Whitney the Muslim

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

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

Anyway.

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

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

Week 8 Shift 1

By the time I got back, my DKA/wannabe escapee guy had not escaped, but had made everyone on the unit so angry they wished he would. His nonstop bitching and creepy remarks, combined with his gross treatment of his girlfriend and his frequent not-jokes about how we should just let him shoot up because he was going to anyway, had really not endeared him to any of the staff.

When I arrived, he smirked at me, then informed me that he would be leaving at 0930 whether I wanted him to or not, and if I had any shit left to do for him I better get it done in a hurry. And that he would have a long list of breakfast foods from the cafeteria, but didn’t want to stay on the line and wait to order, so he would just tell me and I would have to call down and order for him. When I told him he could either order his breakfast or go hungry, he shrugged. “Fine,” he said. “I have my own insulin, I’ll give myself a dose and go into hypoglycemia, and you’ll get fired.”

I have honestly never had a pt so openly threaten to harm himself to manipulate me. “I’ll give you IV dextrose,” I said, “and your insulin will mysteriously go missing while you’re unconscious, and you’ll wake up just fine except you’ll be hungry. Here’s your phone, you decide if you want breakfast or not.” Then I went and reported all this to the charge nurse and documented it.

His girlfriend met me in the hallway a little later. I won’t tire you with the entire conversation—it was very long and wandering and difficult to listen to—but the gist of it seemed to be that she wanted to stay in the methadone program and get clean. If she stayed with him, she said, he would never let her get clean; but if she left him, who would take care of him?

“I think you’re right,” I said. “He’s gotta find his own rock bottom, and hope that it isn’t a grave. If you want to get better, you’re definitely going to have to get away from him, and you’re going to need some professional support while you’re remodeling your life.”

“But what if he dies?”

“Then he dies, chickadee. Maybe you won’t die too. When you’re drowning, you gotta kick off your shoes.”

I know there’s not much hope for her. But I really hope, if she dies of this, she’ll at least die without that asshole being rude to her the whole time.

At any rate, I got that dude’s discharge paperwork done in record time. I am already a lightning discharge nurse, which usually helps out my pts who really really want to get home in time for the game, but I had him ready to go by 9:15. I cornered the hospitalist that was seeing him and told her she could either give him discharge orders or sign his AMA*, that I had everything ready to go for him to leave, and that the only medical reason I could see to keep him was that he’d threatened to inject himself with insulin so I’d have to order his breakfast. We could have stretched that into a suicide threat, but honestly, it wasn’t. And there wasn’t much else we could do to help him.

(*AMA, in this case, has nothing to do with reddit—it just means Against Medical Advice.)

If I seem callous about this, know that I have zero interest in whether a person is addicted to a substance—it’s a disease we understand very little about, and one that destroys lives as ruthlessly as any sepsis or stroke. The mental health issues that so often accompany addiction, those I have even more sympathy for: my family is not without its comorbidities, and I have seen firsthand over many years the impact of addiction, bipolar disorder, major depression, personality disorders, and post-abuse trauma, all untreated and all devastating. I see this shit every day on the ICU, and it’s a parade of tragedies that never fails to make me sick with frustration that I can’t save them.

But there are, among the tragedies, people who victimize others in their tragedy. Just as it’s hard to feel fully sympathetic for a person who survived horrific childhood abuse and goes on to abuse their own children, it’s very difficult to feel that sympathy for a person whose lifestyle is so self-destructive and so poisonous that they won’t let their loved ones escape the same trap, and whose attitude toward the people they’re hurting and the people who care for them is one of loathing and snide gloating.

And there are people who are offered the help and support they need, and laugh at the people who offer and how disappointed they are when those gifts are refused.

Not a lot of sympathy, no. I was glad to see him go. He asked if he could keep his IV “for convenience.” I gave him an incredulous look and then “accidentally” pulled his IV out with one sharp yank.

“Oops,” I said. “Usually I leave those in until right before discharge. Oh well, you’re leaving soon anyway.”

He and his girlfriend sat in the room, rolling cigarettes from the tupperware of tobacco, until I escorted them to the door. On the way out he joked that maybe he’d offer me a ride in his truck sometime. I couldn’t even feign a farewell smile.

Meanwhile, next door, a coworker of mine landed a pt with Evans Syndrome, a rare autoimmune disease that causes your body to eat all its blood. The pt was acutely psychotic for some unknown reason and lay in bed screaming as if being burned with hot irons. Pain medication did nothing; anxiety medication helped. He couldn’t tolerate anything touching his body and ripped off his ECG leads and clothing constantly. We didn’t bother putting in a foley, but any time he needed to urinate, he would start screaming extra loud and rolling back and forth, cursing and wailing, until he finally let it all loose and soaked the bed/floor/wall/everything in the room.

The second time this happened, I was helping hold his legs down while he struggled to kick and bite the nurse, and the dam broke just as he started bucking. The ensuing arc of piss undulated across the room like one of those floppy-hose kids’ toys that squirts water at shrieking babies in the back yard. He got himself in the face pretty good, and it shut him up for a minute, his whole face contorting in puzzlement as he smacked his lips and snorted. Then he saw that he’d peed comprehensively all over the other nurse—he only got my arm a little—and started laughing hysterically until he passed out from more Ativan.

Meanwhile I had a second pt to take care of: a woman whose uterus had been removed earlier this year for cervical cancer, whose extensive internal scarring had formed massive adhesions and twisted her small intestines until pieces of them died. She’d undergone immediate surgery to resect the dead bowel, and been in pretty good shape afterward. Yesterday morning, however, she had become confused, then gone into respiratory distress. Early in her confused state, she’d pulled out her feeding tube, vomited, and possibly aspirated before finally being intubated and sedated. My job, today, was to support her through what could either be the return of bowel ischemia, or the beginning of ARDS.

She required lots of fluid support and plentiful pressors. She could hardly tolerate turns, and her urine output was minimal at first, though it picked up as we started Lasix to get rid of her sixteen liters of extra fluid. She was in Tiberius’s room, which felt very strange, because her family was also delightful and friendly and religious.

By midafternoon it was pretty obvious that she had ARDS. What’s more, her intestines started to pick up slack and give me some really gross noises, which is fantastic to hear in a pt whose guts are still stunned from massive injury and surgery. But man, that ARDS was not treating her well, and we kept cranking her fiO2 and PEEP up to keep her ventilated… and, eventually, oxygenated. It takes a lot for your lung tissues to stop exchanging oxygen well. We finally found a nice plateau at a whalloping PEEP of fourteen. (Five is the average. Ten is what you get when you’re ARDSy. Twelve is considered a bit much.)

The rest of the day was a matter of balancing her pressures with her body’s ability to tolerate pressors. Levophed made her arms and legs mottle deeply and turn icy cold, and didn’t have as much impact as I would have hoped on her blood pressure. The PEEP was making it hard for her heart to fill and squeeze effectively, which dumped her BP, which in turn made it difficult for her body to get rid of the excess fluid that had accumulated in her body.

There are three spaces in your body where fluid can hang out. Well, I mean, there are lots of places where fluid hangs out, but there are really only three we care about when we’re thinking about fluid overload and blood pressure.

One space is inside your cells. They’re just little water balloons, right? Some DNA and RNA and a mitochondria or two floating around in there, maybe some enzymes doing heavy lifting, some proteins grabbing shit and gluing it together… and, you know, water. This part is pretty boring to me unless a) my pt has been exposed to cyanide or b) my pt is going to need some kind of insulin fuckery to move sugar or potassium into their cells.

Another space, which I am HIGHLY obsessed with, is the vascular space—your actual bloodstream. Water, albumin to thicken the water and keep it osmotically the same as everything else, blood cells, dissolved gasses and sugars and shit… but mainly, blood pressure. Blood volume. If you’re bleeding out, the first thing I’ll give you won’t be blood, it’ll be saline; it’s the same salt concentration as your blood, and it will expand your blood volume so that the blood cells you have left can actually get around and your heart has something to pump.

Remember: if you ain’t got pressure, you ain’t got shit.

But there’s a third space: the areas between the cells, the structural nooks and crannies of the flesh. And when you’re massively inflamed, that space fills up. When your finger gets stung by a bee and swells up, you don’t suddenly get twice as many finger cells—rather, your inflamed cells call out for help, and your body responds by flooding the areas between them with water so that your white blood cells and antibodies can move around more easily and clean up the toxins. Your finger swells up.

When your whole body undergoes systemic inflammation, as with sepsis, that is a whoooooole lot of swelling. And all that water has to come from somewhere—namely, your vascular space. Pretty soon, there’s not enough water volume in your blood for your heart to circulate effectively, and your bloodstream is drying up, and your organs are dying for lack of blood flow while your body happily carries on dumping all its water into your puffy fingers like it’s gonna do any good there.

That’s the basic dynamic of sepsis. And this lady, with her aspiration pneumonia and her fucked-up guts, was septic as all hell. We had boosted her blood volume over and over with fluid boluses, and done our damnedest to pull the fluid back from her third space into her vascular space, but in the end all you can really do is try to interrupt the septic/inflammatory processes with antibiotics and other drugs, support their blood pressure with volume and pressors, and wait for them to pull out of it so you can dry them out again.

Thus, we gave her Lasix. Albumin first, to draw the fluid into her vascular space; then, after thirty minutes, Lasix to diurese her, to pee off the fluid so it didn't overload her struggling heart and increase the pressure and fluid drainage inside her lungs.

It was a long, exhausting afternoon, full of minutiae and sweating into my eyes. Her mottled flesh continued to spread, and her edema increased visibly from the beginning to the end of my time with her. I don't have a good feeling about her outcomes. I suspect she will never be stable again until she's dead.

Meanwhile, another crazy substance-abuse pt was admitted down the hall. I could hear him screaming and cursing even while I was turning my lady, and one of the other nurses poked her head in to ask if I still had the key to the velcro restraint box (I did not).

Things seem to come in waves on the ICU. We’ll get a bunch of STEMIs in a row, then a bunch of GIBs, then a bunch of ARDS. In reality, it’s probably just a normal distribution of all the shit that can go wrong in a decent-sized city; to the endlessly superstitious nurses on the ICU, it means that once you get two pts with similar symptoms, you are destined to get at least two more in the next week or so. This happens often enough to turn our confirmation bias into rock-solid religious conviction. Not looking forward to the next round of crazy.

But who knows? I could just be destined for admit after admit with stuck gut and sepsis. Or I could be too tired to think straight. I suspect the latter is more accurate. Time to pass out.

Week 7 Shift 3

This shift did not start well. I gave report the night before to a nurse who has, best I can tell, the most brutal ball-shriveling resting bitchface I have ever seen in my life. Alex* is extraordinarily pretty, always immaculately groomed, incredibly capable and conscientious, and has the amazing power to make me feel like a feeble, wriggling brine shrimp during report.

“What have his sugars been running?” No eye contact.

“Oh, uh…” /checks the lab sheet “Not too high. Uhhh… One-sixties. See.”

Her lips thin out. “Mmmm-hmm. Did you cover him?”

“I gave him… uh… one unit at noon. And uh…. I didn’t cover his last blood sugar.”

Flat stare. “You didn’t.”

“No, it was… his blood sugar was like… one point above the cut-off. I didn’t want to crash him.”

“Mmmm-hmmm. So I’ll cover that, then, and recheck in four hours. When I’m supposed to. Did you get all the tubing changed?” Her expression is somewhere between of course you didn’t and I can’t fucking believe this.

“Yeeeeeah.” Then I wither in my seat and stare at my report sheet for a while. She never says anything hurtful or really judgmental, she just has a tone. Also did I mention she’s beautiful? That makes it a thousand million times worse. I always tell myself after report with her that I didn’t fuck anything up, that I did a good job this shift, that the things I didn’t get done were things I had good reasons not to do.

So, having given report on the crazy lady to her, I came back in a little terrified in case I had missed anything.

Instead, she informed me that she’d got a sitter for the pt again once her daughters had left for the evening—our night CNA who always stays over, Rose*—and that she’d really gone nuts last night. Great. Alex also said that she’d had two seizures last night, both of them beginning with the characteristic left-eye jerk that she usually pulled, and ending with tonic-clonic seizing.

She’d also had something that Alex described as “really weird,” an apparent syncopal episode. She’d recovered afterward, although her mental status was not so great for the rest of the night, but she’d gone apneic (unbreathing) and unresponsive for almost a full minute, and her heart had raced. Her post-ictal period had been extremely short.

“I don’t think it was a seizure,” said Alex. “She didn’t jerk her eyes around. But I don’t know what else it could be. Honestly? I was about to start coding her when she came to. The doc said that if she’s not back to normal by eight this morning, we’re going to start a bunch of lab panels and get a CT scan. Which won’t be fun, because she literally will not be still.”

Sure enough, she was fidgeting in the bed, occasionally mumbling to herself, pushing at the blankets with her hands and then pulling them back up. God, putting her in a CT scanner was gonna be hell. But hey, 0715, she had forty-five minutes to get some sunlight and snap out of it. My other pt was my little GI bleed fella again, so I got a ten-second “nothing new, discharge today” from the nurse and came back to see about getting my fidgeter out of sundown land.

Rose was a huge help. “We can just get her up to the commode,” she said, “and then maybe if she does well we can put her in the chair for breakfast, have her look outside. That should bring her around.”

So we hoisted her up to the commode, and she immediately dumped a gallon of dilute urine and let out a huge sigh of relief.

I fixed her gown. “Better?”

She nodded, then looked up at me with a puzzled expression on her face. “My name is Martha*,” she said, as if just remembering this fact.

“Yeah,” I said. “You ready to sit in the chair, Martha? We have some toast and scrambled eggs for you.”

A big emphatic nod. She looked really confused, kind of blindsided, and I didn’t blame her—if she was snapping out of sundowners, she would just now be entering the period where she starts genuinely waking up, the way I often stagger to the toilet in the morning without being quite sure whether it’s day or night. Rose helped me stand her up in the waltz position—her hands on my shoulders, my hands gripping her gait belt, my knees braced against hers in case hers buckle—and we started the process of pivoting to sit in the chair.

About halfway there, she made a strange expression. “My name is Martha,” she said again, and her pupils spilled wide, and her body went completely slack.

Rose and I barely kept her from hitting the floor, mostly by hauling on her gait belt and thighmastering her lower body with our knees up into the waiting recliner. She was completely limp, taking little hiccup-breaths, going gray in the face. Her eyes stared into the middle distance. “She’s having a seizure,” said Rose. On the monitor, her heart raced, then fell into a high bradycardia, rate of 55. Her bladder emptied. She wasn’t really breathing, and even the hiccup-breaths were diminishing into nothing.

We kicked the chair into full recline and I grabbed the ambu breath bag. “Check her pulse,” I said. On the monitor, her heart rate cruised down into the forties. “Check her pulse! Does she have a pulse!”

“It’s a seizure,” said Rose, but she fumbled for a pulse—wrist, throat, groin. “It’s just a seizure!” Meanwhile she kicked the bed into flat mode, max inflate, pulled the CPR board off the head, and slapped her walkie-talkie to call for a respiratory therapist and the flex nurse. We all do this: we say what we really hope is true, and the whole time we prepare for what we really hope isn’t true. Rose moves very quickly; the flex nurse, Franklin*, ducked into the room within seconds.

“You guys need help getting her back to the chair?” He looked at Rose prepping the bed, me bagging air into the pt’s lungs while still trying to find the flicker of pulse I’d felt before, and raised his eyebrows.

“Code,” I said. “Press the button!” Rose smacked the alarm and the whole unit dissolved into organized chaos.

“Jesus,” said Franklin. “You don’t fuckin do half of report, do you?” He dove over the bedside commode, nearly slipped in the lake of urine from my technically-dead pt, and helped me cradle-lift her in one adrenaline-filled swoop back into the bed, where we laid her flat and started compressions. On the monitor, her heart rate alarmed in the twenties with a wide complex—slow movement of electricity throughout the heart, a very bad sign—until we took up the lead-hammering pace of CPR.

Good pulses with compressions. The RT took over bagging. The intensivist—one I forgot to introduce before, a mild-mannered fellow with a soothing presence and a way with difficult families—pushed into the room just behind the code cart, which the charge nurse was plugging into the wall while Franklin stuck defibrillation pads to the pt’s chest. “What happened,” he shouted—codes are incredibly loud—and I told him the very short, very confusing story: she was on the commode, she stood up, she died.

We coded the ever-loving shit out of her. Pulseless Electrical Activity was all we got—not even a shockable rhythm, just that useless, flaccid bradycardia on the monitor with no physical pulse at all. PEA arrests tend to have incredibly bad outcomes; the heart is too fucked for the electrical system to even realize the muscle is dead.

In the middle of all this I walkie-talkied the unit secretary to ask her not to let any visitors past the desk for this pt. I mean, god for-fucking-bid that her daughters walk into this shit: their mother blank and staring in a bed, her few unbroken ribs mashing into pieces under my hands, blood foaming up in the breathing tube we’d just crammed down her throat, naked violent death at its least lovely.

Nothing worked. Nothing even started to work. Rose and I were both in a pretty bad emotional state—this was not the pt we’d have expected to code. For fuck’s sake, she had broken ribs and a UTI! And, okay, it looked like she’d thrown a clot and had a pulmonary embolism—the blood clotted in the tube as the lab tech drew it from her arm—and there wasn’t much we could have done about that, but I thought about last night’s syncopal episode and about the expression on her face as she died in my arms and felt absolutely, bottomlessly sick.

We called it after thirty-five minutes, a lifetime to code a woman in her eighties. The intensivist went in the hallway to call her family, and managed to get through to the two most anxious daughters, both of whom went completely to pieces over the phone. The other daughter wasn’t picking up her phone.

I arranged her as best I could, then took over the phone after the intensivist, calling the organ donation group (a legal requirement, typically to rule a pt out for donation) and the medical examiner’s office (another legal requirement, in case someone dies under suspicious circumstances or there’s a chance of hospital wrongdoing), trying to get the okay quickly to take the breathing tube and IVs out. You can’t take anything off or out of the pt until you get the ME’s okay.

While I was on the phone with the ME, the daughter whose phone had been off rounded the corner, ignored my attempt to flag her down, and pushed into the room. “Mom,” she started, then screamed: “Mom! MOM! Somebody help!”

God almighty, the unit sec hadn’t stopped her at the desk. Her sisters hadn’t got through to her either. She hadn’t answered because she’d been on the road, coming here, to visit with her mother over breakfast.

I’m just glad it was the more level-headed one. Of course she was devastated, absolutely wrecked—but she’s more familiar with death, and she was able to integrate it and understand it much sooner than her sisters would have. By the time her sisters arrived, I had taken out all the tubes and wires, brushed her hair, tucked her in, and had her looking halfway like herself again, except for a smear of blood beside her pillow that I covered with a washcloth.

I called the chaplain. Turns out the chaplain was off that day. The family hovered in the waiting room, terrified to go see their mother’s body, wailing and crying, at least one daughter nearly fainting twice. I called the weekend chaplain, who often covers on her days off, and asked if she’d be willing to come in and sit with the family while I finished up their paperwork and helped them get to a settling point.

She came in. I owe her big. Unfortunately, after she talked the family into going home and awaiting a call from the funeral home to go see her recovered body there, she hung around and tried to be emotionally supportive to me, at a time when I had a shit-ton of paperwork to manage and really wasn’t feeling terribly in need of a shoulder to cry on.

Mostly I was pissed as fuck, and frustrated, and I wanted to punch something. Every last fucking thing that could have gone wrong seemed to have gone wrong. I couldn’t believe she was dead; I could not believe that we had failed to keep her daughter from being surprised with her death. I was very polite with the chaplain, but finally I hid in the bathroom until she left.

Then I went into my GIB guy’s room for the first fucking time that whole shift. It was now 0830.

I gave him his breakfast, which was mostly cold by now, and took his blood sugar so he could eat it. I smiled graciously the entire time and apologized for taking so long. “I guess you heard everyone in the unit running around like crazy,” I said. “We were trying to save another pt who had taken a bad turn.”

He dug into his toast and asked: “Were they okay?”

“Not as okay as I hoped.” I don’t want to lie to people, but I can’t always tell them the truth, and either way it’s bad form to bomb somebody’s day with a spiel about how their neighbor just died.

As I emerged into the hallway, Alex appeared, expression of stern disapproval firmly in place. “That went badly,” she said, and I braced myself to defend my actions. “Here, I got you this.”

It was a Starbucks latte. A real, honest to god Starbucks latte. I am a little ashamed, but not much, to tell you that I got a little misty. “Thank you so much,” I said.

“You did really well,” she said. “I can’t believe she just coded like that. And her family… You handled that really well.” Then she left for home, while I sipped my latte and rejoiced in the knowledge that her chronic bitchface doesn’t reflect her actual opinion of me.

Ten minutes later, the guy showed up to carry Martha’s body away, and I finally gave the GIB guy’s morning meds and helped him to the bedside commode. I don’t mind telling you I was sweating like a horse the whole time. Waltz position and pivot, knees locked to knees, the whole time I’m chanting in my head: Please don’t code, please don’t code.

He didn’t code. He did shit an absolute lake of filth. I bet he felt better after that.

After this I took a nap. My blessed coworker and patron saint Mavi covered me for what we euphemistically called an “extended break,” and I spent forty-five minutes facedown on the break room sofa, dreaming about a bubble bath full of little adorable swimming mammals that would pop up through the bubbles and squeak, then dive like otters.

I awakened to the charge nurse shaking me gently. “Can you take the guy in twelve*? He has a sitter.”

Okay. Whatever. “What’s going on in twelve?”

“His nurse is getting a fresh VATS and he’s just… a little heavy.”

“Oh good. Sure. Whatever.”

He wasn’t just a little heavy. I mean, physically, he weighed maybe 200lb, but he was in four-point locking Velcro restraints with a bedside sitter and an ass full of Haldol injections. The dude is in his late twenties, a Type 1 diabetic, with a serious drug problem.

I don’t mean that he’s addicted to something, although I’m sure he is. I don’t even mean that he’s taking something nasty on the regular, although I’m sure he is. I mean that this guy will, apparently, do literally anything to avoid sobriety, up to and including begging Robitussin from a pt family member in the waiting room. I don’t think he even got enough Robitussin to get high.

And at any rate this was two days ago, when he was on the med-surg floor, before he went completely apeshit, ripped the whiteboard off the wall, threw a chair at his nurse, and ran down the stairwell to escape from the hospital. He was in for DKA and pancreatitis, and definitely didn’t seem to be in control of his faculties, so we hunted him down; he was in his truck in the parking garage, screaming and banging on the window because he couldn’t figure out how to get the door open.

He had taken a whole bunch of god-knows-what—tested positive for amphetamines, cocaine, opioids, and benzos, although the latter two he’d had in-hospital with his pancreatitis pain and his alcohol withdrawal. Oh yeah, his blood alcohol level was elevated too.

We weren’t able to figure this out until he had been thoroughly restrained, jabbed with an obscene amount of Haldol, shot up with about 4mg of IV Ativan, and strapped down while he drifted off into a mumbling daze. His blood pressure was out the roof—not uncommon for cocaine, especially crack, which we suspected because a) he’s homeless and poor as shit and b) he had a bunch of copper brillo pads in his passenger seat. He was also difficult to sedate, which we expect with meth usage… and he was insanely violent and psychotic, which we expect with the kind of bullshit gas-station drugs that get sold as ‘potpourri’.

I mean, he successfully tricked us into keeping him from being sober for another 12 hours. But he did not endear himself to us, what with all the punching and broken furniture.

By the time I got him, he was starting to calm down, and I was able to ease him off the restraints, although the sitter remained. His girlfriend came in, tearful, also obviously accustomed to sleeping in cars and shooting up, and I got her a sandwich and a warm blanket and told her to go ahead and sleep in the recliner for a while. When she woke up, her boyfriend was still semiconscious and mumbling, so she and I had a little contract chat: she goes to the methadone clinic, so I promised her that while her boyfriend was in the hospital, she could stay here and sleep in the chair and have three meals a day—as long as she attends her methadone clinic meeting times and doesn’t bring in any drugs or alcohol, which are absolutely forbidden on campus.

An hour later I caught her rolling a cigarette (no, not even a joint, a cigarette—loose tobacco leaves in a greasy recycled lunch-meat Tupperware), and explained that if she lit it up in here, the ceiling sprinklers would come on and drench everything. “It’ll ruin your phone,” I noted, and the pt spoke up from his groggy muttering to shout: “Put my phone in the drawer!”

I started to suspect that he wasn’t as gorked out as he seemed.

An hour after that I took his blood sugar and it resulted at 422. “What did you eat,” I asked him.

“Nothing! I haven’t eaten in, like, days.”

A cursory bed-shake revealed four full-sized Butterfinger wrappers and an unmistakable pile of Oreo crumbs. Like really, dude. We had a talk: “I know you want to get out of here as fast as possible, but you realize if you drive your blood sugar up, you’re just gonna end up back here, right? And if you have to have an insulin drip started again, you won’t be able to leave easily?”

He shrugged. “I’m leaving here tonight, even if I have to escape.” Big smile. “Hey, you wanna come with me? There’s always room in my truck.”

His girlfriend started complaining, then called me a whore. I left the room “to let you guys get control of yourselves,” and heard her berating him as I left.

“Why do you say shit like that? It’s not even funny!”

“It’s just my sense of humor, babe. Roll me a cig?”

God. Gaaaaaawd. By this point he was 100% conscious and aware, just being a total asshole. Every time I went in the room, he gave me a steady stream of “humor” about how he was leaving in an hour even if he had to hit someone, how the doctor had dropped by and said he could have dilaudid, how he would “sign whatever you guys say” to get out this evening because “I gotta meet a guy for some drugs. Just kidding!”

His expression didn’t say ‘joking’. His expression said that he thought I was stupid enough to believe he was joking.

A lot of people tell inappropriate jokes in the ICU. It’s a stress-coping mechanism, usually, if not a flattering one. A lot of people who feel out of control of their lives and bodies try to make the staff uncomfortable to re-establish their own feeling of autonomy. Typically I’ll handle this by setting strict boundaries, leaving the room with an admonition for the pt to get themselves under control, and looking for other places to give the pt some perception of autonomy. You can tell that it’s a stress response—they laugh with brittle force, they make lame uncreative jokes and remarks, they show their teeth and the whites of their eyes. There’s a little panic in their voices, a little aggression in their eyes.

Some people harass staff because they’re depressed, detached, feeling hopeless. They’re terminal, or their condition may never improve. They feel out of control, but they also feel like the world around them is hostile and unsafe. They self-deprecate as much as they attack; they have a bleak laugh, monotone voice, the kind of jokes that cut deeper than they should. They kinda joke like Robin Williams: all mania and grief.

(I could never watch Robin Williams comedy. He just looked so sad all the time. He looked like he was joking so he wouldn’t cry, or like he was trying to make someone laugh to keep them from swinging at him.)

These people need to feel control, but they also need to feel safe. They need palliative care, to help them find ways to live meaningfully at the end of their lives. They need a wry sense of humor to deflect their jabs, and to help their grim outlook become an enemy they can despise instead of surrendering to.

This guy… well. Some pts have zero intent of changing their lives, and resent being in the hospital at all. Some pts think they’ve tricked you, because here you are taking care of them when they hate you and would gladly hurt you if they could get away with it. Some pts think you’re a sucker, their bitch, their waitress; they make remarks and take potshots because they can, and they want to remind you that in their minds, they’ve already won.

I can’t stand pts like that. I hate seeing the expressions on their faces: the smirking challenge, the gloating, the certainty that they can get away with anything they try to pull. It turns my job from a joy and a labor of love into a gross afternoon of feeling wasted and exploited.

About an hour before end of shift, I got to give up my GIB guy and take on a new admit from the OR, a tiny old woman with Alzheimer’s who fell in her assisted living facility and now has a broken clavicle, broken facial bones, and a brand-new left hip repair. I barely had time to get her settled before shift change.

As I was waiting to give report, the afternoon charge came up to check on me. This is the same charge from yesterday afternoon, the one who knew my pt. “Oh,” she said, “did you transfer Martha to the floor?”

Explaining that was not fun.

After I gave report and was headed to clock out, I passed my tiny old lady from the other day, the one with the Diet Dr. Pepper and the razor-edged, if slightly unhinged, wit. “Hey,” she called, “can you come get these men out of my bed?”

“Which men,” I asked, poking my head into the room. She was alone, lying in a bundle of blankets.

“These men behind me,” she said, gesturing to the pillows shoved under her left side. “I’m all wore out! I’ve had enough. Tell ‘em to go home.”

I took the pillows out and told her the gentlemen wouldn’t be bothering her any longer. Then I made it halfway to the garage before I started wondering what, exactly, she’d thought those “men” were up to in her bed, wearing her out.

I hope I grow up to be an old lady just like her.

With an hour to go til report, I took a walkie-talkie call from the charge. “I need you to give report to Franklin on your GIB guy,” she said. “There’s a fresh hip coming up from the OR who went into a-fib on the table, and I need you to recover her until the nocs get here.”

“Shit, why can’t Franklin land her?”

“Franklin has the heart. So you’ll need to keep an eye on the GIB guy for him, and give your 1800 meds, because he won’t be able to get into the room easily.”

Sigh. “How about I just keep GIB for an hour and give report to the night nurse, and not waste time reporting to Franklin before the hip gets here?”

“Oh, could you do that? Thanks!” Click.

Yeah, whatever. GIB guy was happily chowing down on dinner, and I brought him his 1800 phosphorus-binding med (oh yeah, he was on dialysis too, and required medications to prevent his phos from climbing too high between trips to the fridge).

(The fridge here refers to the huge chunky dialysis machines that our dialysis nurses push up and down the hallways and use to scrub our pts’ blood. We call them “fridge nurses” and exchange good-natured jabs about the relative superiority of our respective nursing careers. Most of the hospitals in this area either keep their own dialysis fleet or employ the major dialysis-nurse agency in the city, which means that I’ve known most of them for years even though I changed facilities last year.)

The fresh hip was a little old lady with Alzheimers who had taken a dive while going to the bathroom and ended up with a broken clavicle, hip, and left hand. The stress of surgery had irritated the shit out of her heart, which went into a-fib, raising her risk of clotting. When the top chamber of your heart is just wiggling around ineffectively, it forms the perfect environment for clots to form—a warm, open compartment with walls that massage the blood rather than pushing it. And since she’d just had surgery, anticoagulating her was not an option.

So we started her on a diltiazem drip to slow her heart rate—she was quite fast—and laid her flat to recover. And then it was time to give report.

After which I went the fuck home and made dinner, checked with my sister to make sure she was doing okay at the GED tutoring sessions and to ask if she has an internship lined up yet, and then went out for an hour with my writing buddy to work on something besides a shift report: a highly simplified D&D campaign I’ve been running for some friends who wanted to learn tabletop RPGs but were intimidated by all the numbers and charts. It’s a small dumb thing that’s more story and flimflam than hard game-crunching, but I’ve been enjoying it, and it’s adapted well enough to a beginning group that it’s keeping ten simultaneous players occupied nicely. Plus my writing buddy is a game designer type so I can pick his brain for help when shit gets real, and he plays NPCs when I need them.

This is my first time DMing since I was in college. I am not good at it, I don’t think. But we have fun. 

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.