My splenic rupture pt had a rough night. It’s not uncommon for people over the age of 70 to get confused at night when they’re in a strange place, sick, covered in tape and wires, and this can lead to some really risky situations. In her case, she pulled out her PICC line, which was put in yesterday to replace the internal-jugular central line she pulled out the night before. I came in to find her wrists strapped down and her nurse sitting at the bedside, gently talking to her to keep her occupied and soothed.
Used to be, as soon as you started acting like you might pull something out, you got your wrists strapped down with restraints. These days, we pay a lot more attention to delirium, and restraints dramatically increase both the incidence and severity of delirium. The night nurse who cared for her while I was sleeping is a damn good one and I trust him, so when I saw the soft bracelets on her wrists I knew things had gone to shit.
She’d pulled her PICC while making eye contact with him, holding his hand with her free hand, and saying that she felt pretty good. Grab and rip. After this she pulled two peripheral IVs, removed her oxygen a dozen times, and tried to pull out her foley catheter. The night nurse felt that restraints were the only way to keep her IV access in, so he sat beside her for the rest of the night, talking to her to keep her from going completely crazy.
Sunlight is the usual cure for this kind of delirium, which is so common we call it “sundowning” and expect it with certain age groups. Once the sun comes up, you can usually transition the pt from wrist restraints to puffy mittens, then open the fingertip part of the mittens, and finally free their hands entirely. Sometimes it’s even quicker than that.
Delirium is very different from dementia. Often, severe acute illness will combine with other factors like dehydration, sleep deprivation, and unfamiliar medications to make a patient forget where they are and what day it is, possibly even thinking they’re in a different country or it’s 1970 or that I’m a Nazi captor in a WWII prison. (This is depressingly common in older folks from Europe, many of whom were terrified as children that they would be captured and tortured by enemies of war.) We call that confusion, initially, but if confusion has an acute onset (they aren’t like this at home), the pt can’t focus long enough to follow a brief set of instructions (“I’m going to spell a few words, and I want you to squeeze my hand whenever I say ‘A’.”), and they can’t get their bearings enough to answer simple questions (“Will a stone float on water?”), they’ve moved past mere confusion and are delirious.
In a state of delirium, a pt is likely to hurt themselves—falling, pulling out tubes, etc—and is at very high risk of having weird delusions and hallucinations. These are a big deal because, in the delirious state, your mind can’t really differentiate between reality and the bizarre ideas that come with confusion and delirium, and it processes these as if they’re fact. You can end up having intense, vivid PTSD flashbacks to things like being smothered by aliens, raped and tortured by Nazis, shoved into a box and left there for hours, and burned alive—even though none of these things actually happened. The flashbacks and mental fuckery can last for literal years afterward. People who become delirious in the ICU generally have cognitive issues for a long time after discharge. (We see this a lot in re-admits, who aren’t quite themselves when they leave and return a month later completely whacked out.)
Perhaps most immediately worrying, delirium can disguise other major signs of danger, like altered level of consciousness, pain, and feelings of impending doom.
So I progressed her pretty quickly from restraints to mittens to open mittens. Too quickly—she pulled out one of her IVs. She has another, though, so I stopped the bleeding and let it rest. I feel like her mental status is one of the most vulnerable aspects of her health right now, and it would be awful if she (an independent woman who teaches music) ended up in a nursing home when she leaves here.
Anyway, as the shift progressed her lethargy continued, and she had trouble articulating almost anything she said. Head CT from yesterday was totally clean, neuro checks negative except for lethargy and verbal difficulty, blood sugar and hematocrit stable, abdomen stable, and finally we just settled in to “watch and wait.” I asked her son if she wears glasses, because although she claimed not to, she also didn’t know what state she lived in… Son brought in glasses and a novel she’d been reading, and a little later in the afternoon she came around just fine.
Still a little worried about her. Drowsiness after a splenic rupture is usually a sign that the pt is about to take a turn for the worse. But she had plenty of time to make that turn, and instead finished up my shift with a quick trip to the bedside commode and a bit of worrying-aloud about whether she would be able to get up the stairs at home. (She will be strong enough to get up the stairs by the time we send her home-- physical therapy opens almost every intial interview with, believe this or not: "Do you have stairs in your house?" This is a goon joke.)
As for my pt with the GI bleed, she was quite thoroughly recovered. She was downgraded to medical status halfway through the day, and after a bit of consultation with the blood bank, the doctor decided to go ahead and top her off with the last unit of matching, prewashed blood they had on hand, then send her home in the morning. Her family came in to visit during the afternoon, and her kids were so excited to see her that they literally jumped up and down, in place, for almost thirty minutes. One of them would settle down, and the other would kind of chill out, and then the first one would start bouncing again, and pretty soon they'd just be hopping in place, talking three hundred mph in their weird little shrieking voices. Kids are basically insects, is what I'm saying.
At three, afternoon shift change time, I traded out-- GI bleed passed off to a nurse with a group of other medical/telemetry overflow pts, new pt picked up. This guy was still critical care status, having been extubated around 1030, and he had a very distinct set of challenges to present me.
He is a developmentally delayed man, about forty, mentality between six and eight years old. Very polite-- turned his face and covered his mouth when he coughed, waved at everyone-- but easily frustrated and, for obvious reasons, very stressed out. He had been at his adult family home, eaten a bunch of dinner, aspirated it somehow, and gone into respiratory-cardiac arrest. 911, CPR, intubation, bronchoscopy with washout, extubation the next day. Really good outcome, no neuro deficit from baseline.
His lungs were still pouring sputum in response to the dinner invasion. Listening to his chest was like sticking your stethoscope into a washing machine full of shoes. Every few minutes he would cough up huge rippling mountains of sputum, which he had a very hard time managing and would suck back down his windpipe maybe one out of three times, causing another coughing fit. He did NOT like having the suction catheter in his mouth. He also wanted dinner, and some soda, and the speech therapist unsurprisingly made him strict NPO (nil per os, aka nothing by mouth) because he genuinely couldn't swallow his own spit without choking.
He'll probably get that functionality back, to a degree, but we still have to assess what made him aspirate in the first place.
In the short term, I got a packet of honey from the condiment drawer, smeared a trace of it on the suction cath (also called a yankauer, a plastic wand for sucking things out of the mouth and upper throat), and offered it to him as a "honey straw." He loved it. There wasn't enough honey to cause any trouble, and honey doesn't come off easily, so I wasn't worried about choking... and it encouraged him to keep it in his mouth almost constantly, coughing up crap and immediately jamming the "honey straw" back in his mouth. I refreshed it every hour or so and he cleared his airway wonderfully the whole time.
The real challenge came from his severe chronic constipation. An abdominal CT performed yesterday on admit, for his hugely distended belly, revealed that his colon was PACKED with shit. Cecum to rectum, dilated to a terrifying degree, crammed full of poop that hadn't seen the light of day in months. They loaded him with a truly amazing volume of bowel meds, and the night before he had started out with a few semi-liquid stools-- the kind of thing that manages to seep through the shit tunnel gridlock and keep you from backing up so hard that you die.
And he was backed WAY up. He kept burping and it smelled distinctly of shit. His OG tube, pulled out with the breathing tube when he was extubated, had been pulling something that the doc initially worried about because it looked a little like coffee grounds (a sign of gastric bleeding)... but which, when the OG tube came out, was pretty clearly just backed-up shit. Shit from his STOMACH. That is not supposed to happen and is a very bad sign.
Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets.
As I sloshed through that cleanup, trying not to breathe more than strictly necessary, I realized that this shit had been inside him for one hell of a long time. The smell had that intense death-rot odor you get when you've been hoarding that particular nugget for quite a while. That corn wasn't last week's veggie side at the cafeteria, dude. I bet you a dollar he gnawed that shit off the cob at his grandma's house for Christmas.
The fecal journey continued with inspiring diversity. One delicately-jointed, bubble-textured oblong came out looking like a Baby Ruth bar. One delivery was thick and slushy, but contained crumbly elements that glued themselves to everything they touched and pilled up like a hoodie in the dryer.
We attempted to get him up to the bedside commode at one point, hoping to catch the bounty in a bucket rather than the bed, but as he prepared to sit down he suddenly decided that there was a better potty out in the hall somewhere, and took off running with his gown flapping behind him. Two steps into his flight, his sphincter lost control. Spatters and ribbons festooned the tile in a pseudo-Farsi calligraphic scrawl. The CNA and I caught him before he could open the room door; she guided him by the shoulders back to his plastic throne, and I cupped my hands under a washcloth to form a towel-cup that I clamped to his backside, catching the steaming runoff to prevent any more modern art.
After a while, he exhausted himself on the bucket, and we got him back into bed. Five minutes after that he had another coughing fit and ripped a gargantuan chunky fart right into his disposable bed-liner. I heard the expulsion lap up against his thighs like the bubbles popping in a pot of boiling oatmeal. The pulmonologist came up to ask me a question and started coughing at the smell.
Some days are just like this. I passed that guy off to night shift with sincere condolences and warnings.
It occurs to me that I would not want to eat anything honey-flavored while in the room with a smell like that. But this pt happily smacked away on his "honey straw" even while his gut was blasting out everything he'd eaten this year, not so much as blinking. You know what? Whatever makes him happy. That's what.
The only real upside is that, being developmentally delayed, he could be convinced that this shit was hilarious, and wasn't really offended when we acknowledged that his shit stank. Some people get really upset if you don't manage to keep a straight face as you clean up their poop; some people just get incredibly embarrassed and feel horrible, and my heart goes out to those people, because I can't take a dump if anyone in the building knows I'm taking a dump and I would rather pretend at all times that I don't actually have bowel movements. (This is probably a leftover of my upbringing somehow, but I don't care to examine it too closely.)
You just gotta be really good at keeping your poker face strapped on. Gross wound? Learn to smile through it. Gallons of liquid shit? Reassure the pt that you've seen so much worse. (You have.) Crusty vadge plopping out cheese curds the size of thumb joints while you're trying to scrub the area for a catheter? Keep your face pleasantly neutral and talk about something else.
This job is allllll about winning people's confidence. It's much harder to care for someone whose guard is up, who distrusts you, or who feels awkward when you walk into the room. If they can relax and feel comfortable, if they can trust you, they have a much better experience and will tolerate a lot more of the pain and indignity that comes with a hospital stay, knowing that you're not doing this shit for fun either and that you won't judge them for anything that happens.
A particularly weird aspect of this is the importance of not reacting to anything with shock, panic, or visible distress. Like if you stub your toe and they see you wince and hop around, they're going to be wondering: is she gonna hurt me by accident too? Is she really in control of the situation? Can she be distracted at a critical moment, and possibly let me die because she just jammed her thumb in a drawer? These aren't conscious assessments, they're just part of the natural human reaction to being powerless and needing a team member you can trust. So one of the reflexes I've cultivated as a nurse is keeping a straight face when I bang my elbow, stub my toe, or otherwise remind myself that my body is pretty vulnerable and these hospital rooms are fucking crowded. If I drop something on my foot, I'm gonna politely excuse myself to another room before I descend into hissing and cursing.
I don't want my pts to ever feel like they have to comfort or protect me. I don't want to seem physically or professionally vulnerable to a person whose life may depend on my capability and strength. I want questions to be surface-level, where I can encourage my pts to articulate them and have them answered. I want to avoid situations in which my pts have to assess the situation without full access to relevant information, which means that even if my toe-stubbing happens because I'm focused on their cardiac output, I don't expect them to be able to explain my priorities of attention to themselves and decide that I must have been looking at something more important.
I am probably a fucking nutjob. I overthink things. I am paranoid and obsessive. This might make me a better nurse, or it just might make me a crazy person thinly disguised as a medical professional. Either way, I am probably the only person most people will ever meet who can make them feel safer just by smiling noncommittally as I wipe their ass.
Three days off after that shift. My kid sister moves in this evening, and will probably absorb most of my time for a couple of days.
Thank you guys so much for the encouraging messages and stuff. I get really shy sometimes when people praise my writing and I have to sit in a quiet place and squeak and drink tea, and eventually I muster up enough resistance to reply en masse while turning red and occasionally pausing to mash my hands against my mouth. You are all way too nice to me.
Showing posts with label the art of nursing. Show all posts
Showing posts with label the art of nursing. Show all posts
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 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.
Tuesday, July 14, 2015
Week 2 Shift 2
Every morning at my main facility we all cluster around the front station, receive our assignments, collect our walkie-talkies, and get a quick summary of the daily shift news. Yesterday’s morning started out very strangely for me, because I was unusually late and clocked in at 0645 exactly, when group report starts. This meant that by the time I made it to the front desk, everyone else already knew who I’d be taking care of, and they all watched me approach with this blend of pity and relief that told me right away what was about to happen.
I was getting an albatross.
I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.
Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.
Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.
I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.
Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.
What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.
He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:
--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.
--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.
--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.
Lucky me.
So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.
HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.
I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.
My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.
After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?
At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.
She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."
I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.
Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever.
To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.
The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.
So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.
CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.
This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.
It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.
Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.
I was getting an albatross.
I’ve only been working on this particular ICU for about six months, so I only have about three pts in my frequent-flyer nemesis roster. You get these pts by being unusually good at managing their bullshit, by being newer than everyone else and therefore not having been “fired” yet from the pt’s care team, or by having some other connection to them (speak their language, look like their beloved granddaughter, know how to pack their huge gross chronic wound) that makes it easier for you to take the assignment than for someone else. Everyone gets frequent fliers, and sometimes they become like mascots, or cute but frustrating pets, or (in rare cases) like part of the family.
Sometimes, though, they are mind-breaking time sinks with poor boundaries and unrealistic expectations of care and revolving-door care issues. They are chronically ill and rarely compliant. They have complicated needs that make it difficult to transfer or discharge them: mechanically ventilated at home, profoundly noncompliant with dialysis, covered in massive wounds, deathfat. Somehow they never fucking die.
Crowbarrens* is that guy. His metal-as-fuck name (I wish I could share the real thing) belies his whiny needy bitch-ass behavior and ready nurse-hitting fist. Bedbound at home with his neurodegenerative disease, he lives off his slavishly devoted wife, whom he bitches at and curses almost constantly, even when she’s not there. He hits; he demands female staff; he refuses to use a call bell and prefers to scream. His continual anxiety issues make him feel eternally short of breath, and his endless gargled litany of I CAN’T BREATHE, I CAN’T BREATHE doesn’t help much either. He uses his home ventilator with an uncuffed trach that allows him to eat, which he does every chance he gets, so he’s enormous. His tiny wife tries to placate him with food when he starts hitting her.
I don’t know why the hell they haven’t been broken up yet by some legal loophole. He returns to our ICU every three to four weeks like clockwork and is here for three to six days, minimum. This is because his wife gets frustrated and exhausted—he doesn’t let her sleep or leave the house, either—and calls 911 with some excuse, usually shortness of breath. Then she spends the few days of respite stocking the house, cleaning, sleeping, and getting ready to resume care for this complete turd of a human who will come back to her home and slap her around whenever she brings him anything he asks for.
Rumor has it, a few years back she snapped and took a baseball bat to him. Then she called 911 and reported that she had assaulted her husband, and meekly accompanied him to the hospital to await judgement; the social workers declined to get Adult Protective Services involved on grounds of “fucker had it coming.” I have no idea how true this is, but everyone believes it, which should tell you something about Crowbarrens.
What that means for his caregivers is constant verbal abuse, refused care, hitting, and bellowed orders. Nothing relieves his shortness of breath except heavy sedation. You can drug him into a stupor and he will still call out occasionally: I CAN’T BREATHE. We manage this with an endless parade of anxiolytics, opioids (to reduce respiratory drive), nebulized respiratory medications piped through his ventilator circuit, and verbal feedback on his oxygenation status (always 100%) and tidal volumes (always 850mL+). The distress is entirely perceived. Knowing this doesn’t help very much.
He’s my albatross because I am the tallest and meanest. (I’m not really the tallest anymore—I used to work on a unit where I was the only gangly white girl on a unit of tiny, shapely Filipina nurses and tiny, ancient Filipina senior nurses, so at 5’8” I was practically a human skyscraper. I come by the meanest part honestly though.) My whole family is insane and I am very accustomed to dealing with behaviorally difficult people, so when I get a Crowbarrens I kinda go for a three-part approach:
--First I try limit-setting and sharply defined boundaries. I will come into the room once every fifteen minutes; I will suction your trach once every hour. If I see anything alarming on the monitor or I have something to bring you, I will come more often than fifteen minutes, but you’ll see me or someone I send AT LEAST every fifteen minutes. I won’t suction your trach any more often because over-suctioning causes irritation, which will make you feel more short of breath. Every choice is presented not as ‘yes’ or ‘no’ but as ‘now’ or ‘later’.
--Failing that, I have the pt repeat the boundaries back to me, simplifying as necessary. When will I be coming back to the room? How do you call when you need me? Why are we going to wait a little longer on the trach suctioning? If their memory is too bad to handle a fifteen-minute break without forgetting, I start repeating a very rigid script instead of having them repeat back, validating concerns but not acting on them. Your oxygen level is 100% and you’re moving eight liters of air with each breath, which is very good. You must feel very short of breath, considering all the suctioning we’ve done lately, so I’m going to wait a little longer before I tickle your throat again.
--If that’s not successful, I have two options, depending on whether the pt is really too brain-fucked to comprehend anything or is just being a manipulative ass. In the former case, I go completely apeshit and spend the whole shift wishing I could die and/or binge on Netflix instead of being at work. In the latter case, I assume there’s some personality disorder on the same spectrum with borderline, and foster a desperate sense of dependency and attachment. This is not at all healthy, I’m sure, but there you have it: Crowbarrens and his wife haven’t fired me yet, and even though I am the number-one asshole on the unit and force him to do awful things like ‘sit in a chair’ and ‘take pills’ and ‘fear my disapproval so much that he keeps his hands to himself’, he still asks for me by name.
Lucky me.
So that was my day. Somebody had loaded him with bowel medications and he was shitting like Mt. St. Helens every forty-five minutes. Most of the boundaries and limits from the last visit held nicely, though, and as long as I held up my end of the bargain—every fifteen minutes, without fail—he behaved himself and even calmed down when I told him his breathing was fine.
HD lady was, some fucking how, still alive. She even woke up enough to start refusing dialysis and telling her kids she's ready to die. Yeah, they took her down for another washout, patched her gut, and now we're just waiting for the next hose to pop.
I could NOT believe she was still alive. Not only should that last leak have killed her, but anybody with decision-making power should have seen the amount of Saw-level torture we're putting her through and called a halt. God save us all from the mercy of our grandchildren.
My other pt was a cute old guy who had gone into flash pulmonary edema a couple days after having a lobe of his lung removed because of a lump. He was intubated and sedated and his family was sweet and anxious. Lots of education about his condition, pathophysiology, and medical needs. The intensivist did a speed-bronchoscopy at his bedside, sucked out a few mucus plugs, and declared him “probably ready to extubate tomorrow.” He was sicker than Crowbarrens, but much much less work.
After the 1500 shift change I finally got my lunch break, and spent it unconscious. From outside the break room, as I drifted off, I could hear Crowbarrens yelling. Fuck you, old guy. Take a fifteen-minute break from swinging at people, okay?
At 1530, as I emerged blinking and drool-crusted from the break room with pillow-lines on my face, my HD lady was extubated to comfort-only care. Her family had finally read the writing on the wall, and agreed to let her go.
She woke up a little after they extubated her, and was able to say a few words to her husband before she passed: "Love you, ???? bear. Love you sweetie."
I didn't catch all of it. Her whole family gathered in the room, grieving. She was loved.
Later I got the hell into it with one of the CNAs. She is very experienced and has worked on that unit for a long time, and is in nursing school, but this seems to manifest in her as a) she knows fucking everything and tries to tell you what to do and b) she is almost impossible to pin down for turns and clean-ups and other mundane chores. There is a standing rule that if a CNA comes to help a nurse and the nurse isn’t ready to do the job, the CNA moves on to the next chore and comes back whenever.
To this CNA, that means if I call her up and ask her to grab a bottom sheet while I grab the wipes and then meet me in room 20 to clean up a poopslide, my lack of sheet & wipes means I’m “not ready” and she’s not obliged to help me. Plus, if I call her and she’s busy but “will be there in a bit,” that means she’ll sweep by in anywhere from five to thirty minutes and if I’m not standing at the bedside with the whole room ready to go, instead of calling me back, she just moves on. She also bails on any cleanup or chore the moment the absolute essentials are done, leaving me with a trash can full of shit, a half-naked patient whose crotch I’m still wiping, and a pile of unshod pillows that will need cases put on before I can use them to prop up the pt’s arms and legs.
The critical parts, to her, are the parts where we take turns lifting the pt to wipe ass and roll the laundry out of the way, then put clean laundry and two pillows under their butt. The rest is for me to do. She’s busy, you see.
So as the intensivist set up next door for his speed-bronch, calling me repeatedly so he could get his job done, I was still up to my elbows in Crowbarrens’s panniculus, trying to get him clean enough and decent enough to leave him alone for thirty minutes, breathing the incredible stink of the trash can full of shit that the fucking CNA had actively declined to carry across the hall and throw away on her way out. What would have taken two people maybe five minutes to finish up took me fifteen, during which time the intensivist cooled his heels. I didn’t get the room finished until after the bronch, which meant the room was filthy and reeking when the pt’s wife showed up to visit.
CNA work is incredibly exhausting and difficult. It’s easy to burn out. It can be tricky to negotiate when you have different ideas about what you’re supposed to do. I have met very few CNAs I didn’t respect enormously. But her bare-minimum practice makes my job incredibly hard sometimes, and I definitely caught her in the hallway later and Had Words. She expressed that I was a crazy and demanding asshole and that my expectation that she would grab laundry on the way to bed changes and help finish cleanups was completely unrealistic. I said I would arrange to have everything at the bedside when I called her, but that I expected her to follow up with me if I wasn’t in the room more than ten minutes after my first call, and that I expected her to stick with cleanups until the room was either moderately decent for family to see, or until the nurse specifically said she wasn’t needed anymore.
This is the extent of my conflict management skills. She tentatively agreed but also said she expected me to “behave myself.” Not sure what that means exactly.
It set a bad tone for the end of my shift. I walked back into Crowbarrens’s room, caught him berating his wife, and chewed him out until he actually apologized. I must have looked like some kind of glass-eyed monster. Then I sat outside the room, making stern eye contact with him the whole time until my relief came on. He did not once complain of shortness of breath. I think he finally found something else to worry about.
Then I went home, opened my laptop, and fell asleep before I could even log into facebook. So that was my shift.
Sunday, July 12, 2015
Week 2 Shift 1
By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
Subscribe to:
Posts (Atom)