Hugging, Mrs. Beaumont, and the Fat Cunt Guy

Let’s just get this out of the way: I’m weird about hugging. I’m not the type to have anxiety attacks when someone invades my space, although I know plenty of people who are. I just grew up in Texas. The sheer number of people who’ve armpitted me in Wal-Mart on the grounds that our grandparents used to go to the same hairdresser…

And while we’re admitting things, I’ll get this off my chest: I think pts are gross. Their families are gross. I, while I’m inside the hospital, am gross. Literally everything and everyone within a block of my job is disgusting and I generally assume that anything touching me while I’m at work is probably covered in a thick fondant of shit and dead roaches.

It might be a little dysfunctional, but this is just how my brain works. It helps me keep track of who’s touching me and how much shit I have on my body at any given time.

So you can imagine how delighted I was when I introduced myself to my pt and her daughter and was immediately greeted with a full-frontal hug.

Mrs Leakey, Jelena, and Wen Li

So, uh, I’ve been on hiatus.

I’ve been working on a few chapters for a book proposal, and trying to get things pretty enough to be useful for publication, but I really REALLY prefer blogging to book writing (at least in this format) and I’d like to get back to this. So I plan to keep working on the blog, not necessarily shift-by-shift but following specific batches of pts, and work on the book between posts.

The upside to this is: I have a lot to tell you guys about. I expect to update once a week from here on out, and I actually have a backlog of posts ready to go, so there shouldn’t be any major hiccups for a while.

You have been wonderful and supportive, all of you, and I promise that if any of you is ever unfortunate enough to end up under my care, I will wipe your asses with the warm wet wipes.

(I also told a trio of trusted coworkers about my blog, so they could peek over it and make sure it’s both factual and HIPPA-compliant. All three of them immediately identified Crowbarrens. Life is good.)

Anyway. Let me tell you about Mrs. Leakey.

Week 8 Shift 2

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.

Week 2 Shift 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 2 Shift 1

By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat. 

I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.

Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late. 

Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.

He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.

A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy. 

Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.

It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.

I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak. 

Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.

It's just much easier to package this as a superstition.

I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.

After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery. 

They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.

This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.

And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.

But that's just, like, my opinion, man.

My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.

Wait until they find out how I feel about the Silmarillion.

PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.

HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:

--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.

It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid. 

She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.

She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.

We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.

Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.

The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.

I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.

By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.

Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.

Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.

I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.

The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.

I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.

Now I'm going to have a nap.

Week 1 Shift 3 (7 of 7)

I slept until 0900 this morning, laid in bed playing Monument Valley on my phone until 1045 (I have legitimately not played this game at all despite all my friends telling me I would love it), then convinced myself that brunch and a shower sounded better than just lying in bed forever. The shower was amazing because it took place in the middle of the day with no time constraints and I could shave everything and spend plenty of time staring at the wall and thinking about absolutely nothing. Showers are usually ten minutes of scrubbing, shampooing, and telling myself aloud: "Come on, come on, you're okay." They usually take place at 0530. 

This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.

Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.

The point of all this is: I will write up this report in extreme comfort.

Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)

Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.

Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?

Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.

Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down. 

One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.

Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.

Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker). 

The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.

The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.

And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.

Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable. 

Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right. 

He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.

The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.

Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.

Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.

This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.

The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"

Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.

She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point. 

Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.

PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.

I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.