy. His acute lung injury was reaching the point where he couldn’t maintain decent oxygen levels, let alone ventilate effectively. Worse, he’d started to show signs of severe brain injury, small seizures that ramped up throughout the day until (right around the time I left) he was in status epilepticus, a massive seizure storm that we couldn’t seem to get under control. Needless to say, if my guy was going to be trouble, he was going to be my trouble.

Naturally, he showed up looking like yesterday’s shit. Blood pressure tanking, legs cold and mottled, foley catheter having drained less than 5mL of urine per hour (we start worrying at 30mL/hr) for the last six hours, nostrils flaring to suck in more air even while the ventilator forced each breath in. His anion gap—a measure of his energy status on the cellular level—was incredibly elevated, along with his blood glucose, which suggested that his sugar was staying in his blood rather than being eaten by his cells. His body was acidotic, which supported that idea—starving cells shit out torrents of lactic acid—but, weirdly, his potassium levels were low.

Those of you who have been following this blog for a bit have already been bashed over the head with the relationship between insulin, sugar, and potassium, but I will explain it again for the new admits. Insulin isn’t a magic anti-sugar substance—it’s just the key that opens your cells’ mouths so they can eat the sugar out of your blood. It also lets them eat potassium, which is a positive anion that keeps the inside of the cell electrically imbalanced against the outside (where negative sodium ions and other such things float around). Between the potassium, which is the electricity that powers the cells’ pumps, and the sugar, which is the gasoline that powers their engines, insulin keeps your cells purring along like that Nissan 240Z pignose you had in college and will never forget.

(I did not have that car. I barely know what that car is. My husband had that car and still obsessively draws pictures of it, rhapsodizes about it, and laments its demise to this day. He likes engines a lot and likes to stay up late at night and look at pictures of old Soviet planes until three in the morning, hurriedly switching windows back to wholesome Miata portraiture when I stumble to the kitchen for a glass of water. This is a dumb derail and I will stop.)

If there’s not enough insulin, or if your cells have become resistant to insulin, your blood sugar will soar as your cells starve. Potassium lingers in the blood, slowly throwing off the balance of positive and negative until muscle cells—especially heart muscle cells—can’t function properly. As your cells rip themselves to pieces, looking for anything they can burn for energy, pouring out lactic acid diarrhea from eating their own garbage, your heart begins to short out and beat erratically.

So it was really weird that he was hypokalemic—LOW on potassium. Especially since his kidneys had started failing, and thus weren’t able to dump any potassium. Even weirder, his lactic acid levels were still fairly low. (I can tell you now, days and days later, that even nephrology was never quite able to pin down the reason behind the rhyme with this one. Actual quote, with warning for medical blather: “Anion gap acidosis. The large anion gap is unexplained by the minimally elevated lactate or phosphorus level. The acidosis is larger than the ABG or serum bicarb suggests since he is currently receiving 180 mEq per day of sodium bicarbonate. Doubt ketosis. Doubt salicylate at this point in hospitalization. Because of ileus, could possiblly have d lacate. No heavy lorazepam (he did have several doses IV) or other propylene glycol ingestion.”)

But all this weirdness aside, I can tell you he was sicker than shit. His abdomen was HUGELY distended and hard to the touch. It’s not uncommon for people with pancreatitis to have swollen, painful bellies—really, that’s usually what brings them in—but this was just out of control. I laid him flat to turn him, and his blood pressure bombed. His ice-cold, mottled legs had no pulses. I sat him back up and he recovered his blood pressure, and I developed a hunch.

Low blood pressure from sepsis isn’t positional. Positional hypotension usually means that either the aorta is so scarred up (usually from smoking) that the heart can’t push blood hard enough to reach the brain when you stand up, or that something is crushing your heart in one position and not in another position. I suspected abdominal compartment syndrome. 

Compartment syndrome is what happens when some part of your body is so swollen that it fills up its entire "compartment" and crushes itself, preventing blood from circulating to the tissue. Compartment syndrome in an arm or a leg can result in losing the limb, and the primary treatment is a fasciotomy: a deep slash that opens the muscle sheath-- the fascia-- so the swollen tissue has somewhere to expand to.

But what if you have massive pancreatitis, and your intestines are so swollen they're crushing all your internal organs, blocking your aorta, preventing blood from returning to your heart, and blocking any blood flow to themselves at all?

One carefully worded discussion with the intensivist-- who was moving the drowned boy into a rotoprone bed, which would rock him gently face-down to help drain his lungs and keep them open-- I got permission to put in a consult by a GI surgeon. "If he's pissed," said the intensivist, "I'm gonna tell him it was the pushy nurse that put in that order." We get along well and are facebook friends, but he's testy when pressed and haaaates being told what to do.

Whatever. Put in the consult with a note of my own-- STAT PLEASE SUSPECT ABD COMPARTMENT SYNDROME-- and within an hour the GI surgeon had cleared his slate and called in the team for an open abdomen washout.

He returned three hours later with his guts still open. A plastic bag contained his bright-red, massively swollen small intestine, sutured to the edges of his incision. Gooey abdominal fluid poured from every crease and seam. His urine output picked up a little, but to this date he hasn't recovered kidney function yet. His legs turned pink again, and his breathing eased. His guts had been crushing him to death.

I had him almost stable by the time night shift arrived. I gave report, helped clean and turn and mop his juices out of the bed, and staggered out of the hospital. I was so tired I slept in my car for an hour before I could drive home.

I will tell you all more about his care and progress tomorrow, and hopefully get caught up completely, as I finally DON'T work tomorrow. For now, I will tell you that there is an actual photograph of his guts posted on my Patreon, and that shit only gets crazier.

Rachel was readmitted that day. She was having sharp pleural pains in her side, and she has a pneumothorax. She's getting another chest tube, but isn't expected to stay long. She's gained ten pounds since discharge and is as sweet as ever.

A forty-five-year-old woman died that day of sudden-onset pneumonia with hypoxia. We are all a little stressed over all these young, incredibly sick pts.

Week 2 Shift 2

Every morning at my main facility we all cluster around the front station, receive our assignments, collect our walkie-talkies, and get a quick summary of the daily shift news. Yesterday’s morning started out very strangely for me, because I was unusually late and clocked in at 0645 exactly, when group report starts. This meant that by the time I made it to the front desk, everyone else already knew who I’d be taking care of, and they all watched me approach with this blend of pity and relief that told me right away what was about to happen.

I was getting an albatross.

I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.

Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.

Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.

I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.

Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.

What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.

He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:

--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.

--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.

--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.

Lucky me.

So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.

HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.

I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.

My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.

After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?

At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.

She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."

I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.

Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever. 

To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.

The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.

So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.

CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.

This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.

It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.

Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.

Week 1 Shift 2 (technically 6 of 7)

Today started off much better than yesterday. Got my pts back; the little old man with bradycardia recovered overnight and was able to go home by 0930 without having to get a pacemaker. He was delighted and I was also glad for him, not least because getting discharged to home from the ICU almost never happens before lunch. I am a discharge beast though. Spent maybe twenty minutes after his discharge quietly charting in the end of the hallway where the lights hadn't been turned up yet. The suction canister in the empty room created a strange auditory illusion, as if I were sitting near a pond full of frogs all chiming at once. The dim light and weirdly outdoor sound is very soothing and I am relaxed as I drink my first coffee of the day and finish documenting that my patients are still alive and functioning.

The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.

Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain. 

He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.

Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.

He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.

After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.

Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.

"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."

"Why can't I eat what I want? I'm sick, I need comfort food."

"Sir, you just had a heart attack."

He looked at me like I had just started speaking Urdu. "...And?"

Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.

Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.

Darwin is coming for you, sir.

At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.

At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.

Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.

Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die. 

I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.

I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.

The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.

I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.

She really is getting better. I think she stands a chance.

There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.

I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.