Well, I definitely got the crazy little lady this
morning, and no, my attempt at jinxing her didn’t work. But more on that in a
bit.
My adorable pt with the screaming hearing aids had
really bad sundowners last night, and spent all morning groggy and slow to
communicate. Even after I put in her hearing aids, she mostly just lay in bed
napping, drifting off mid-sentence every time I tried to have a conversation
with her. Somebody had given her a bump of dilaudid last night for an episode
of back pain, and she apparently processes opioids slower than I process an
entire brick of cheddar cheese, so she was completely zorked most of the
morning.
Her family came in and stood around the bed, morose,
watching her mutter in her sleep. “She’s really gone downhill,” said her son.
“Yesterday she was so bright and awake, and she was up in the chair for hours…
Today she barely wakes up to say hello. What happened?”
I explained about the pain medicine and our plan to
closely limit her opioid administration from here on out, and added that her
labs were all improving and her vital signs were solid, and that I was
recommending to the MD for her to be transferred to a unit with a lower level
of acuity. The family was uneasy, and I don’t blame them—I was keeping a weather
eye out for weirdness myself, because while I had a pretty good explanation for
her behavior (or lack of behavior), any time family says their loved one is
different, I pay attention. I can’t tell you how many times I’ve caught
something that would have gone unrecognized—a heart attack, a stroke, a major
status change—just because I pay attention when family is worried.
(Sometimes I have to completely ignore worried family,
when their worry is pathological and they’re doing themselves and their families
no favors… more on that later. And yet, if the family is worried, even if it’s
just because they’re always worried, I stay at a higher level of worry all day.
Not necessarily about the pt, especially if I can look at them and tell that
they’re doing fine, but I have plenty of my own shit to worry about and if
we’re having a party anyway, heeeey!)
In this case, I was definitely watching her closely,
especially when family brought in some edible and drinkable treats to try and
coax her into eating. I was concerned that, despite her passing her swallow
eval earlier, she would (in her current groggy state) fall asleep while chewing
and end up with a hamburger in her lung. I hovered by the bed while her
daughter leaned over and bellowed in her ear: “MOM. DO YOU WANT SOME DIET DR.
PEPPER.”
And man, her face lit up like Mardi Gras in Las Vegas.
Her eyes popped wide open and she levered herself upright in bed like a vampire
popping out of the coffin. “Do you have any?”
After that, she was still prone to drifting off, but
now she had a vested interest in staying awake. Family? Pssshhh, you can see
them anytime. Diet Dr. Pepper? Now that is worth feigning alertness.
Fortunately, she really wasn’t in need of a lot of
care, and the doc agreed around 0900 to downgrade her acuity to telemetry. I
say ‘fortunately’ because my other pt Martha*, the crazy lady from last night,
demanded almost all of my time.
Her history of bipolar disorder has provided her with a
history of lithium use, and last year she attempted suicide by taking all of
her lithium pills at once. The ways in which people attempt to kill themselves
just horrify me. Taking two bottles of Tylenol? Finishing off your Wellbutrin
in a single go? Jesus, are you trying to make sure you suffer on your way out?
I mean, I sincerely hate the idea that anyone has to deal with the utter
bleakness of chronic depression and the spiral that leads down to suicide, and
I wish to god nobody killed themselves at all, and I hate that our society
makes mental illness such a hush-hush no-funding issue that people can reach
that point of suffering without having the resources they need to escape… But
the shit that people do to themselves trying to kill themselves, that shit is
like an Eli Roth porno. Even handguns fail frequently enough; it’s not uncommon
for a person to attempt suicide, fail, and have an entire lifetime of medical
fallout to deal with… or six weeks of pure torture in the ICU before they
finally manage to actually die.
And of those who succeed in slow motion… they all want
to live by the time they die. It’s awful.
Please don’t fucking kill yourself. Entirely aside from
the fact that you’ll miss all the movies of the next few decades, that you’ll
miss the chance to fake your own death and escape to a South American country
and become the mysterious foreigner who lives in the jungle, that you’ll leave
behind a body that somebody has to clean up… you have a pretty significant
chance of ending up in a nursing home, just conscious enough to feel pain and
humiliation, for the rest of your life.
Give it another year. Do something different. Talk to
somebody about it. Don’t end up on my unit with ARDS from inhaling your own
vomit when the pills kick in. If the Huntington’s is closing in and you really
gotta go before you turn into a slack-lipped veggie on a vent, plan that shit
out and have your family by your bed. If you don’t think you could convince
someone to sit by your bedside while you die, it’s not time for you to die yet.
Anyway, that’s a grim little side note. The point is,
this lady took all her lithium pills, and after a major round of dialysis, she
ended up with a seizure disorder, diabetes insipidus, and maybe about
two-thirds of her original IQ. This time around, she’s in the hospital because
a week ago she tripped and fell at home, broke most of her ribs on the left
side, and ended up with a hemothorax—a big pool of blood in the space her left
lung was trying to occupy—plus pneumonia from her immobility and from being
unable to breathe deeply and cough without pain, plus dehydration from the DI,
plus a UTI.
Diabetes insipidus is a totally different animal from
what we usually refer to as ‘diabetes’. Diabetes mellitus—those of you with
some base in languages may recognize the root of ‘mellitus’ to mean ‘honey’—is
sugar diabetes, which I have ranted about at length here. Type 1 diabetes
mellitus means all the insulin cells in your pancreas were devoured by your
immune system in a bizarre childhood autocannibalistic orgy, and you probably
need an insulin pump; Type 2 diabetes mellitus means your body is growing resistant
to insulin and your pancreas is maybe not pumping out as much as you need,
often because you have a genetic predisposition or (more likely) your fat cells
are overstuffed and trying to tell you to lay off the cheesecake.
It’s called ‘mellitus’ because your kidneys are dumping
sugar, and your piss turns sweet. Doctors used to have to taste their pts’
urine to see if they were diabetic. It’s never been a good career for the
mentally well.
Diabetes insipidus, therefore, means that your urine is
insipid instead of sweet—it’s bland and watery. Lucky doctor. The problem here
is that, inside your braincase, your pituitary gland (yes, the gland
responsible for dragging you through puberty) has become fucked up somehow. In
addition to hairy-armpit hormones, your pituitary gland regulates your water
balance, secreting a hormone called vasopressin to remind your body that it
actually needs water to survive. (In higher doses, vasopressin also causes your
vasculature, your blood vessels, to constrict and increase your blood pressure…
thus the name ‘vasopressin’. We use a synthetic version of this regularly on
the ICU to raise blood pressure in septic pts.) So if you have a pituitary
tumor, or massive brain trauma, or certain types of toxicity like lithium… you
will constantly gush gallons of dilute watery fifteenth-beer piss, even though
you’re dehydrated and dying of thirst and could really, really use all that
water you’re filling your Depends with.
So this woman was constantly in desperate need of a
trip to the ladies’ room, which is hard to manage when you’re completely
deranged from a urinary tract infection, your entire left chest is hamburger on
the inside, and you aren’t firing on all cylinders to begin with. She couldn’t
bring herself to use a bedpan, and initially she was too dizzy and sick to get
up to a bedside commode, so she would try to hold it until she just couldn’t,
then fill the bed with a liter of water-pee and start screaming. Nothing we
said to her made any sense to her. She hit and kicked and screamed, and it took
her daughter and a sitter to keep her in bed and safe and calm.
Her daughter looked familiar. I’d seen her last night
in the hallway, but now that I was in the room with her, she looked really
familiar. After the first ten minutes of introductions, I recognized her with a
start—she’d been the caretaker for a pt I cared for at my last facility, and
she’d been an absolute nightmare. A few delicate questions confirmed my
suspicion, and she recognized me too.
She had been enormously controlling, extremely anxious,
convinced that we were neglecting her ward even though her nurse could never
even get out of the room. She would regularly decide that the pt needed
something—a breathing treatment, a new medication, a very specific positioning,
an aggressive round of nasotracheal suctioning—and she would insist on it until
the doc either gave in or had a stern, invariably ugly talk with her about appropriate
care. She was absolutely unable to manage her stress, and this led to her ward
being absolutely punished with unnecessary and uncomfortable turns every time
she got comfortable.
But this just meant I’d had time to establish a rapport
and a set of boundaries with her, and thank living fuck, I was able to get
those back into place pretty quickly. I promised to genuinely consider any
request she made, but told her I wouldn’t sugarcoat anything or perform any
kind of care that I felt endangered her mother, and that if she got stressed
out I would stay in the room for fifteen minutes at a time while she went to
the waiting room to collect herself.
It worked pretty well.
Then she fired the sitter. The new guy who’d come in
for the morning shift is this super sweet CNA I’ve worked with several times, a
tall black guy with a genuine smile and dimples to boot, who spent thirty
minutes with me last time he floated to our floor while we scrubbed a massive
Code Brown off the walls even though he could by rights have ducked out halfway
through. He is a wonderful, compassionate human being whose bedside manner is
gentle as a lamb and soothing as a fifth of whiskey, and within thirty minutes
of his assuming sitter duty, the daughter fired him for being ‘intimidating’.
“My mom is kind of old-school,” she said, clutching her
elbows and speaking in low tones, trying her damnedest not to sound racist as
hell. “She gets really scared if there’s anyone… intimidating around.” Inside
the room, my pt was holding the CNA’s hand and smiling at him while he asked
her about her grandchildren.
I told her I would see what I could do, and dove into
the chart. Turns out, this cute little old lady with the crazy thrashing etc
had not received any pain medication during her stay besides her scheduled
toradol, which seemed unrealistic to me considering that she had six broken
ribs and regularly freaked out like somebody had filled her bed with bees. She
had PRN dilaudid IV available, and I drew it up and headed into the room.
“Are you having pain,” I asked her.
“No,” she said. “I want to go home.”
“Are you hurting?” Sometimes it helps to ask again a
different way. “Maybe just a little bit?”
“Yeeeeeah. But I want to go home. So I’m not hurting.”
“We’re gonna get you home as fast as I can,” I said,
and pushed the dilaudid. Pts with dementia often have trouble recognizing and
expressing pain, and sometimes they think that if they tell you they’re not
hurting, they can go home faster. Sure enough, five minutes later she was
sleeping like a baby, had peed another liter without freaking out, and had gone
from shallow rapid breathing to deeper, regular breathing.
So I sent the CNA off to the charge nurse to be
reassigned, and gave her round-the-clock dilaudid coverage. She woke up nicely
between doses, no thrashing, coughed on command, and gradually improved to the
point that she could get up to the bedside commode.
Pain control is a big deal. And it amazes me that, with
all her WebMD recommendations for care, her daughter hadn’t seemed to pick up
on her pain. She didn’t need a sitter for the rest of the day.
Her two other daughters dropped by that afternoon. One
was even more anxious than the first, terrified of the hospital, terrified of
her mother’s condition, not wanting to talk about any of it. The other was
fairly laid-back, having worked for a nursing home for a long time, and was
mostly stressed out because her sisters were stressed out.
The pt did have a seizure. It started with her eyes
jerking to the left, which apparently is her characteristic onset symptom; her
daughter called me in, and I gave her Ativan to break the seizure as it kicked
in, so she ended up having a few seconds of genuine tonic-clonic seizing before
lapsing into post-ictal grogginess.
About 1300, just after my hastily-shoveled lunch of
microwave burrito and cottage cheese, the charge nurse cornered me. “I hate to
do this,” she said, “but we have a new pt coming in and nobody to admit them.
Can you give your tele lady to this other nurse, and admit?”
Charge just seems like a position where you have to
constantly deliver bad news and ask people for huge favors. I will definitely
want to train for charge someday, but I also dread the thought of having to
tell someone that I’m screwing them over because their assignment is too easy
and I need somebody to land a clusterfuck and you’re it.
So I gave report and handed off my cute little lady,
who was chugging her fifth Diet Dr. Pepper, and took report from the emergency
room on a frequent flier.
This poor guy has been in the hospital five times
already this year, and god knows how many times last year. He has some kind of
GI bleed, probably in his small intestine, which recurs regularly for no reason
anybody can pin down—no history of alcohol, no NSAID use, no fucking idea. Last
year he had what our GI docs call the “million-dollar workup,” a cascade of
diagnostic tests culminating in a literal swallowed camera capsule that films
your entire gut as it passes through. No results.
This time his hematocrit was really, really low. I gave
him several blood products and wiped his ass a few times while he shit out the
last of the blood, and his GI bleed was over—just a couple days of blood
transfusion and crit checks, and he’d be back home with his mystery bleed,
happy as you please. He’s been here so often that the docs ordered him a full
meal plan as soon as his crit stabilized, recognizing his telltale signs of
recovery. Usually GI bleeders have to wait a while to eat… we just know that
this poor guy is done bleeding once he starts getting hungry, and there’s no
use in keeping him ravenous all the way up to discharge.
We did an EGD though, because we kind of have to,
because it would be shitty to miss a bleeding ulcer just because he’s never had
one before, and have him perf his stomach and die. It was a five-minute affair
and he was damn near awake for the whole thing—he said he was used to it by
now. That is not a thing I can imagine getting used to. He had a beautiful pink
happy stomach lining though. His breakfast of scrambled eggs was still intact
and recognizable and made me extremely hungry. I really need to start bringing
multiple freezer burritos per shift.
I got hiccups toward the end of shift. I used to get
them all the time on nights, usually between three and four in the morning, big
whooping hiccups that sounded like some kind of lost stork wandering the
darkened hallways calling for its young. My coworkers used to make relentless
fun of me. Well, guess what, these coworkers also make fun of me when I start
yelling HOOP uncontrollably in the middle of shift.
I could close my mouth and kind of muffle them, but
that hurts. So fuck you, I’m gonna contribute to noise pollution, and you can
all suck it and/or wear earplugs.
I hope this doesn’t become a regular thing.
At 1500 shift change, the new charge nurse dropped by
and poked her head into the room. The pt’s daughter gasped. “Oh my god, I
didn’t know you worked here now!” Turns out, this particular charge nurse once
directed the adult family care center where my pt’s mother spent her declining
years, had known my pt since she was a teenager, and had held all three anxious
daughters while they were all still in diapers.
There was a distinct change in the dynamic after that—they seemed to
trust us more, now that their old friend was in charge, and I didn’t have to
enforce boundaries quite so stringently.
It’s a small fucking world, my friends. I never met
this charge nurse before I started working here, and now here I am, taking care
of a pt she practically raised, whose daughter I knew from another facility as
a pt caregiver. This isn’t a huge city/region (technically the two facilities
are in different cities, part of the sprawl of the central metro), but I am
always amazed at how often I run into nurses I know from other places, pts I
took care of years ago, and people I have to pretend not to recognize lest I
violate HIPAA or make shit awkward.
Been checking up on my abd guy. Yeah, he’s still alive.
Why, how, I’m not sure. His hemorrhagic necrotizing pancreatitis and total
kidney failure have reduced his quality of life to “constant torture when he’s
not in a coma.” Lots of legal pushing later, and they’ve assigned him a
guardian ad litem… who now has to jump through a million legal hoops and decide
whether or not to let him just die.
It’s not an easy choice. He’s very far removed from
anyone who could speak for him. His roommate, who only realized he was
hospitalized because nobody was using the toilet paper for three days, says he
has a daughter somewhere…. But he’s never said her name, just called her ‘my
daughter’. He left no living will, no advance directive, nobody with a durable
power of attorney.
His coworkers keep coming by to check on him. They’ve
all shelled out to get a rental storage unit for his belongings; they show up
in their work uniforms, still sweaty and obviously exhausted from their shifts,
to stand by his bedside for a few moments and tell him what’s going on at work.
We can’t tell if he understands any of it. He opens his eyes sometimes to
painful stimuli.
They obviously care about him a lot, and to me this
means something. Most people who suffer from major addictions don’t have a lot
of people who care about them; they sever their ties, drive away their
families, and are slowly devoured by whatever chemical owns them, alone. Even
recovering addicts usually spend a little while with their only friends being
fellow recovering addicts, if they’ve been addicted for some time. At least
that’s what it feels like.
But it’s telling that this guy, despite being a
profound alcoholic, separated from family and friends, struggling with
addiction, is still someone that his coworkers care about. They’ve worked with
him for a long time. Some of them know that he had big issues with alcohol, and
have delicately made the awkward effort to inform his nurses so we can “make
sure that gets taken care of too.” They really miss him, and that means
something to me—even feeling isolated, even in the throes of addiction, even
sweating on his deathbed… he (like many other addicts) is still loved. And they
are so glad to see him get help that they’re holding out hope he’ll recover,
even though he’s long past the point where his death can be more than delayed.
It breaks my heart. I wish he’d got help sooner. He would
have been surrounded with love.
In the meantime, all I can really hope for him is that
he dies soon, and quickly. Maybe somebody will show up for him that has some
legal authority.
Fucking depressing, man. On a bright note, today one of
the consulting MDs accidentally locked himself into the staff bathroom, jamming
the doorknob somehow. While the environmental services guys scrambled to try
and get him out, he kept up a steady litany of exhortations and pleas: “You
guys have to hurry, I gotta get out of here. I took a power dump in here. You
gotta get me out, guys. Take off the hinges…”
I’d laugh harder if I didn’t occasionally get locked in
a room with a pt who’s shitting uncontrollably. The aftermath of a
three-pounder is nothing you wanna breathe in a closed space.
