This shift did not start well. I
gave report the night before to a nurse who has, best I can tell, the most
brutal ball-shriveling resting bitchface I have ever seen in my life. Alex* is
extraordinarily pretty, always immaculately groomed, incredibly capable and
conscientious, and has the amazing power to make me feel like a feeble,
wriggling brine shrimp during report.
“What have his sugars been
running?” No eye contact.
“Oh, uh…” /checks the lab sheet “Not too high. Uhhh… One-sixties. See.”
Her lips thin out. “Mmmm-hmm. Did you cover him?”
“I gave him… uh… one unit at noon.
And uh…. I didn’t cover his last blood sugar.”
Flat stare. “You didn’t.”
“No, it was… his blood sugar was
like… one point above the cut-off. I didn’t want to crash him.”
“Mmmm-hmmm. So I’ll cover that, then, and recheck in four hours. When I’m
supposed to. Did you get all the tubing changed?” Her expression is somewhere
between of course you didn’t and I can’t fucking believe this.
“Yeeeeeah.” Then I wither in my
seat and stare at my report sheet for a while. She never says anything hurtful
or really judgmental, she just has a tone.
Also did I mention she’s beautiful? That makes it a thousand million times
worse. I always tell myself after report with her that I didn’t fuck anything
up, that I did a good job this shift, that the things I didn’t get done were
things I had good reasons not to do.
So, having given report on the
crazy lady to her, I came back in a little terrified in case I had missed
anything.
Instead, she informed me that
she’d got a sitter for the pt again once her daughters had left for the evening—our
night CNA who always stays over, Rose*—and that she’d really gone nuts last
night. Great. Alex also said that she’d had two seizures last night, both of
them beginning with the characteristic left-eye jerk that she usually pulled,
and ending with tonic-clonic seizing.
She’d also had something that Alex
described as “really weird,” an apparent syncopal episode. She’d recovered
afterward, although her mental status was not so great for the rest of the
night, but she’d gone apneic (unbreathing) and unresponsive for almost a full
minute, and her heart had raced. Her post-ictal period had been extremely
short.
“I don’t think it was a seizure,”
said Alex. “She didn’t jerk her eyes around. But I don’t know what else it
could be. Honestly? I was about to start coding her when she came to. The doc
said that if she’s not back to normal by eight this morning, we’re going to
start a bunch of lab panels and get a CT scan. Which won’t be fun, because she
literally will not be still.”
Sure enough, she was fidgeting in
the bed, occasionally mumbling to herself, pushing at the blankets with her
hands and then pulling them back up. God, putting her in a CT scanner was gonna
be hell. But hey, 0715, she had forty-five minutes to get some sunlight and
snap out of it. My other pt was my little GI bleed fella again, so I got a
ten-second “nothing new, discharge today” from the nurse and came back to see
about getting my fidgeter out of sundown land.
Rose was a huge help. “We can just
get her up to the commode,” she said, “and then maybe if she does well we can
put her in the chair for breakfast, have her look outside. That should bring
her around.”
So we hoisted her up to the
commode, and she immediately dumped a gallon of dilute urine and let out a huge
sigh of relief.
I fixed her gown. “Better?”
She nodded, then looked up at me
with a puzzled expression on her face. “My name is Martha*,” she said, as if
just remembering this fact.
“Yeah,” I said. “You ready to sit
in the chair, Martha? We have some toast and scrambled eggs for you.”
A big emphatic nod. She looked
really confused, kind of blindsided, and I didn’t blame her—if she was snapping
out of sundowners, she would just now be entering the period where she starts
genuinely waking up, the way I often stagger to the toilet in the morning
without being quite sure whether it’s day or night. Rose helped me stand her up
in the waltz position—her hands on my shoulders, my hands gripping her gait
belt, my knees braced against hers in case hers buckle—and we started the
process of pivoting to sit in the chair.
About halfway there, she made a
strange expression. “My name is Martha,” she said again, and her pupils spilled
wide, and her body went completely slack.
Rose and I barely kept her from
hitting the floor, mostly by hauling on her gait belt and thighmastering her
lower body with our knees up into the waiting recliner. She was completely
limp, taking little hiccup-breaths, going gray in the face. Her eyes stared
into the middle distance. “She’s having a seizure,” said Rose. On the monitor,
her heart raced, then fell into a high bradycardia, rate of 55. Her bladder
emptied. She wasn’t really breathing, and even the hiccup-breaths were
diminishing into nothing.
We kicked the chair into full
recline and I grabbed the ambu breath bag. “Check her pulse,” I said. On the
monitor, her heart rate cruised down into the forties. “Check her pulse! Does
she have a pulse!”
“It’s a seizure,” said Rose, but
she fumbled for a pulse—wrist, throat, groin. “It’s just a seizure!” Meanwhile
she kicked the bed into flat mode, max inflate, pulled the CPR board off the
head, and slapped her walkie-talkie to call for a respiratory therapist and the
flex nurse. We all do this: we say what we really hope is true, and the whole
time we prepare for what we really hope isn’t true. Rose moves very quickly; the
flex nurse, Franklin*, ducked into the room within seconds.
“You guys need help getting her
back to the chair?” He looked at Rose prepping the bed, me bagging air into the
pt’s lungs while still trying to find the flicker of pulse I’d felt before, and
raised his eyebrows.
“Code,” I said. “Press the
button!” Rose smacked the alarm and the whole unit dissolved into organized
chaos.
“Jesus,” said Franklin. “You don’t
fuckin do half of report, do you?” He dove over the bedside commode, nearly
slipped in the lake of urine from my technically-dead pt, and helped me
cradle-lift her in one adrenaline-filled swoop back into the bed, where we laid
her flat and started compressions. On the monitor, her heart rate alarmed in
the twenties with a wide complex—slow movement of electricity throughout the
heart, a very bad sign—until we took up the lead-hammering pace of CPR.
Good pulses with compressions. The
RT took over bagging. The intensivist—one I forgot to introduce before, a
mild-mannered fellow with a soothing presence and a way with difficult
families—pushed into the room just behind the code cart, which the charge nurse
was plugging into the wall while Franklin stuck defibrillation pads to the pt’s
chest. “What happened,” he shouted—codes are incredibly loud—and I told him the
very short, very confusing story: she was
on the commode, she stood up, she died.
We coded the ever-loving shit out
of her. Pulseless Electrical Activity was all we got—not even a shockable
rhythm, just that useless, flaccid bradycardia on the monitor with no physical
pulse at all. PEA arrests tend to have incredibly bad outcomes; the heart is
too fucked for the electrical system to even realize the muscle is dead.
In the middle of all this I
walkie-talkied the unit secretary to ask her not to let any visitors past the
desk for this pt. I mean, god for-fucking-bid that her daughters walk into this
shit: their mother blank and staring in a bed, her few unbroken ribs mashing
into pieces under my hands, blood foaming up in the breathing tube we’d just
crammed down her throat, naked violent death at its least lovely.
Nothing worked. Nothing even started to work. Rose and I were both in
a pretty bad emotional state—this was not the pt we’d have expected to code.
For fuck’s sake, she had broken ribs and a UTI! And, okay, it looked like she’d
thrown a clot and had a pulmonary embolism—the blood clotted in the tube as the
lab tech drew it from her arm—and there wasn’t much we could have done about
that, but I thought about last night’s syncopal episode and about the
expression on her face as she died in my
arms and felt absolutely, bottomlessly sick.
We called it after thirty-five
minutes, a lifetime to code a woman in her eighties. The intensivist went in
the hallway to call her family, and managed to get through to the two most
anxious daughters, both of whom went completely to pieces over the phone. The
other daughter wasn’t picking up her phone.
I arranged her as best I could,
then took over the phone after the intensivist, calling the organ donation
group (a legal requirement, typically to rule a pt out for donation) and the
medical examiner’s office (another legal requirement, in case someone dies
under suspicious circumstances or there’s a chance of hospital wrongdoing),
trying to get the okay quickly to take the breathing tube and IVs out. You
can’t take anything off or out of the pt until you get the ME’s okay.
While I was on the phone with the
ME, the daughter whose phone had been off rounded the corner, ignored my
attempt to flag her down, and pushed into the room. “Mom,” she started, then
screamed: “Mom! MOM! Somebody help!”
God almighty, the unit sec hadn’t
stopped her at the desk. Her sisters hadn’t got through to her either. She
hadn’t answered because she’d been on the road, coming here, to visit with her
mother over breakfast.
I’m just glad it was the more
level-headed one. Of course she was devastated, absolutely wrecked—but she’s
more familiar with death, and she was able to integrate it and understand it
much sooner than her sisters would have. By the time her sisters arrived, I had
taken out all the tubes and wires, brushed her hair, tucked her in, and had her
looking halfway like herself again, except for a smear of blood beside her
pillow that I covered with a washcloth.
I called the chaplain. Turns out
the chaplain was off that day. The family hovered in the waiting room,
terrified to go see their mother’s body, wailing and crying, at least one
daughter nearly fainting twice. I called the weekend chaplain, who often covers
on her days off, and asked if she’d be willing to come in and sit with the
family while I finished up their paperwork and helped them get to a settling
point.
She came in. I owe her big.
Unfortunately, after she talked the family into going home and awaiting a call
from the funeral home to go see her recovered body there, she hung around and
tried to be emotionally supportive to me, at a time when I had a shit-ton of
paperwork to manage and really wasn’t feeling terribly in need of a shoulder to
cry on.
Mostly I was pissed as fuck, and
frustrated, and I wanted to punch something. Every last fucking thing that
could have gone wrong seemed to have gone wrong. I couldn’t believe she was
dead; I could not believe that we had
failed to keep her daughter from being surprised with her death. I was very
polite with the chaplain, but finally I hid in the bathroom until she left.
Then I went into my GIB guy’s room
for the first fucking time that whole shift. It was now 0830.
I gave him his breakfast, which
was mostly cold by now, and took his blood sugar so he could eat it. I smiled
graciously the entire time and apologized for taking so long. “I guess you
heard everyone in the unit running around like crazy,” I said. “We were trying
to save another pt who had taken a bad turn.”
He dug into his toast and asked:
“Were they okay?”
“Not as okay as I hoped.” I don’t
want to lie to people, but I can’t always tell them the truth, and either way
it’s bad form to bomb somebody’s day with a spiel about how their neighbor just
died.
As I emerged into the hallway,
Alex appeared, expression of stern disapproval firmly in place. “That went
badly,” she said, and I braced myself to defend my actions. “Here, I got you
this.”
It was a Starbucks latte. A real,
honest to god Starbucks latte. I am a little ashamed, but not much, to tell you
that I got a little misty. “Thank you so much,” I said.
“You did really well,” she said.
“I can’t believe she just coded like that. And her family… You handled that
really well.” Then she left for home, while I sipped my latte and rejoiced in
the knowledge that her chronic bitchface doesn’t reflect her actual opinion of
me.
Ten minutes later, the guy showed
up to carry Martha’s body away, and I finally gave the GIB guy’s morning meds
and helped him to the bedside commode. I don’t mind telling you I was sweating
like a horse the whole time. Waltz position and pivot, knees locked to knees,
the whole time I’m chanting in my head: Please don’t code, please don’t code.
He didn’t code. He did shit an
absolute lake of filth. I bet he felt better after that.
After this I took a nap. My
blessed coworker and patron saint Mavi covered me for what we euphemistically
called an “extended break,” and I spent forty-five minutes facedown on the
break room sofa, dreaming about a bubble bath full of little adorable swimming
mammals that would pop up through the bubbles and squeak, then dive like
otters.
I awakened to the charge nurse
shaking me gently. “Can you take the guy in twelve*? He has a sitter.”
Okay. Whatever. “What’s going on
in twelve?”
“His nurse is getting a fresh VATS
and he’s just… a little heavy.”
“Oh good. Sure. Whatever.”
He wasn’t just a little heavy. I
mean, physically, he weighed maybe 200lb, but he was in four-point locking
Velcro restraints with a bedside sitter and an ass full of Haldol injections.
The dude is in his late twenties, a Type 1 diabetic, with a serious drug
problem.
I don’t mean that he’s addicted to
something, although I’m sure he is. I don’t even mean that he’s taking
something nasty on the regular, although I’m sure he is. I mean that this guy
will, apparently, do literally anything to avoid sobriety, up to and including
begging Robitussin from a pt family member in the waiting room. I don’t think
he even got enough Robitussin to get high.
And at any rate this was two days
ago, when he was on the med-surg floor, before he went completely apeshit,
ripped the whiteboard off the wall, threw a chair at his nurse, and ran down
the stairwell to escape from the hospital. He was in for DKA and pancreatitis,
and definitely didn’t seem to be in control of his faculties, so we hunted him
down; he was in his truck in the parking garage, screaming and banging on the
window because he couldn’t figure out how to get the door open.
He had taken a whole bunch of
god-knows-what—tested positive for amphetamines, cocaine, opioids, and benzos,
although the latter two he’d had in-hospital with his pancreatitis pain and his
alcohol withdrawal. Oh yeah, his blood alcohol level was elevated too.
We weren’t able to figure this out
until he had been thoroughly restrained, jabbed with an obscene amount of
Haldol, shot up with about 4mg of IV Ativan, and strapped down while he drifted
off into a mumbling daze. His blood pressure was out the roof—not uncommon for
cocaine, especially crack, which we suspected because a) he’s homeless and poor
as shit and b) he had a bunch of copper brillo pads in his passenger seat. He
was also difficult to sedate, which we expect with meth usage… and he was
insanely violent and psychotic, which we expect with the kind of bullshit
gas-station drugs that get sold as ‘potpourri’.
I mean, he successfully tricked us
into keeping him from being sober for another 12 hours. But he did not endear
himself to us, what with all the punching and broken furniture.
By the time I got him, he was starting
to calm down, and I was able to ease him off the restraints, although the
sitter remained. His girlfriend came in, tearful, also obviously accustomed to
sleeping in cars and shooting up, and I got her a sandwich and a warm blanket
and told her to go ahead and sleep in the recliner for a while. When she woke
up, her boyfriend was still semiconscious and mumbling, so she and I had a
little contract chat: she goes to the methadone clinic, so I promised her that
while her boyfriend was in the hospital, she could stay here and sleep in the
chair and have three meals a day—as long as she attends her methadone clinic
meeting times and doesn’t bring in any drugs or alcohol, which are absolutely
forbidden on campus.
An hour later I caught her rolling
a cigarette (no, not even a joint, a cigarette—loose tobacco leaves in a greasy
recycled lunch-meat Tupperware), and explained that if she lit it up in here,
the ceiling sprinklers would come on and drench everything. “It’ll ruin your
phone,” I noted, and the pt spoke up from his groggy muttering to shout: “Put
my phone in the drawer!”
I started to suspect that he
wasn’t as gorked out as he seemed.
An hour after that I took his blood sugar and it resulted at 422. “What did you
eat,” I asked him.
“Nothing! I haven’t eaten in,
like, days.”
A cursory bed-shake revealed four
full-sized Butterfinger wrappers and an unmistakable pile of Oreo crumbs. Like
really, dude. We had a talk: “I know you want to get out of here as fast as
possible, but you realize if you drive your blood sugar up, you’re just gonna
end up back here, right? And if you have to have an insulin drip started again,
you won’t be able to leave easily?”
He shrugged. “I’m leaving here
tonight, even if I have to escape.” Big smile. “Hey, you wanna come with me?
There’s always room in my truck.”
His girlfriend started
complaining, then called me a whore. I left the room “to let you guys get
control of yourselves,” and heard her berating him as I left.
“Why do you say shit like that?
It’s not even funny!”
“It’s just my sense of humor,
babe. Roll me a cig?”
God. Gaaaaaawd. By this point he
was 100% conscious and aware, just being a total asshole. Every time I went in
the room, he gave me a steady stream of “humor” about how he was leaving in an
hour even if he had to hit someone, how the doctor had dropped by and said he
could have dilaudid, how he would “sign whatever you guys say” to get out this
evening because “I gotta meet a guy for some drugs. Just kidding!”
His expression didn’t say
‘joking’. His expression said that he thought I was stupid enough to believe he
was joking.
A lot of people tell inappropriate
jokes in the ICU. It’s a stress-coping mechanism, usually, if not a flattering
one. A lot of people who feel out of control of their lives and bodies try to
make the staff uncomfortable to re-establish their own feeling of autonomy. Typically
I’ll handle this by setting strict boundaries, leaving the room with an
admonition for the pt to get themselves under control, and looking for other
places to give the pt some perception of autonomy. You can tell that it’s a
stress response—they laugh with brittle force, they make lame uncreative jokes
and remarks, they show their teeth and the whites of their eyes. There’s a
little panic in their voices, a little aggression in their eyes.
Some people harass staff because
they’re depressed, detached, feeling hopeless. They’re terminal, or their
condition may never improve. They feel out of control, but they also feel like
the world around them is hostile and unsafe. They self-deprecate as much as
they attack; they have a bleak laugh, monotone voice, the kind of jokes that
cut deeper than they should. They kinda joke like Robin Williams: all mania and
grief.
(I could never watch Robin
Williams comedy. He just looked so sad all the time. He looked like he was
joking so he wouldn’t cry, or like he was trying to make someone laugh to keep
them from swinging at him.)
These people need to feel control,
but they also need to feel safe. They need palliative care, to help them find
ways to live meaningfully at the end of their lives. They need a wry sense of
humor to deflect their jabs, and to help their grim outlook become an enemy
they can despise instead of surrendering to.
This guy… well. Some pts have zero
intent of changing their lives, and resent being in the hospital at all. Some
pts think they’ve tricked you, because here you are taking care of them when
they hate you and would gladly hurt you if they could get away with it. Some
pts think you’re a sucker, their bitch, their waitress; they make remarks and
take potshots because they can, and they want to remind you that in their
minds, they’ve already won.
I can’t stand pts like that. I
hate seeing the expressions on their faces: the smirking challenge, the
gloating, the certainty that they can get away with anything they try to pull. It
turns my job from a joy and a labor of love into a gross afternoon of feeling
wasted and exploited.
About an hour before end of shift,
I got to give up my GIB guy and take on a new admit from the OR, a tiny old
woman with Alzheimer’s who fell in her assisted living facility and now has a
broken clavicle, broken facial bones, and a brand-new left hip repair. I barely
had time to get her settled before shift change.
As I was waiting to give report,
the afternoon charge came up to check on me. This is the same charge from
yesterday afternoon, the one who knew my pt. “Oh,” she said, “did you transfer
Martha to the floor?”
Explaining that was not fun.
After I gave report and was headed
to clock out, I passed my tiny old lady from the other day, the one with the
Diet Dr. Pepper and the razor-edged, if slightly unhinged, wit. “Hey,” she
called, “can you come get these men out of my bed?”
“Which men,” I asked, poking my
head into the room. She was alone, lying in a bundle of blankets.
“These men behind me,” she said,
gesturing to the pillows shoved under her left side. “I’m all wore out! I’ve
had enough. Tell ‘em to go home.”
I took the pillows out and told
her the gentlemen wouldn’t be bothering her any longer. Then I made it halfway
to the garage before I started wondering what, exactly, she’d thought those
“men” were up to in her bed, wearing her out.
I hope I grow up to be an old lady
just like her.
With an hour to go til report, I
took a walkie-talkie call from the charge. “I need you to give report to
Franklin on your GIB guy,” she said. “There’s a fresh hip coming up from the OR
who went into a-fib on the table, and I need you to recover her until the nocs
get here.”
“Shit, why can’t Franklin land
her?”
“Franklin has the heart. So you’ll
need to keep an eye on the GIB guy for him, and give your 1800 meds, because he
won’t be able to get into the room easily.”
Sigh. “How about I just keep GIB
for an hour and give report to the night nurse, and not waste time reporting to
Franklin before the hip gets here?”
“Oh, could you do that? Thanks!” Click.
Yeah, whatever. GIB guy was
happily chowing down on dinner, and I brought him his 1800 phosphorus-binding
med (oh yeah, he was on dialysis too, and required medications to prevent his
phos from climbing too high between trips to the fridge).
(The fridge here refers to the
huge chunky dialysis machines that our dialysis nurses push up and down the
hallways and use to scrub our pts’ blood. We call them “fridge nurses” and
exchange good-natured jabs about the relative superiority of our respective
nursing careers. Most of the hospitals in this area either keep their own
dialysis fleet or employ the major dialysis-nurse agency in the city, which
means that I’ve known most of them for years even though I changed facilities
last year.)
The fresh hip was a little old
lady with Alzheimers who had taken a dive while going to the bathroom and ended
up with a broken clavicle, hip, and left hand. The stress of surgery had
irritated the shit out of her heart, which went into a-fib, raising her risk of
clotting. When the top chamber of your heart is just wiggling around
ineffectively, it forms the perfect environment for clots to form—a warm, open
compartment with walls that massage the blood rather than pushing it. And since
she’d just had surgery, anticoagulating her was not an option.
So we started her on a diltiazem
drip to slow her heart rate—she was quite fast—and laid her flat to recover.
And then it was time to give report.
After which I went the fuck home
and made dinner, checked with my sister to make sure she was doing okay at the
GED tutoring sessions and to ask if she has an internship lined up yet, and
then went out for an hour with my writing buddy to work on something besides a
shift report: a highly simplified D&D campaign I’ve been running for some
friends who wanted to learn tabletop RPGs but were intimidated by all the numbers
and charts. It’s a small dumb thing that’s more story and flimflam than hard
game-crunching, but I’ve been enjoying it, and it’s adapted well enough to a
beginning group that it’s keeping ten simultaneous players occupied nicely.
Plus my writing buddy is a game designer type so I can pick his brain for help
when shit gets real, and he plays NPCs when I need them.
This is my first time DMing since
I was in college. I am not good at it, I don’t think. But we have fun.
