Week 7 Shift ACTUAL 1

I posted my reports out of order. Friday's was actually supposed to be today's, and vice versa. Mea maxima culpa, and also whatever dude.

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Started out this morning with a couple of sweet pts—my first day back since Tiberius died. I was kind of hoping for a pair of raucous assholes I could joke around with and care for without working too hard; instead I got two cute tiny old folks, both with Parkinson’s, both with lung cancer.

One had undergone a right mid-and-lower lobectomy, leaving him with nothing of his right lung but the upper lobe. The other had undergone chemo, had a really rough time of it, and then come back for her checkup to find that the cancer had spread quickly, after which she developed a UTI and sepsis.  The former will be going home in a few days—the surgery was successful. The latter will also be going home in a few days—antibiotics will have her comfortable enough to enjoy her remaining months at home.

The lobectomy pt had a little extra challenge to face. He’s orthostatic at home: when he sits or stands up quickly, his body can’t keep his blood pressure steady, and he faints. He fell a month ago and broke a small bone in his foot, requiring him to wear an immobilizer boot whenever he gets up to walk. Not that he was walking far; the previous shift had tried to take him for a walk down the hall, and he had made it as far as the med cabinet before his eyes rolled back in his head and he dropped like a rock. His chest tube made it even trickier to mobilize him, since it drained into a big square box called an atrium that had to be carried along everywhere he went.

And he really wanted to walk around. His pain was well-controlled with an epidural in his back, which numbed him from nipples to liver, preventing him from feeling the full impact of the huge surgery. Pain control is crucial in major thoracotomies like this one—I think Tiberius had an epidural too, immediately after his pneumonectomy and before things went south—because, as with cardiac surgery pts, this pt population is at huge risk of death if they lie still for too long. They need the pulmonary hygiene of coughing, which is almost impossible to manage if you’re in agony every time you breathe in; they need the blood-pumping action of muscles massaging their legs’ veins to return the blood to their hearts; they need to be able to breathe deeply, so their lungs don’t collapse, and the volume of air you breathe in declines sharply when you’re in bed all day.

None of these things are particularly compatible with a fresh open chest. If you’ve ever cracked a rib, you know what I’m talking about: fighting the urge to cough, breathing in sips and whispers, cursing your significant other like the Nosferatu because he strolled through the room and made a stupid pun and you laughed unexpectedly.

I cracked a rib about a year ago because I was at the pub for Drink & Draw with a bunch of my artist friends, and was invited by one of them—a massive Hawaiian man whose job is an even split between “draw monsters for video games” and “travel around the world giving workshops on how to draw monsters for video games,” both of which are hard-drinkin’ jobs—to help him finish off some shots that a group of art students had bought for him. I am an inveterate lightweight who gets a little woozy after a couple glasses of wine, so it was deeply stupid of me to take him up on his offer. At some point I asked him if people tried to fight him in bars, and joked that I (one hundred twenty-five pounds of hair and freckles) should totally fight him sometime. He responded by picking me up in a bear hug, which cracked my rib. He was very sorry and expressed disbelief that anybody could break that easily; I was very sorry and expressed a lot of vomit and groaning.

Anyway. This dude had to walk if at all possible. With fear and trembling we propped him up on the edge of the bed, and let him sit there for a while, reminding him over and over that he needed to wait to stand up until his body caught up with its new position. A few false starts later, and we propped him up on the cardiac walker—its big elbow cushions make it easy to walk with, and staff are known to rest their forearms on it and dangle their feet to help relax their spines during a hard shift. Heck, I like to lean on it and sail down the hallway, propelling myself with gentle taps of the toes, scaring the piss out of the CNAs and smacking into the medicine cabinets as I go. (This only happens in the late afternoon, when things have calmed down a bit.)

On the walker, he made it out into the hallway and down the hall before he turned white, slumped sideways, and said: “Leave me alone, I feel fine.” His eyes stayed open, but his head sagged and his knees wobbled. The charge nurse came running up, pushing a rolling recliner she’d snagged from a nearby room. “I ain’t sittin down,” said the gentleman as he slowly toppled, trailing his chest tube behind him.

“Sir, you’re passing out,” I said, trying to maneuver his swerving backside into the recliner while bending around the walker and juggling the chest tube atrium. “Please, sit down.”

“I feel fine,” he repeated. He was definitely staying awake, but his body was absolutely done with this standing-up bullshit.

“You look like a package of used hot dogs,” I said. “Sit the hell down.”

He started laughing, which I guess was too much for him, because he lost consciousness and slumped back (mostly) into the recliner like a sack of wet bricks. Thirty seconds later, as his body caught up with the change, he came back to… still laughing. “Hot dogs,” he said. “Hot dawgs. This girl’s a pistol, bang bang.”

I’ve had worse compliments. Once a pt told me: “I’d marry you, honey, but you’re a bitch from hell.” Still a little heartbroken over that one. But I have to agree with him.

His chest tube had kinked off when he flopped over on it, and the pressure differential had him feeling a little stuffy by the time we got him back in his room. I straightened the tube and hooked the atrium up to wall suction, and he gave a little start as a huge bubble slurped from the tube through the water seal. “Whatna hell was that,” he barked.

“Well, sir… your chest farted.”

More laughter. “Does your mama know bout your mouth?”

I assured him that my mother was a good, upstanding Baptist woman who would rather not know about my mouth, locked the chair brakes, and went to the break room to open palm slam a cup of coffee and two ibuprofen for my unhappy back.

I try to take care of my back. Lots of nurses get hurt and end up on disability. Back injuries build up over time and then suddenly seem to happen all at once, and I don’t want to end up slipping a disk mid-turn. I use the equipment at hand, follow strict body mechanics protocols, and am shameless about demanding help from other staff. Still, nursing is a high-contact sport, and sometimes you just throw yourself between someone else and the floor.

I’m not always funny, either. Sometimes I hit a charming, exhausted zone where my filters are down and the words fly fast, but shortly after that I turn into a blathering mule who can’t get three words out in a row. Panic increases my chances of witticism; exhaustion makes me sound clever. People are often surprised that I can tell a quippy story with a solid punch line and then be asleep before everyone is done laughing.

So I tell people about black holes. They come from supermassive stars, I tell them: huge flaming whirling nightmares so massive that hydrogen is crushed into iron at their cores. At last each one collapses under its own weight, crushing itself into nothing, waves and particles of radiation squirting out of its terrible fist at every crack and seam. And just as the star reaches the point of no return, ripping through space-time itself, swirling into the inescapable singularity, an enormous gout of brilliant blue light pours out, scouring everything in its path with searing, perfect illumination: Cherenkov blue.

That’s me, right before I collapse. I get tired, groggy, lazy; then, for a few moments, I am brilliant and clever and unstoppable and incisive; then I am lying on the break room sofa in a puddle of my own drool.

Anyway. I digress, boringly.

My other pt, the one who will go home on comfort care, is loopy as a rabbit in the grass. She is also deaf as a loaf of bread. She has hearing aids, which she hates wearing, and I don’t blame her because they scream constantly from the feedback hell of being turned up to max and shoved into her wax-plastered brain-holes. She grimaces and nods and looks completely confused while you try to talk to her, and the whole time there’s this distant metallic squeal like robots fucking. She is, however, so cute I can hardly stand it.

She keeps saying these things that sound like complete wacko non sequiturs, that make sense a few minutes later in context. She was cold, so I brought her a blanket from the warmer, one with blue stripes on it. She declined it: “Not with the red! I’m not a traitor!” Okaaaaaay. She did have a big red allergy bracelet on. I got her another blanket, one with no stripes, which she accepted.

A little later her family arrived, and as I relayed this story to them, they nodded sagely. “Of course,” they said, “those are XXXX University colors, and she cheers for XXXX State.”

I mean, I like football. I hated it when I lived in Texas, where football is a religion and the weather during football season is the best evidence we’ll ever have of God’s wrath, but since I moved to Seattle I’ve learned to enjoy it. (Something about how obnoxious and balls-out gleeful the fans are, and also about how Richard Sherman was fucking hot even before he opened his gorgeous mouth and a whole higher education drifted out of it like a fleet of sexy butterflies. Pardon me, I’m going to have a drink of water now.) I am the worst possible kind of football fan, and I still don’t think I could maintain that level of team spirit while slowly dying in a hospital bed.

We got her up to the chair for a while—yes, we ICU beasts have a total obsession with mobilizing our pts—and then had trouble getting her back into bed a few hours later, during shift change as I passed her off to the next nurse. Fortunately the oncoming guy was strong and good-spirited, and we wrestled her back into bed without dropping her somehow, even when she wobbled and her knees went completely limp. “The black-eyed ones always did that to me,” she quavered as we tucked her in. “Weak in the knees.” I was halfway home before I realized she was talking about the night nurse, who is a genuinely attractive young man with lots of muscles who quite literally swept her off her feet.

My lobectomy pt transferred up to telemetry immediately after that, keeping me late to give report to the upstairs nurse. I stressed the importance of taking things VERY SLOWLY with him, and told the whole grisly story of his afternoon walk. “Are you sure he’s tele status,” protested the nurse, and I don’t blame her, because nobody wants a pt who can turn into a floppy lump at a moment’s notice.

“Yeah,” I said. “Bye!”

I am a dick. Sorry, folks, that you have to know that about me.

(Generally speaking, orthostatic hypotension isn’t a reason to keep a pt on the ICU, especially if they’re orthostatic at baseline and need exercise to get moving again, which the tele floors are better at administering since ICU is focused on early mobility. It would have been very bad form, and dangerous to the pt, for me to pass him off without explaining how serious his orthostatic hypotension could be, but I honestly didn’t have time to coax the upstairs nurse into recognizing all this.)

As I left, they were already moving a new pt in, a tiny little lady who screamed and thrashed and hit everyone within reach. Her daughter stood in the hallway, dancing from foot to foot in that telltale hand-to-breastbone posture of a family member who is going to be ridiculously anxious the whole time. I will bet you one US dollar that I get that pt in the morning, and that she hits me.

Maybe I can jinx her into being a perfect doll.

Week 5 Shift 3

Day three with Tiberius. I showed up at work a little early, caught up with the night nurse, then headed to the charge nurse station and insisted that he MUST be made 1:1. They asked if I could take a telemetry overflow admit on the side, and I gently but firmly reminded them that I regularly balance absolutely unreal workloads and am very good at handling high-acuity spreads, and that the last time I insisted on a 1:1 the guy ended up with an open abdomen that afternoon. I got Tiberius 1:1.

Which is a good thing. His sedation was cranked way the hell up, which was appropriate-- even his breathing impulse was completely knocked out on 250mcg of fentanyl per hour + precedex at an obscenely high dosage (got an MD order to double the hourly dosage if necessary, rounded out about 150% of the normal max). And yet he was still waking up from time to time, glaring rings of white around his irises, the expression of puzzled horror that comes with sudden sharp agony. I've had my share of dental work done-- consequences of growing up without owning a toothbrush-- and I recognize the expression well enough, although I'm sure nothing that's happened to my mouth even comes close to the torture of two chest tubes, a partially-closed thoracotomy, a pneumonectomy, and multiple bronchoscopies per day. I dosed him with fentanyl until his blood pressure bombed, and his pressure was still labile for the rest of the morning, dumping whenever he dozed off and soaring whenever he awakened to stabbing pain.

The intensivists had switched out; Dr Sunny was covering him today, and I pitched my case for a new sedative. Given that he was still periodically vomiting, even though we weren't giving him anything by mouth/feeding tube except for a few ground-up pills every day, I was slinging antiemetics at him left and right, and the night nurse had reported a significant prolongation of the QT interval-- the time it takes for the heart to recover from each beat. (The risk being that his heart would try to start the next beat before his ventricles were fully recovered, which could cause his ventricles to freak out and fibrillate, a deadly arrhythmia.) I did some crazy ECG analysis and research and determined that his T wave-- the marker of repolarization, or post-beat recovery-- wasn't prolonged, but he did have a U wave, which is not uncommon for a pt on amiodarone (an antiarrhythmic we were giving him to control atrial fibrillation). The U wave is an extra little bump after the big T bump (after the jagged QRS complex), and apparently it represents the post-beat recovery of the papillary muscles, the little muscle-fingers that anchor and pull your heartstrings to stabilize and open your heart valves. The night nurse had measured from the beginning of the QRS to the end of the U, which made for an incredibly prolonged QT interval, but after a little fishing around on the internet (hey, we google stuff all the time on the ICU!) I found that most cardiologists recommend a slightly different approach.

You measure from the beginning of Q to the end of U only if the U wave is conjoined to the T wave, obscuring the end of the T. If the line returns to its baseline before the U starts, you only measure to the end of the T. Measured this way, he had a perfectly normal QT interval, and I was able to hand Dr Sunny a spittle-flecked piece of paper covered in deranged scribbling and caliper scratch marks and walk away five minutes later with an order for propofol.

It worked beautifully. Thirty mcg/hr of propofol later and Tiberius was sleeping like a baby. 

His wife, Amanda*, was finally joined by a bunch of family from around the country. They have a pretty large family, with various health issues and other things delaying their travels, but the trickling-in of relatives became a steady influx. They are a delightful family, some of them members of a very conservative religion, but free with their affection and bright in their humor and generous with their love. I am not a religious person-- I have some deep and intense spiritual drives that are still bleeding where they were severed, and I still dream of something more satisfyingly divine than the mannequin-god behind the curtain of my milk-faith, but I also have some major bones to pick with organized religion-- but if I had to live in a church faith, I would want one that let me laugh and gossip and cry with my husband's sister and her wife, one that made his grandmother's travel-induced diarrhea an affectionate family joke instead of an unclean shame, one that gave me stories and hope and peace with either life or death, whatever pain or loss followed in its wake.

Good people. Dear people. I wish I could give them the miracle they're hoping for.

While all this was happening, there was a code blue in the ER, followed by a rapid transfer of the pt to the room two doors down, where the horrible family had been before. (They were moved last night because the workstation-computer-cart caught on fire, shortly after which the grandfather had another hypoglycemic episode because the family paused his tube feeds again while they were trying to turn him WHILE THE STAFF WERE TRYING TO EVACUATE THEM FROM THE ROOM. Security was called and the family was limited to one member in the room at a time, with a warning that whichever of them was present next time he had an episode would be banned from hospital grounds.)

This new pt was an older man with a medical-condition necklace on: heart failure, diabetes, etc. It didn't matter much to me, since I didn't get report on him and didn't have any part in his actual care. Except that, ten minutes after arrival, he coded again, and because I was close by I jumped in to help. There wasn't much to do, as everyone else had their hands on the code stations: med nurse, push nurse, chart nurse, resp therapist, and shock nurse. However, from the door I could see that the two-man rotation on chest compressions was having a hard time, mostly because the pt had nothing hard under his back and had to be compressed deeply into the bed to get enough smash to move his ventricles. So I dove in, spiderwebbed through the lines and tubes to the head of the bed, ripped off the CPR board, and shoved it under him at the next compression switch, put the bed on max inflate for a harder surface, and jumped in at the next round to be the third man in the compression chain. Three is a good number; otherwise your arms get really tired.

I am relatively new at this facility, and we are pretty good at preventing codes, which means that I haven't been in a full-bore code in a major role yet. I've carried flushes and even pushed meds, but codes are fast and wild and require strong communication, which means that I'm still at the stage where chest compressions are an appropriate role for me to fill-- a role I share with CNAs and even housekeeping staff in a pinch. I don't mind-- compressions are a workout, and good compressions can make all the difference.

However, this dude was completely fucked. Flash pulmonary edema filled his breathing tube with bubbling red at every compression. His heart wobbled through ventricular fibrillation with the kind of half-assed exhaustion that doesn't respond to shocks. Med after med failed to get a response; shocks and compressions were like rocks thrown down a well. In the hall, his family wailed and collapsed against the wall, and shouted for us to save him. A nurse from down the hall gently guarded the door to keep the more frantic family members from seeing the bloody wreck of a corpse that we were preparing to stop beating.

We called it after twenty minutes. His chest was the texture of new banana pudding, before the cookies have a chance to get soggy-- bone fragments scraping the sternum, muscle and fiber pounded to a pulp. 

CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest.

The family burst into the room, still screaming, still demanding that we bring him back. "Keep going," they said, "he's strong, he'll be fine."

The RT popped the ambu bag off his breathing tube, and blood flecked my left elbow where I stood, wringing the numbness from my fingers over his demolished chest. Someone had thrown a pillowcase over his genitals. His skin was the mottled color and temperature of cheap cotto salami. "Wake him up," his son shouted at me from the door.

Instead I leaned over him and closed his eyes. "I'm so sorry," I said. I don't think his son heard me over the post-code chatter in the room, but he fell silent and white. There's a finality to that gesture that speaks more to our sense of gone, lost, dead than any words or blood or broken bones. They retreated into the hallway and sobbed there until the chaplain ushered them away to a private room. I scrubbed my bloody elbow in the sink and slipped out among the other staff, back to Tiberius, back to smile and offer support to Amanda while she and her family told stories about his childhood.

That disconnect is like a ringing in the ears. Death is touch and go: it touches you, and you go. If you're the lucky asshole in scrubs, you go into a different room, and think about it later. If you're the unlucky asshole in the gown, you go where we all go, eventually.

Anyway, after that I insulted the living hell of out an RT by accident, calling her a "respiratory technician" instead of a "respiratory therapist." I actually am shit at terminology like that sometimes and I felt terrible, but I think she understood my ignorance. Any RTs reading this probably just bared their teeth at me a little. Sorry, dudes, I couldn't do a quarter of my job without you. My apologies for fucking with your fiO2.

After that, I spent the evening fine-tuning Tiberius. He needs another surgery, a repeat thoracotomy to finish closing the stump and properly close his back, which looks like fucking hell. Before we can do that, we need every possible advantage to keep him alive, which means crazy tuning up and blood pressure management and cardiac output optimization. I can't describe to you how boring this process is, or how riveting. It's a game; manipulating numbers, one up one down, tightening your margins and leaving wiggle room; it's also a slog, poking this button and that button and making puckered mouths at the monitor while you try to decide whether this is a fluke or a trend. Overall, though, he trended upward. 

By the time night shift arrived, I was beyond exhausted, and worried sick because I knew I would have a day off tomorrow. I wrote up an extensive report sheet on him to be handed off to night shift, complete with goals, responses to titration on each drip, and precipitating events associated with each previous destabilization. I think the night nurse was a little insulted when I handed it to her, until she started looking over it and asking questions. By the time I left she was making a few addenda of her own to the list, and running off copies. I wished her good luck and godspeed, said goodbye to Amanda, and staggered to the breakroom to clock out and take a fifteen-minute nap before trying to drive home.

I called in the next day and asked how he was doing. Fine, they said. Stable and gaining. Still in ARDS, still on pressors, still requiring extensive sedation, but still alive.

Week ???? Shift ???????????

Some things I forgot to mention last time:

At 1100, shortly after I received the abdomen pt, I called up the charge nurse and politely requested to have him made 1:1. I don't ask for this often, and pride myself on my ability to balance multiple high-acuity pts safely. But part of this ability involves my recognition of when the load is too heavy for safety-- anyone can pretend they have things under control right up until a pt codes-- and when I realized this pt had hourly insulin checks, constant potassium replacements from an electrolyte replacement protocol (the intensivist declined to start a potassium-containing IV fluid despite refractory K+ levels below 2.8, the cutoff point below which the heart starts to starve and freak out, on the grounds that his renal failure would cause his K+ to skyrocket eventually), q2h labs, and 200mL+ output every hour from his NG tube (thus the potassium loss: stomach juices contain a lot of K+)... I had also just started levophed to pull his blood pressure up, couldn't find peripheral pulses in his feet, and was calling the RT in frequently to handle his ventilator-bucking. Yeah, at this point I decided he wasn’t going to be compatible with the high-need lady next door on bipap, no matter how clean she was now.

I was pretty sure he’d code by mid-afternoon.

The charge nurse came in, looked around, and agreed with me. So after 1100 he was 1:1. This came in really handy when the GI surgeon took him down for that washout.

So for the next couple of days, he wore me out. His open abdomen wept constantly through the drains in the intestine-containment bag, and every thirty minutes he required a full dressing change just to control the flow. His insulin infusion had to be cranked up from one algorithm to the next, as higher and higher doses failed to control his wild hyperglycemia. Worse, as I finally caught up on his blood sugars the next morning, his anion gap stayed wide open—the acidosis continued, and although his potassium finally caught up and began to rise as his small bowel obstruction stopped backing four liters of stomach juices out of his NG tube every day, the problem was clearly not a sugar/insulin imbalance.

Anion gap acidosis has a number of possible sources, although insulin deficiency is probably the most common. A few of them were addressed in that nephrologist’s note I quoted the other day. Another occurred to me during my camping trip this weekend, as I was studying for the CCRN test I took today (AND FUCKING PASSED YESSSS I AM A CCRN NOW). This guy is an alcoholic, and had been sick for a little while, homebound. What if he got into some alcohol that wasn’t drinkable? Specifically, methanol? It would explain some other major things, like the encephalopathy and his eventual failure to maintain pupillary reflexes.

Man I got no idea. I haven’t actually taken care of a pt with methanol poisoning, so all my knowledge is book knowledge. Methanol, aka wood alcohol, is an alcohol much like ethanol (booze), except that it turns into formic acid in your body, destroys your eyesight permanently, causes brain swelling, and tends to result in horrible death. I’ll have to look that up when I get back to work on Saturday.

Anyway. He stayed very high-acuity for the next few days; I was 1:1 with him the next day, and the day after that I was first admit, but ended up not admitting because the only person who came up from the ER was a telemetry overflow. He was one of those pts who isn’t panic-level crazy, but whose workload nurses describe to each other as “steady.” Basically, there’s something to do at least once every ten minutes, some of these things taking as long as twenty or thirty minutes and requiring multiple RNs or the help of a CNA, and you spend very little time charting because you’re constantly scanning medications or taking blood sugars or turning or changing dressings or titrating drips.

In this case, about halfway through the second day, the intensivist ordered lactulose enemas to be given every four hours, in hopes of stimulating his bowel to move. I took extreme issue with this because I could SEE the guy’s intestines and they were obviously too swollen to twitch, let alone move stool effectively, but considering that his colon was relatively un-irritated per report of the GI surgeon and the enemas were only about 250mL volume (we often give 1L-2L enemas!), I figured it couldn’t hurt. And sure enough, after the second enema he dumped a decent handful of mucoid stool, although his small intestines were obviously still not moving.

How did we administer these enemas? The traditional way involves turning your pt on their left side, sticking a tube up their rectum, and draining a bag of fluid into their butt to get the shitslide cookin’. Turning this guy onto his left side would have been… tricky, so instead I pulled the rubber tube off the business end of a foley catheter, lubed it up a bit, jammed it up his butt via the “lift balls, grope for anus” method, and inflated the balloon with a syringe of saline. Then I mixed up the enema, drew it up into a giant Toomey syringe of the kind we use to instill fluids into a GI tube (it holds about 60mL at a time), and flushed it all through the rubber hose into his colon. Between flushes I clamped it off with a large hemostat, the kind we use to clamp chest tubes shut. An hour or two later he dumped the full enema, still clear, into the bed. Time to start over.

Turning was tricky. Any time we moved him, he would grimace and his blood pressure would skyrocket—even though he was heavily sedated and receiving a pain med drip, he was clearly having a lot of breakthrough pain. His blood pressure tended to run dangerously low whenever he wasn’t in pain, though. So I would dose him with a huge bolus of fentanyl, wait about two minutes for it to kick in, watch his blood pressure start to bomb (watching in real time through an arterial line), and then do all the turning and washing and dressing changing and whatnot.

Ventilated pts also get their teeth brushed or their mouths swabbed and suctioned once every two hours, usually right before we turn them so there isn’t a drool river when we’re moving them around every two hours. 

The whole time, we were hunting desperately for someone to make decisions on his behalf: a family member, a designated power of attorney, anybody. His kidneys weren’t pulling out of their tailspin, and the buildup of nitrogenous wastes in his body wasn’t doing him any favors. Before we made the huge step of initiating dialysis, though, knowing that this would be a long healing process with a huge amount of involved and intensive care, it would have been really nice to know if he’d have wanted it.

This being a weekend, and this fellow being a member of a specific healthcare group that has its own social workers and discharge nurses that aren’t available on weekends for whatever goddamn reason, I found myself doing most of the work of contact hunting. I called his job and, without being able to give them any details over the phone, asked if he had any next-of-kin numbers. None of them worked. I called his home phone, got his roommate, learned that he had a daughter he had only ever referred to as “my daughter;” received a phone call from a coworker of his who had heard he was out sick, and found out that he has a landlady who “might know somebody;” called the landlady and learned that he had family somewhere in a Middle Eastern country “who don’t speak any English and I don’t know their names;” and was finally suggested to contact a religious leader of his community, who might have access to lineage papers.

By the time I got to that point, it was Monday morning, and the social workers were back on the job. So I spent about an hour pushing them over the phone, giving them a full report of everything I’d done to seek contact, and signed off on his “call the family” duties.

Meanwhile, down the hallway, the drowned kid circled the drain for days. His lungs were torn to shreds by the lake water; his anoxic brain injury caused him to start seizing for hours at a time; his mother went completely insane before my eyes and descended from “horrified and grieving mother” to “crazy woman in filthy clothing laugh-sobbing in the end of the hallway all day and all night.” God, we all felt terrible for her. She threw a shoe at the palliative care people when they came by. 

He went into a rotoprone bed, as I think I said before, and coded in it. A rotoprone bed is no minor thing in ICU practice. It’s like a huge padded coffin/cradle into which a pt can be packed, then wrapped tightly in cushions and panels and straps, then rotated until their face is hanging downward so their lungs can drain. Once they’re proned, we open the back of the bed and let them lie there, gently swinging back and forth with their belly facing the floor, letting their lungs stretch and drain and slowly recover. It’s very effective when used early, and was originally marketed for H1N1 support, since young pts who survived the initial respiratory catastrophe of that strain would recover easily enough in a week or two.

Now we use it for ARDS, acute respiratory distress syndrome, which can happen for many reasons ranging from pneumonia to aspiration to pancreatitis. In ARDS, the lungs become so inflamed that their tissues turn thin and stiff, they can’t exchange gas well, fluids weep into the air sacs, and even the blood vessels lose their pliancy and become hard and resistant to blood flow. 

We use a lot of things to treat ARDS. Paralytics can help reduce the pt’s inclination to fight the ventilator, and minimize their oxygen usage; Flolan (epoprostenol) is a ruinously expensive inhaled medication that dilates the blood vessels of the lungs to allow improved blood flow; chest physiotherapy can sometimes be used to help break up secretions and move fluids around; and, of course, antibiotics and steroids and protective settings on the ventilator to prevent lung damage. And PEEP.

Remember how a bipap mask adds a kick of pressurized air at the end of the breathing cycle to keep the airways (large and small) open? PEEP (positive end-expiratory pressure) is similar to that. Cranking up the pressure helps force fluid back into the veins, keeps the air sacs open, and increases the pressure gradient of air vs blood so that air exchanges more effectively across the membranes. Usually ventilation (CO2 shedding) is harder than oxygenation, but in ARDS pts often have oxygenation just as bad as their ventilation. 

I’ve seen ARDS fought effectively. I cared for a pt once who was very young, got a nasty pneumonia, spent days and days in the rotoprone bed, and was eventually transferred to the local children’s hospital to receive ECMO—extracorporeal membranous oxygenation, in which blood is drained from the body, oxygenated through a membrane, and pumped back into the body constantly. She ended up doing well, and sent us a letter about a year later to let us know that she had not only survived, she had recovered enough to walk across the stage at her graduation.

The drowned kid will not be so lucky. Even if his lungs manage to recover from the lake water problem, his brain is completely fucked from the continued hypoxia. We are, essentially, buying the family time to say goodbye.

Which is a victory, sometimes. If we define death as failure and any kind of life as success, then pretty soon our successes are often hollow—we have quite a few pts who end up suffering for a very long time and being shipped back and forth between the hospital and a long-term acute care facility—and our failures are nearly constant.

You have to look for other definitions of success and failure, here. Sometimes our victories are good deaths. Sometimes we work our asses off day and night to make sure a pt is comfortable as they’re dying. Sometimes we finally manage to talk the family into letting go; sometimes we struggle to win them the few days they need to come to terms with their loss. Sometimes we squeeze enough time to let the plane land and the taxi speed from the airport, so that the kids can be there when their father dies. Sometimes we wash our hands of a code and catch our breaths, and the corpse cools in the room while we go back over the entire crisis and realize that we did everything right and they died anyway. But it’s still a victory, just as all these others are victories: we did everything right.

But they died anyway.

And sometimes we practice our skills on a pt who has made every possible bad choice and is dying of their bad choices, knowing that our care is futile and the resources we spend are wasted, but knowing that when the next pt comes in needing that unusual procedure, we will be that much fresher in our practice. That’s a victory, if you squint.

And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.

Which is to say: when the drowned kid died, my last day before I went on that huge long camping trip and didn’t post for a while, we were all devastated. His mother cried like an animal, gagging and groaning and clawing at her arms, and we all twisted our mouths and ground our teeth and remembered that we were people and wished we weren’t.

Rachel went home again. Her younger child’s birthday is coming up.

That same day, the last day before camping, I sent my open abd guy down to have his belly incision revised. They will slowly close it until at last his intestines are all contained, giving him time for the swelling to diminish between each revision. Then, because he wasn’t expected back up before my end of shift, I took two more pts: a comfort care pt in his thirties with Huntington’s, who was starting to lose his ability to swallow his secretions and was choosing to go home to die rather than move forward with a tracheostomy, and an older fellow with severe hearing loss who had come in for a very mild GI bleed from an ulcer in his stomach.

The comfort care pt’s case was relentlessly sad. His young wife is pregnant; he is not expected to live to see the child. He declined to make a video for the baby, saying that he didn’t want his son to see him like this. His family are rollicking good-ol-boy country folk, and they all sat in his room picking on him affectionately and watching Pawn Stars. They were delightful; they had faced this monster directly, and chosen not to be destroyed by its inevitable rampage, and as a result they were wonderfully supportive and caring. They helped move his cramped arms and roll him gently when he needed to be repositioned; they joked that his stubble “looked like wanderin’ pubes.” They ate five boxes of Fruit Roll-Ups in the room (making me crave Fruit Roll-Ups), and tirelessly suctioned his mouth with a soft plastic tube so he wouldn’t choke.

We tried out atropine drops to dry up his mouth, and they worked fairly well, although he still needed some suctioning from time to time. He was just waiting for the hospice group to pick him up in the morning and bring him home, where he can spend the rest of his life in comfort, surrounded by family. He got the shittest deal on the table, but I think he’s choosing the best possible option with it.

The GI bleed old guy told me about gladiator diets (beans and porridge, with burned plants to provide magnesium?) and house paint (never just use flat white, it looks too bare!) and nail storage (lots of yogurt containers!). He was advanced from a clear liquid diet to a full liquid diet, and delighted in his tray of four different kinds of soup instead of “all that sweet stuff they’ve been trying to trick me into eating.” He called me darlin’ and ma’am and Nurse Elise. He was an absolute doll and I wish all my pts were like him. Plan was to send him home the next day.

The next day I left for my camping trip, and haven’t been back to work yet. The trip was wonderful—I moved into a hammock by Lake Crescent, out on the peninsula, one of the prettiest places I’ve ever camped—and then I came home, finished my studying, took my CCRN exam, slept for a full day, and went to Cardiology Summer School today (first of three Fridays spread throughout the summer, lectures by a popular nurse educator in the area). Tomorrow, I go back to work.

I did stop by and check on my open abd guy. He is still alive and seems to be doing well, though the dialysis nurse was in his room setting up shop when I poked my head in. I didn’t see his abdomen, though. Maybe it’s closed by now. I will check his chart tomorrow and see what all has been going on while I was eating hot dogs and smores at the lake.

And I had my ninety-day review at this facility (I worked there for three months as a traveler before hiring on full time). My manager said there have been absolutely no complaints about me, which makes me pretty giddy, but added that the charge nurses were surprised by how easily I fell asleep on my nap breaks and how often I spend my breaks napping.

I really don’t know what to say to that. I’m fucking exhausted all the time at work and I sleep like a dead rock every chance I get. I just kind of stammered something about being ex-night-shift and wandered away. I thought break naps were one of the crucial characteristics of the nursing profession in general? Maybe I’m just lazy. That is a very real possibility.

I wonder if I’ll get my abd guy back tomorrow. I guess I should head to bed soon, since I have to be up in six hours. Shit, I think I figured out why I nap on all my breaks.

Week Five Please Send Help Too Much Work

Thursday I rolled into work around 1045, having juggled my hours to accommodate the concert. Getting out at 1500 on Wed was just enough time to let me stagger home, wash my gross self, nap for an hour, and put on some real-people clothes before the festivities commenced. Coming back in at 1100 on Thurs let me sleep in, which I desperately needed (and still need, and will always need even when I don’t get it). So I was well-rested, well-fed, and wearing my best work pajamas when I showed up at the nurses’ station and asked about my assignment.

Charge nurse put on a very serious face and asked if I would be comfortable getting oriented to hearts at this facility today.

Open hearts are a big deal, the moneymaker of any ICU that does them. Nurses that take fresh open heart recoveries are rigorously trained, tested, precepted, and even given classroom time on the unit’s dollar to make sure they’re fully equipped. Heart pts are delicate, touchy, and heavily regulated, but a really sharp RN with lots of training can keep everything moving smoothly despite the inevitable hiccups. I had not taken a fresh open heart in something like nine months, because even a few months before I left my last facility, the open-heart program became a dangerous place for a relatively inexperienced nurse.

A second-day heart pt had been assigned to a non-heart night nurse due to understaffing, with the idea that the heart-certified charge nurse would be able to back her up and keep things running smoothly. Instead, the pt lost conduction (valve replacements often do, though it’s less common for this to happen on the second or third days) and dropped their heartbeat completely. They ended up coding her for almost thirty minutes before someone thought to hook up her pacemaker, and after thirty more minutes without success they called the code.

The charge nurse was hung out to dry, and retired to PACU a few months later. The unfortunate unit nurse assigned to the pt was scapegoated roundly, despite having never been trained on hearts and therefore lacking the reflex to hook up the pacer to the V-wires sticking out of the pt’s chest. Every hiccup in every recovery for the next six months was scrutinized, written up, and presented “in a meeting” between managerial staff and the heart nurse in question. Everyone on the unit was trained in temporary pacer management, but when the heart RNs requested additional training to address the hiccups that were obviously such a big problem now, they were given no more education—just stripped of autonomy and grilled after every case.

I voluntarily removed myself from the heart list. Which is sad, because I fucking love hearts. They are a huge rush and the detail and precision and reflex required is a serious, galvanizing challenge. There’s also an element of prestige to the open heart program, which I like because I am a bit shallow and vain. Succeeding at the challenge makes me feel like a Real Nurse instead of the secret imposter I usually feel like I am.

The imposter thing is a huge deal in my life. Even writing this diary is kind of terrifying to me, because I know that I’m getting some things wrong and there are probably people shaking their heads and wondering why I suck so bad. I’ve worked ICU since 2008 and I still regularly encounter things that make me feel like a clueless kid wearing borrowed scrubs, things I should have known but didn’t, moments of dumb that make me cringe for months. I am deeply afraid of appearing stupid or uneducated or incompetent. One of the hardest things in my practice is recovering rusty skills—things I used to do well, but which I haven’t done for a while, and which I might be expected to perform competently but will probably make mistakes with. I am constantly ashamed of myself, and sometimes this makes me defensive or aggressive when I really shouldn’t be.

Mostly I channel it into fighting my innate laziness. I don’t want to look like a piece of shit nurse who can’t do anything without her hand being held, so I constantly educate myself, refresh my skills, pay attention to the details, and attend to the shitty boring jobs as well as the exciting flashy ones.

So taking this heart pt was very important to me, and although my shamepanic drive geared up for a beating, I accepted the assignment. As a psychological incentive, there was also an element of the unit really needing a few more heart nurses—my other great fear is abandonment, which means that I am at my most comfortable and secure when I feel necessary. It’s vital that I keep that impulse in check, because a hospital will chew you up and spit you out if you can’t resist the phrase “we really need you.” And nobody in a hospital is truly indispensable, so at some point in every work situation I will inevitably encounter the truth that I will never be perfect and that perfection is not required for me to be valuable. But I allow myself a few smug moments sometimes to enjoy my employers’ gratitude and/or relief, just as I occasionally remind myself that if I don’t get my job done right, I will get in just as much trouble as the next nurse down the hall.

My value is earned, and if I fuck around and make messes, other people are entitled to avoid me—which means that the approval and security I crave is a predictable resource I can expect if I fulfill certain realistic expectations, and am entitled to demand if it’s inappropriately withheld.

There was a time when I handled things with much less self-awareness. Approval and love were like an endless series of rocks thrown into the emotional well of my insecurity, each little splash a momentary fix, while the whole time I acted like a crazy person, trying to drive the source of approval away to “prove” that my fears were legitimate and that the splashes would stop coming. I was an incredibly challenging person to care about. I think the only reason I finally escaped that personality hellhole was that I got into nursing, where my value was measured in life and death and hourly wage. It’s hard to lie to yourself about patient outcomes.

I’m pretty sure nursing saved my life.

I’m also pretty sure this diary is not at its best when I’m navel-gazing in it. Lo siento, my friends.

Anyway, Mavi*, one of the best heart nurses on the unit, offered to be my second/preceptor for the day. She is a tiny Filipina woman with beastly skills, ice-cold reflexes, and the kind of gentle, humorous nursing style that makes everyone around her comfortable and happy.

We prepared the room and sat down to get me oriented to the paperwork and charting. Every fresh heart has a primary nurse (in this case, me) and a second (Mavi), with distinct roles in the recovery process—there is a hell of a lot of work to do during those first few hours. Every facility documents its hearts a little differently, and every surgeon has their own preferences and quirks, and every heart nurse needs to get familiar with the details very quickly so they can be second nature by the time they’re making decisions about which medication to start.

This surgeon doesn’t like SCDs (leg massager pumps used to prevent blood clots from forming), prefers to be texted rather than paged, dislikes high doses of epinephrine used as a pressor, and is blazing fast at his job. He also plays jazz guitar, was once an aerospace engineer (his first career), and is in active military duty through some branch or other. I was a little intimidated, to be honest. Mavi put the surgeon’s number in my phone while we looked over the procedural chart for landing a fresh heart, which she wrote a while back and which has become official paperwork because it rocks.

Off-pump call came about four hours after surgery started, which was incredible, considering that the guy had a valve replaced (requires cutting into the heart itself), a coronary artery bypass graft (CABG, requires harvesting a vein or artery from somewhere else in the body), and a double MAZE procedure (a labyrinth of burn scars in both atria to prevent atrial fibrillation). This is a whole lot of stuff to have done in a single surgery, let alone in a mere four hours of surgery.

Elevator call is typically an hour after off-pump call. Once the pt is taken off the bypass pump and their heart is restarted, the team still needs to close the chest and perform a few other little tune-ups, then watch the pt until they’re satisfied that he’s stable. Then they give one last notification to the ICU and load the whole crew into the elevator. So the pt arrived, intubated and still working off the anesthesia, with a churning nest of OR nurses, techs, and anesthetologists squirming all over him. Mavi hooked him up to monitors while I checked on his chest tubes; Mavi drew up his initial labs while I charted until my eyes started to sweat. Mavi performed foley care; I ran hemodynamics through his swann catheter, checking on the function of his various cardiac components. I listened to his heart and lungs—this is especially important in valve surgeries, since a valve problem will usually be audible as a murmur—and Mavi examined his pacer wires and vent settings.

He was atrially paced. Many valve pts come back with their pacer wires hooked up and firing, either by directly stimulating the ventricles (the big chambers at the bottom of the heart, the ones with all the kick) or by starting the electric cascade in the atria (the little chambers whose job is mostly to pack extra blood into the big chambers and stretch them out bigger so they can beat harder). Some surgeons prefer to let the ventricles fill on their own and just pace from the ventricles themselves. In valve surgery, the actual heart itself is cut and the nerves are very unhappy, especially the nerves responsible for relaying messages from the atria (where each beat starts) down to the ventricles (where the beat ends with a big push). Angry, swollen, shocky nerves don’t relay impulses well, and thus any beat that starts at the top of the heart—whether natural or atrially paced—may not get conducted all the way to the bottom.

But that atrial kick gets a lot more mileage out of each beat. Imagine holding a water balloon in your fist, and squeezing it until it pops. If the balloon was filled just by dunking the empty balloon into a bucket of water, it won’t have much water inside, and your fist will have to squeeze really hard to pop the balloon. But if you hooked the same balloon up to a water hose and filled it until it was ready to pop in the first place, the balloon itself wants to return to its original shape—it has mechanical elasticity, and your fist only has to work a little to make it pop. In this case, the ‘pop’ is the force of perfusing your entire body with blood, and the water hose is the atrial kick that forces extra blood into your ventricles. So atrial pacing is a great place to start a cardiac pt. If you lose conduction, you can always hook up the ventricular pacer wires and stimulate beats that way.

His blood pressure and cardiac output, of course, started to drop very quickly. The recently-cut heart is stiff and shocky and stressed out, and its walls don’t want to move very well. Plus, the body is reacting to the insult of being cut up and partially exsanguinated by shifting fluid around its various spaces, pulling water out of the blood into the tissues where it’s mostly useless except to swell up and make you look puffy. So we administer fluids, to replenish the thirsty bloodstream, and we administer albumin, which thickens up the blood (increases its osmolarity) to suck water back out of the tissues into the blood vessels.

To support the blood pressure, we use several different medications by steady drip. I am pretty used to using dobutamine as a front-line inotrope—that is, the first drug I turn to when I need to stimulate the heart to squeeze harder instead of faster. This surgeon, however, prefers epinephrine, aka adrenaline, which both speeds the heart (a chronotrope) and increases its contractility (an inotrope). As the pt’s recovery continued, we shifted from the fluid-moving phase to the vasodilation phase, in which the body really wants to relax its veins and dump all its fluid into the tissues. Here we started using phenylephrine, also known as neosynephrine, which is a pure vasopressor—that is, it tightens up your blood vessels, and doesn’t affect the workings of your heart. In the same way that you get higher pressure by squirting water through a straw than through a hose with the same force, tighter blood vessels increase pressure… although they resist the heart’s beats a little harder.

One of the other big bad pressors, norepinephrine/noradrenaline, is also known as Levophed… or, in ICU parlance, leave-‘em-dead. It will squeeze the living shit out of your blood vessels until your toes drop off, which is what happened to my CRRT lady a while back. If you find yourself using norepi on a cardiac surgery pt, something has gone extremely wrong. The other two pressors, vasopressin and dopamine, I will probably talk about later, when I have a pt I’m using them on.

Within about two hours of his arrival on the unit, he awakened enough from general anesthesia that he could open his eyes, lift his head, and follow commands, so we pulled out his breathing tube and let him breathe on his own. A little morphine for pain, a few ice chips for his dry throat, and he was happy as a clam in sauce.

He was also convinced that I spoke exclusively German, and was courteous enough to speak exclusively German to me. I do not speak German at all, so occasionally I would rattle back at him in hospital Spanish (I cut my ICU teeth in Texas) and he would recoil, startled. He is a world traveler and historian and as he came back to his senses throughout the afternoon he and I had many wonderful conversations in English. Any time he drifted off though, he would wake up, look at me, and start speaking German again.

Man, I don’t know. I don’t even look German. I have enormous bushy brown hair, a prominent forehead, freckles, glasses, and the kind of sloppily-assembled facial features you get from slightly inbred trailer trash that grew up in the river bottom. I look like leftover tax dodger and piney-woods moonshiner and hastily concealed ancestor ethnicity back when Irish was considered ‘ethnic’. I am white as shit, but not in the classy-lookin’ European way, is what I’m saying. Four years ago, before suffering my way through braces, I had buck teeth.

I’m not exactly pretty, but fuckin hell man, I don’t have to be. I am the apocalyptic definition of ‘personality hot’. I’m the lady equivalent of that weird-lookin fucker on TV that’s sixty years old and worryingly asymmetrical in the face parts and could bang your girlfriend in the bathroom at your favorite bar after five minutes of conversation. I am also incredibly arrogant and don’t speak a word of German. It’s quite possible that he was just telling me how my face is so gnarly it’s giving him flashbacks to WWII.

We joked a little about our respective experiences with foreign languages, and he taught me a little about the ways in which Italian deviates from Spanish. I taught him to say “qapla’.” I can’t help but feel that I got the better end of that deal.

Anyway, linguistic barriers aside, by the time we had this guy settled down and feeling pretty good, I had an imperial shit-ton of charting to get done, so Mavi watched him for a bit while I had lunch and then tore into the paperwork. The surgeon came by to see how the guy was doing, and I noticed that he was wearing an honest-to-god Starfleet insignia badge on his white coat, which after my earlier Klingon language lesson seemed like a much stranger coincidence than it probably was. We ended up having a nice chat about Star Trek, after which a couple of the RTs came up and started reminiscing about Jimmy Doohan, who apparently used to come to this hospital for pulmonary fibrosis because he lived nearby. (I would consider this HIPPA material except that it’s freely available information from Wikipedia.) He was apparently funny and personable, hated being called “Scotty,” and once left AMA because he hadn’t had any alone time with his wife in a week.

The RTs apparently thought very highly of his wife, who was much younger than him but who genuinely seemed to care about him and connect with him on a personal level. “They were great people,” said the surgeon. “I was always a little intimidated by him though.” Then he started talking about how his engineering career was spurred by his love of Star Trek, and how he missed NASA because he had felt like a member of a modern-day Starfleet there. I turned into a brick of shy-terror and finished my charting in record time.

After that, we got my pt sitting up on the edge of the bed so his feet could dangle, reminding him to hug his heart-shaped splint pillow tightly to relieve tension on his chest, then popped him back into bed and tidied up the room for the next shift. He was scheduled for at least one more major exercise activity, probably an hour sitting in a recliner, before bedtime. Exercise is critical to the early recovery phase; a pt who lies in bed the whole time will have nasty consequences. Lungs collapse and close up and fill with fluid; chest tubes clot off, and fluid builds up around the heart; blood clots up in the legs and causes pain and swelling, with a huge risk of pulmonary embolism; and the whole body misses the opportunity to tune itself up after the surgery, leading to increased swelling, decreased cardiac output, and severe constipation.

Tomorrow he’ll walk around the unit four times, and spend at least half the day in a chair. After that we’ll really start pushing. His case will be a smooth one, barring any major unanticipated events, and he’ll probably go home in a week or two. Before the surgery he couldn’t walk without collapsing because his heart was too starved for oxygen and too backed up from his scarred-up valve; when he gets home, lord willin’ and the creek don’t rise, he’ll be able to stroll around the park and even do some gentle gardening.

Other things that happened today…

The screaming lady died. Her ammonia poisoning—hepatic encephalopathy—became so intense that she could no longer speak or make eye contact, and she laid in bed thrashing and groaning in horrible garbled sentences of fragmented non-words as if demons had crawled into her skull and were eating everything inside it. Her family stopped going into the room at all, and huddled outside in knots of two and three, weeping. Palliative care approached gingerly, having been rebuffed many times before, and her closest relative made the decision without even having to be asked.

“Let her go,” he said. “She’s not even really alive anymore.”

We took the fem-stop pressure dressing off her leg, and she bled out and died within five minutes. The absence of her screams was sickening for the first half-hour; then hospital silence seeped into the cracks, a weird relief.

In the car on the way home from a shift, you forget to turn on the radio, you forget that you were going to make that phone call—you soak in the lack of alarms, the lack of dinging and beeping and chiming and clanging. It’s like breathing after you resurface from the water, at first. Your eardrums feel like somebody is pressing on them, blunting out the constant bells you know must still be ringing. Then, as other small daily sounds creep in at the edges, you forget what it was that you were supposed to be hearing. The white hum of road noise, the whoosh and rumble, disappears beneath the sounds of the car passing you in the other lane, the click of your blinker, the subvocalization of the gearshift, the creak of your knee as you depress the clutch and wonder why the fuck you can’t just give up your dignity and buy an automatic for the commute. You remember that you downloaded the new episode of that podcast, and hook your phone up with one hand, and dig that last Kit-Kat bar out of your purse to devour while you drive. By the time you reach your home, the endless litany of alarms is not only missing but forgotten.

That’s how it was with her screaming. An hour after she died, we were all cursing under our breath about the one guy whose monitor kept false-alarming. I almost forgot she had been alive just that afternoon.

We also got in two pediatric cases. Okay, teenagers. One was in a car wreck and had mashed up his legs, but was expected to recover, although his entire family was shaken and white-faced. The other was involved in a drowning incident; his mother had seen him go underwater and not come up, and although there was a nurse nearby who started CPR as soon as they could pull him up, he had inhaled a fuck-ton of lake water. His mother was a complete wreck, and understandably so, but very optimistic and desperately hopeful that he would wake up soon.

We’ve had a few drowning cases. Everyone is keeping a politely neutral face, and of course we’re doing everything we can, but (because I’m writing this a few days later) I can tell you that on Friday he had his first code blue as his lungs succumbed to the inevitable damage of lake aspiration, and that today he’s in a rotoprone bed, seizing.

He might yet make it. Maybe. It’s a long shot. Either way, I’ll be here every day through Wednesday, so if he dies I have about a 50% chance of being here for it.

Week 5 How Many Fucking Shifts Jesus

I didn't write the day of this shift because I was too busy sobbing like an open drain at a Sufjan Stevens concert that night, and then afterward my friend dragged me to her house and forced me to watch (okay, fall asleep trying to watch) Tinkerbelle and the Legend of the Neverbeast. (She has a two-and-a-half-year-old and might be going a little crazy.)

Opened the shift with a decent duo: a GI bleeder and a post-laminectomy. The latter was only under my care for a few hours, as her biggest issue was pain-- a lot of pain-- and she had come to the ICU because all the pain meds made her loopy on the medical floor and they wanted to watch her a little closer. We were concerned by how dramatically her neuro status had declined; she wasn't somnolent or respiratory-depressed at all, as you'd expect with someone having an opioid OD, but she was totally hallucinating and paranoid. We don't like to see major mental status changes in a pt who's fresh off a major back surgery and/or had an epidural (as is common with back surgeries), because there's always the chance of infection in the central nervous system.

She cleared up around 0845 and seemed totally fine. I interviewed her a little more closely about what she thought had happened, and she said: "Oh, I just have these episodes. Never really thought they were a big deal." Straight from there to a head CT, where the radiologist noted what could be a lesion-- possibly a tumor-- in her head. From that point the neuro team got involved, and because she wasn't really critical care status they moved her off the ICU.

That interview process, by the way, is one of the more ticklish and annoying aspects of nursing, but one of the most important if you want to catch things before they go south. Most people are hesitant to offer their own opinions about their medical issues to healthcare staff, which means that sometimes valuable bits of information get withheld because the patient doesn't want to look dumb in front of the doctor. Thing is, we aren't mind-readers, we rarely have a truly comprehensive health history, and we don't always connect the dots with the same one-on-one scrutiny that a person can perform on themselves. We might not be able to take a pt's diagnosis at face value, because we can't expect them to have a full medical education (I mean, shit, I can't diagnose anybody either), but we can definitely get a lot of crucial information from a person's opinions about their body.

It's like: you might not know exactly what's wrong, but by god, you know something's wrong. And we don't always know even that much, until your vital signs start to crash.

There's a saying that, when a pt tells you they're dying, you fucking listen. People don't just toss that phrasing around. They might not be able to tell you exactly why they're dying, but they know their body is about to lose its grip. 

That kinda came into play later in the shift. More on that later though.

My other pt, the GI bleeder, was a bit of a weird dude. He'd gone AMA the week before and returned vomiting blood, and in addition to a massive variceal banding, he also needed a TIPS procedure. 

If you need a refresher on liver failure and what it does to your guts, here's my patho lesson from last week.

So this guy, a chronic heavy drinker who regularly mixes Tylenol PM with his vodka (do not fucking do this, alcohol + tylenol/paracetamol = liver-ripping molecular knives), has a liver so blocked that all his esophageal vessels are bubbling up like a teenager's face. All the blood vessels around his liver and intestines are completely blown out and ready to explode. Medical treatment hasn't helped him at all, and eventually we'll run out of chances to catch his bleeds... so the next step is a TIPS.

A transjugular intrahepatic portosystemic shunt, TIPS, is a tube that connects the blood vessels on either side of the liver. Now the intestines can dump straight into the system, bypassing most of the liver. If you're guessing that this can have amazingly nasty side effects, you are absolutely correct-- jizz proteins and brain-pickling nitrogens and straight-up chunks of shit are free to wander. Your liver is still getting a little filtration done, and making what proteins it can, but if it's almost completely cardboarded sometimes blood doesn't even bother and just travels by shunt... which cuts off blood flow to the liver and can kill you. But hey, you won't bleed to death?

As is common with families that involve alcoholism, this guy's family-- him and his wife, his children being estranged-- was extremely enabling and secret-keeping and just weird, with bad ideas about boundaries. He and his wife insisted that his hospital bed be moved closer to the wall sofa, so that he and his wife could hold hands as he slept; his wife refused to leave the room at any time, and spent weird amounts of time in the room "changing" (ie naked for some reason????) so that any entry to the room had to be preceded by lots of knocking and calling out. Super codependent, super enmeshed, super inappropriate, and super terrified of "being caught." When I stumbled across the pt's wall charger plugged in by the sink, a totally normal thing that everyone does, the wife reacted as if I'd caught her slipping her husband booze. Families afflicted with alcoholism run on secret-keeping, and most family members have a hard time telling what's an actual secret and what's normal, because they're so used to keeping the world at bay. I felt really, really bad for them both, because things will never get better for them without help, and they'll never get help because they're so invested in the secret and so locked into the psychological addiction of enabling. 

But he went down for this TIPS at two, and did pretty well, so he's got maybe another year or two's worth of chances to break the secret and get their lives back.

While all this was going on, Rachel went home. She isn't even going to rehab-- she's been totally off vent for a while, even taking a few steps at a time, and she went home in a medicab to her children and her own home. I hope things go well for her.

The exploding poop guy was doing much better. A few days of nonstop diarrhea had loosened his belly up to the point that, when I poked my head in, I could see the droopy skin of his abdomen flopping as his nurse turned him to wipe his ass. 

A couple of people asked me how somebody can live without shitting for six months. (Hopefully tomorrow I can get caught up on replies?) The answer is: you can't live without shitting for six months. You can, however, be massively chronically constipated, and if it starts slowly and doesn't advance too quickly, your body gradually learns to compensate for the increasing blockage. You shit liquid around the blockage, mostly. But eventually even that deteriorates, and soon you're backed up to your neck. Literally. So this guy hadn't pooped in something like a week, but he'd been working on that week of constipation for so long that it damn near killed him.

The last pt I got for the day was an utter clusterfuck. She was an older woman, a marathon runner, who had developed a hiatal hernia and had it repaired via Nissen fundoplication (wrapping the stomach around the esophagus, which I can't describe any better than Wikipedia). Her wife is an RN and had been staying with her since the surgery a couple of days before, and yesterday had started expressing some concerns about the pt's status: requiring more oxygen, having increased pain, unable to advance her diet, and just "looking weird." Overnight the pt's oxygen needs had increased to the point that, when I finally got report, she had been on a non-rebreather mask at 15 liters, satting 89% O2 (you and I probably sit between 96% and 100%), for almost six hours without anybody insisting there was a problem.

Sometimes nurses make the worst pts. This nurse, however, impressed the hell out of me both with her insight and her grace in light of the medical floor staff's failure to recognize her wife's decompensation... though honestly I would have been a lot pushier than she was. I can't nitpick. She's trauma-ortho and I'm ICU and therefore she's a steady time-managing proceduralist while I'm a neurotic compulsive paranoid with control issues.

The transfer was awful. Charge told me I'd be getting a pt shortly, so I asked my break buddy to watch my TIPS guy while I took a fifteen-minute nap, and notified the charge and the unit secretary to call me on break if report came up. Instead, I enjoyed a nice snooze, checked on my TIPS, poured myself a cup of coffee, and walked down the hallway to find the new pt waiting for me-- no RN, no report, just a confused transport guy from CT and a pt who looked like she was about to crash on me.

As we moved her into the new bed, she grabbed my arm and gasped: "I think I'm dying." Then she was too short of breath to say anything else. I keep my hair back in a sloppy french braid, but I'm pretty sure half of it popped out and stuck up straight in the air. Remember what I said earlier? That's not a good thing to hear from any pt.

She had subcutaneous emphysema with crepitus-- crackling bubbles under her skin-- from her shoulders up to her temples. A quick chest x-ray showed that she had a massive pleural effusion, so I got her sitting up on the side of the bed, and the pulmonologist stuck a needle in her back and pulled out a liter of bloody-clear fluid, which improved her breathing but was extremely alarming. Her wife watched the whole procedure and looked increasingly apprehensive, especially when the pulm ordered the fluid checked for amylase-- one of the enzymes secreted by the pancreas, which belongs in the intestines breaking down your food, not in your lung cavities. 

Sure enough, the radiologist showed up twenty minutes later to tell us that her CT showed a giant rip in her esophagus, with communicating fluid and free air between abdomen, thorax, and mediastinum. This is SUPER BAD AND HORRIBLE and requires immediate surgery. Unfortunately, our cardiothoracic surgeon that day had started an open heart an hour before and wouldn't be available to operate for at least another four hours, and the nightmare in her gut was massive enough that she would need a GI surgeon and a thoracic surgeon to perform the surgery. We intubated her immediately to stabilize her, then transferred her to another hospital in the area, a thirty-minute drive at the end of which the op team was already preparing the OR. I hope she's okay, for her wife's sake. I can't imagine being a nurse, knowing what I know, and watching helplessly as my spouse suffered horrible pain and life-threatening health events. I don't know how she wasn't flipping tables and kicking doctors all night, watching her wife go from nasal cannula to mask to non-rebreather without being assessed for critical care status needs, watching her face blow up with subcutaneous air without somebody at least asking for a chest x-ray to rule out pneumothorax. 

This is why nurses make terrible pts. We get all freaked out and controlling about our care. It's just ridiculous. Any time my husband spends in the hospital is time I will spend gnawing my tongue off in the middle so I don't get thrown off the campus.

Let me tell you, though, getting that pt with no report and no prior warning was more of a wake-up than any amount of freshly-poured coffee that I promptly forgot about and left on the station until it got cold and the unit secretary threw it away. A pt with no report AND massive sub-q (uh, that's subcutaneous in nurse jargon) emphysema will give your sphincters a workout. I had to stay a little late just to write up the incident report. Still a little stressed out just thinking about it.

I only worked eight hours though, and after that I went home and washed up and put on something way too shabby and sloppy to wear to a concert, but I guess it didn't matter because I had a blast. Or possibly an emotional breakdown. It's kind of hard to tell. I will write about today's shift tomorrow, after the morning's meeting with my sister's social worker. 

My sister, btw, is doing really well, but she reminds myself a lot of me at that age-- questionable personal hygiene, terrible time management, serious lack of some basic social niceties. The usual rural-religious homeschooled stuff. But she's just as smart and articulate as I remember, and has charmed my friends and responded well to all our conversations about my expectations for her time in my home, and I'm really glad to have her with me as she starts her adult life.