Thursday I rolled into work around 1045, having juggled my hours to accommodate the concert. Getting out at 1500 on Wed was just enough time to let me stagger home, wash my gross self, nap for an hour, and put on some real-people clothes before the festivities commenced. Coming back in at 1100 on Thurs let me sleep in, which I desperately needed (and still need, and will always need even when I don’t get it). So I was well-rested, well-fed, and wearing my best work pajamas when I showed up at the nurses’ station and asked about my assignment.
Charge nurse put on a very serious face and asked if I would be comfortable getting oriented to hearts at this facility today.
Open hearts are a big deal, the moneymaker of any ICU that does them. Nurses that take fresh open heart recoveries are rigorously trained, tested, precepted, and even given classroom time on the unit’s dollar to make sure they’re fully equipped. Heart pts are delicate, touchy, and heavily regulated, but a really sharp RN with lots of training can keep everything moving smoothly despite the inevitable hiccups. I had not taken a fresh open heart in something like nine months, because even a few months before I left my last facility, the open-heart program became a dangerous place for a relatively inexperienced nurse.
A second-day heart pt had been assigned to a non-heart night nurse due to understaffing, with the idea that the heart-certified charge nurse would be able to back her up and keep things running smoothly. Instead, the pt lost conduction (valve replacements often do, though it’s less common for this to happen on the second or third days) and dropped their heartbeat completely. They ended up coding her for almost thirty minutes before someone thought to hook up her pacemaker, and after thirty more minutes without success they called the code.
The charge nurse was hung out to dry, and retired to PACU a few months later. The unfortunate unit nurse assigned to the pt was scapegoated roundly, despite having never been trained on hearts and therefore lacking the reflex to hook up the pacer to the V-wires sticking out of the pt’s chest. Every hiccup in every recovery for the next six months was scrutinized, written up, and presented “in a meeting” between managerial staff and the heart nurse in question. Everyone on the unit was trained in temporary pacer management, but when the heart RNs requested additional training to address the hiccups that were obviously such a big problem now, they were given no more education—just stripped of autonomy and grilled after every case.
I voluntarily removed myself from the heart list. Which is sad, because I fucking love hearts. They are a huge rush and the detail and precision and reflex required is a serious, galvanizing challenge. There’s also an element of prestige to the open heart program, which I like because I am a bit shallow and vain. Succeeding at the challenge makes me feel like a Real Nurse instead of the secret imposter I usually feel like I am.
The imposter thing is a huge deal in my life. Even writing this diary is kind of terrifying to me, because I know that I’m getting some things wrong and there are probably people shaking their heads and wondering why I suck so bad. I’ve worked ICU since 2008 and I still regularly encounter things that make me feel like a clueless kid wearing borrowed scrubs, things I should have known but didn’t, moments of dumb that make me cringe for months. I am deeply afraid of appearing stupid or uneducated or incompetent. One of the hardest things in my practice is recovering rusty skills—things I used to do well, but which I haven’t done for a while, and which I might be expected to perform competently but will probably make mistakes with. I am constantly ashamed of myself, and sometimes this makes me defensive or aggressive when I really shouldn’t be.
Mostly I channel it into fighting my innate laziness. I don’t want to look like a piece of shit nurse who can’t do anything without her hand being held, so I constantly educate myself, refresh my skills, pay attention to the details, and attend to the shitty boring jobs as well as the exciting flashy ones.
So taking this heart pt was very important to me, and although my shamepanic drive geared up for a beating, I accepted the assignment. As a psychological incentive, there was also an element of the unit really needing a few more heart nurses—my other great fear is abandonment, which means that I am at my most comfortable and secure when I feel necessary. It’s vital that I keep that impulse in check, because a hospital will chew you up and spit you out if you can’t resist the phrase “we really need you.” And nobody in a hospital is truly indispensable, so at some point in every work situation I will inevitably encounter the truth that I will never be perfect and that perfection is not required for me to be valuable. But I allow myself a few smug moments sometimes to enjoy my employers’ gratitude and/or relief, just as I occasionally remind myself that if I don’t get my job done right, I will get in just as much trouble as the next nurse down the hall.
My value is earned, and if I fuck around and make messes, other people are entitled to avoid me—which means that the approval and security I crave is a predictable resource I can expect if I fulfill certain realistic expectations, and am entitled to demand if it’s inappropriately withheld.
There was a time when I handled things with much less self-awareness. Approval and love were like an endless series of rocks thrown into the emotional well of my insecurity, each little splash a momentary fix, while the whole time I acted like a crazy person, trying to drive the source of approval away to “prove” that my fears were legitimate and that the splashes would stop coming. I was an incredibly challenging person to care about. I think the only reason I finally escaped that personality hellhole was that I got into nursing, where my value was measured in life and death and hourly wage. It’s hard to lie to yourself about patient outcomes.
I’m pretty sure nursing saved my life.
I’m also pretty sure this diary is not at its best when I’m navel-gazing in it. Lo siento, my friends.
Anyway, Mavi*, one of the best heart nurses on the unit, offered to be my second/preceptor for the day. She is a tiny Filipina woman with beastly skills, ice-cold reflexes, and the kind of gentle, humorous nursing style that makes everyone around her comfortable and happy.
We prepared the room and sat down to get me oriented to the paperwork and charting. Every fresh heart has a primary nurse (in this case, me) and a second (Mavi), with distinct roles in the recovery process—there is a hell of a lot of work to do during those first few hours. Every facility documents its hearts a little differently, and every surgeon has their own preferences and quirks, and every heart nurse needs to get familiar with the details very quickly so they can be second nature by the time they’re making decisions about which medication to start.
This surgeon doesn’t like SCDs (leg massager pumps used to prevent blood clots from forming), prefers to be texted rather than paged, dislikes high doses of epinephrine used as a pressor, and is blazing fast at his job. He also plays jazz guitar, was once an aerospace engineer (his first career), and is in active military duty through some branch or other. I was a little intimidated, to be honest. Mavi put the surgeon’s number in my phone while we looked over the procedural chart for landing a fresh heart, which she wrote a while back and which has become official paperwork because it rocks.
Off-pump call came about four hours after surgery started, which was incredible, considering that the guy had a valve replaced (requires cutting into the heart itself), a coronary artery bypass graft (CABG, requires harvesting a vein or artery from somewhere else in the body), and a double MAZE procedure (a labyrinth of burn scars in both atria to prevent atrial fibrillation). This is a whole lot of stuff to have done in a single surgery, let alone in a mere four hours of surgery.
Elevator call is typically an hour after off-pump call. Once the pt is taken off the bypass pump and their heart is restarted, the team still needs to close the chest and perform a few other little tune-ups, then watch the pt until they’re satisfied that he’s stable. Then they give one last notification to the ICU and load the whole crew into the elevator. So the pt arrived, intubated and still working off the anesthesia, with a churning nest of OR nurses, techs, and anesthetologists squirming all over him. Mavi hooked him up to monitors while I checked on his chest tubes; Mavi drew up his initial labs while I charted until my eyes started to sweat. Mavi performed foley care; I ran hemodynamics through his swann catheter, checking on the function of his various cardiac components. I listened to his heart and lungs—this is especially important in valve surgeries, since a valve problem will usually be audible as a murmur—and Mavi examined his pacer wires and vent settings.
He was atrially paced. Many valve pts come back with their pacer wires hooked up and firing, either by directly stimulating the ventricles (the big chambers at the bottom of the heart, the ones with all the kick) or by starting the electric cascade in the atria (the little chambers whose job is mostly to pack extra blood into the big chambers and stretch them out bigger so they can beat harder). Some surgeons prefer to let the ventricles fill on their own and just pace from the ventricles themselves. In valve surgery, the actual heart itself is cut and the nerves are very unhappy, especially the nerves responsible for relaying messages from the atria (where each beat starts) down to the ventricles (where the beat ends with a big push). Angry, swollen, shocky nerves don’t relay impulses well, and thus any beat that starts at the top of the heart—whether natural or atrially paced—may not get conducted all the way to the bottom.
But that atrial kick gets a lot more mileage out of each beat. Imagine holding a water balloon in your fist, and squeezing it until it pops. If the balloon was filled just by dunking the empty balloon into a bucket of water, it won’t have much water inside, and your fist will have to squeeze really hard to pop the balloon. But if you hooked the same balloon up to a water hose and filled it until it was ready to pop in the first place, the balloon itself wants to return to its original shape—it has mechanical elasticity, and your fist only has to work a little to make it pop. In this case, the ‘pop’ is the force of perfusing your entire body with blood, and the water hose is the atrial kick that forces extra blood into your ventricles. So atrial pacing is a great place to start a cardiac pt. If you lose conduction, you can always hook up the ventricular pacer wires and stimulate beats that way.
His blood pressure and cardiac output, of course, started to drop very quickly. The recently-cut heart is stiff and shocky and stressed out, and its walls don’t want to move very well. Plus, the body is reacting to the insult of being cut up and partially exsanguinated by shifting fluid around its various spaces, pulling water out of the blood into the tissues where it’s mostly useless except to swell up and make you look puffy. So we administer fluids, to replenish the thirsty bloodstream, and we administer albumin, which thickens up the blood (increases its osmolarity) to suck water back out of the tissues into the blood vessels.
To support the blood pressure, we use several different medications by steady drip. I am pretty used to using dobutamine as a front-line inotrope—that is, the first drug I turn to when I need to stimulate the heart to squeeze harder instead of faster. This surgeon, however, prefers epinephrine, aka adrenaline, which both speeds the heart (a chronotrope) and increases its contractility (an inotrope). As the pt’s recovery continued, we shifted from the fluid-moving phase to the vasodilation phase, in which the body really wants to relax its veins and dump all its fluid into the tissues. Here we started using phenylephrine, also known as neosynephrine, which is a pure vasopressor—that is, it tightens up your blood vessels, and doesn’t affect the workings of your heart. In the same way that you get higher pressure by squirting water through a straw than through a hose with the same force, tighter blood vessels increase pressure… although they resist the heart’s beats a little harder.
One of the other big bad pressors, norepinephrine/noradrenaline, is also known as Levophed… or, in ICU parlance, leave-‘em-dead. It will squeeze the living shit out of your blood vessels until your toes drop off, which is what happened to my CRRT lady a while back. If you find yourself using norepi on a cardiac surgery pt, something has gone extremely wrong. The other two pressors, vasopressin and dopamine, I will probably talk about later, when I have a pt I’m using them on.
Within about two hours of his arrival on the unit, he awakened enough from general anesthesia that he could open his eyes, lift his head, and follow commands, so we pulled out his breathing tube and let him breathe on his own. A little morphine for pain, a few ice chips for his dry throat, and he was happy as a clam in sauce.
He was also convinced that I spoke exclusively German, and was courteous enough to speak exclusively German to me. I do not speak German at all, so occasionally I would rattle back at him in hospital Spanish (I cut my ICU teeth in Texas) and he would recoil, startled. He is a world traveler and historian and as he came back to his senses throughout the afternoon he and I had many wonderful conversations in English. Any time he drifted off though, he would wake up, look at me, and start speaking German again.
Man, I don’t know. I don’t even look German. I have enormous bushy brown hair, a prominent forehead, freckles, glasses, and the kind of sloppily-assembled facial features you get from slightly inbred trailer trash that grew up in the river bottom. I look like leftover tax dodger and piney-woods moonshiner and hastily concealed ancestor ethnicity back when Irish was considered ‘ethnic’. I am white as shit, but not in the classy-lookin’ European way, is what I’m saying. Four years ago, before suffering my way through braces, I had buck teeth.
I’m not exactly pretty, but fuckin hell man, I don’t have to be. I am the apocalyptic definition of ‘personality hot’. I’m the lady equivalent of that weird-lookin fucker on TV that’s sixty years old and worryingly asymmetrical in the face parts and could bang your girlfriend in the bathroom at your favorite bar after five minutes of conversation. I am also incredibly arrogant and don’t speak a word of German. It’s quite possible that he was just telling me how my face is so gnarly it’s giving him flashbacks to WWII.
We joked a little about our respective experiences with foreign languages, and he taught me a little about the ways in which Italian deviates from Spanish. I taught him to say “qapla’.” I can’t help but feel that I got the better end of that deal.
Anyway, linguistic barriers aside, by the time we had this guy settled down and feeling pretty good, I had an imperial shit-ton of charting to get done, so Mavi watched him for a bit while I had lunch and then tore into the paperwork. The surgeon came by to see how the guy was doing, and I noticed that he was wearing an honest-to-god Starfleet insignia badge on his white coat, which after my earlier Klingon language lesson seemed like a much stranger coincidence than it probably was. We ended up having a nice chat about Star Trek, after which a couple of the RTs came up and started reminiscing about Jimmy Doohan, who apparently used to come to this hospital for pulmonary fibrosis because he lived nearby. (I would consider this HIPPA material except that it’s freely available information from Wikipedia.) He was apparently funny and personable, hated being called “Scotty,” and once left AMA because he hadn’t had any alone time with his wife in a week.
The RTs apparently thought very highly of his wife, who was much younger than him but who genuinely seemed to care about him and connect with him on a personal level. “They were great people,” said the surgeon. “I was always a little intimidated by him though.” Then he started talking about how his engineering career was spurred by his love of Star Trek, and how he missed NASA because he had felt like a member of a modern-day Starfleet there. I turned into a brick of shy-terror and finished my charting in record time.
After that, we got my pt sitting up on the edge of the bed so his feet could dangle, reminding him to hug his heart-shaped splint pillow tightly to relieve tension on his chest, then popped him back into bed and tidied up the room for the next shift. He was scheduled for at least one more major exercise activity, probably an hour sitting in a recliner, before bedtime. Exercise is critical to the early recovery phase; a pt who lies in bed the whole time will have nasty consequences. Lungs collapse and close up and fill with fluid; chest tubes clot off, and fluid builds up around the heart; blood clots up in the legs and causes pain and swelling, with a huge risk of pulmonary embolism; and the whole body misses the opportunity to tune itself up after the surgery, leading to increased swelling, decreased cardiac output, and severe constipation.
Tomorrow he’ll walk around the unit four times, and spend at least half the day in a chair. After that we’ll really start pushing. His case will be a smooth one, barring any major unanticipated events, and he’ll probably go home in a week or two. Before the surgery he couldn’t walk without collapsing because his heart was too starved for oxygen and too backed up from his scarred-up valve; when he gets home, lord willin’ and the creek don’t rise, he’ll be able to stroll around the park and even do some gentle gardening.
Other things that happened today…
The screaming lady died. Her ammonia poisoning—hepatic encephalopathy—became so intense that she could no longer speak or make eye contact, and she laid in bed thrashing and groaning in horrible garbled sentences of fragmented non-words as if demons had crawled into her skull and were eating everything inside it. Her family stopped going into the room at all, and huddled outside in knots of two and three, weeping. Palliative care approached gingerly, having been rebuffed many times before, and her closest relative made the decision without even having to be asked.
“Let her go,” he said. “She’s not even really alive anymore.”
We took the fem-stop pressure dressing off her leg, and she bled out and died within five minutes. The absence of her screams was sickening for the first half-hour; then hospital silence seeped into the cracks, a weird relief.
In the car on the way home from a shift, you forget to turn on the radio, you forget that you were going to make that phone call—you soak in the lack of alarms, the lack of dinging and beeping and chiming and clanging. It’s like breathing after you resurface from the water, at first. Your eardrums feel like somebody is pressing on them, blunting out the constant bells you know must still be ringing. Then, as other small daily sounds creep in at the edges, you forget what it was that you were supposed to be hearing. The white hum of road noise, the whoosh and rumble, disappears beneath the sounds of the car passing you in the other lane, the click of your blinker, the subvocalization of the gearshift, the creak of your knee as you depress the clutch and wonder why the fuck you can’t just give up your dignity and buy an automatic for the commute. You remember that you downloaded the new episode of that podcast, and hook your phone up with one hand, and dig that last Kit-Kat bar out of your purse to devour while you drive. By the time you reach your home, the endless litany of alarms is not only missing but forgotten.
That’s how it was with her screaming. An hour after she died, we were all cursing under our breath about the one guy whose monitor kept false-alarming. I almost forgot she had been alive just that afternoon.
We also got in two pediatric cases. Okay, teenagers. One was in a car wreck and had mashed up his legs, but was expected to recover, although his entire family was shaken and white-faced. The other was involved in a drowning incident; his mother had seen him go underwater and not come up, and although there was a nurse nearby who started CPR as soon as they could pull him up, he had inhaled a fuck-ton of lake water. His mother was a complete wreck, and understandably so, but very optimistic and desperately hopeful that he would wake up soon.
We’ve had a few drowning cases. Everyone is keeping a politely neutral face, and of course we’re doing everything we can, but (because I’m writing this a few days later) I can tell you that on Friday he had his first code blue as his lungs succumbed to the inevitable damage of lake aspiration, and that today he’s in a rotoprone bed, seizing.
He might yet make it. Maybe. It’s a long shot. Either way, I’ll be here every day through Wednesday, so if he dies I have about a 50% chance of being here for it.
Showing posts with label screaming lady. Show all posts
Showing posts with label screaming lady. Show all posts
Friday, July 17, 2015
Thursday, July 16, 2015
Week 3 Shift 3
Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Wednesday, July 15, 2015
Week 3 Shift 2
After six days off to hang out with my middle sister, the one who works as a CNA, and get my social life on (it's very sad and lame and involves babysitting and eating teriyaki), I went back to work this morning for a stretch of three days.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Week 3 Shift 1
I totally expected to get Crowbarrens back today, but I guess some other poor sucker got that assignment. I heard him yelling as soon as I got on the unit—I CAN’T BREEEEEATHE—but I ended up at the other end of the hall from him.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
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