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.
Showing posts with label the nurse at home. Show all posts
Showing posts with label the nurse at home. Show all posts
Friday, July 17, 2015
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.
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.
Thursday, July 16, 2015
Week 3 Shift 3
Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Sunday, July 12, 2015
Week 2 Shift 1
By the time I clocked in yesterday morning, the fem-pop guy had been transferred to a telemetry unit in preparation to have him go home later in the day, the neurodegenerative guy had been sent home on hospice (probably won't die immediately, but will be allowed to drink water instead of begging for swabs), and the intensivist was standing at the front station talking about Rachel*, the birthday mom, and her swallow study later that day. They planned to try her out on a Passy-Muir valve, a type of tracheostomy apparatus that allows the pt to push a button so that they can speak and eat.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
I, of course, got back my HD pt, along with the new pt in the next room down, a gentleman I recognized from a previous admission. He had suffered a tremendous stroke about two months ago and lost all use of the left side of his body, along with the right side of his face for some reason. He is also now expressively aphasic, which is to say that he can understand other people's speech but can barely speak for himself. In addition, this guy-- in his sixties, with a history of med-controlled diabetes and vascular disease caused by the diabetes, which led to a coronary bypass and multiple coronary stents despite his active lifestyle and loss of forty pounds after diagnosis-- has become incontinent of stool and urine, and recently started having trouble swallowing.
Once you have diabetes, it's very hard to get rid of it. It's pretty much a downward slide through shredded veins and organs to stroke, heart attack, or renal failure, or some unholy blend of the three. Some people are genetically predisposed, like this fellow, who might have been okay if he'd caught it earlier... but he wasn't feeling the whole 'see the doctor every year' thing and thus didn't realize his sugars were rising until it was too late.
Worse, when he had his stroke, he was in bed with his sleeping wife, and was unable to get help for several hours afterward. So he wasn't eligible for the clot-busting tPA treatment (a strep toxin that causes total breakdown of the body's clotting cascade, which is very useful when your blood is clotted somewhere inconvenient like your heart or your brain). Thus, the sequelae-- the effects of his stroke-- are pretty well set in stone.
He was in for pneumonia, which he got because his half-paralyzed throat was letting chunks of dinner slide into his lungs. After a lot of discussion, he and his family agreed to have a percutaneous gastric tube installed today, so that he could have his food pumped directly into his stomach.
A PEG tube installation is pretty simple. You need a moderately sedated pt, a tube that goes down into their stomach with a camera and flashlight, a scalpel, and a hole-stretching apparatus. A lot of people resist this, because the end result is a tube poking out of your belly through which you get Ensure, and it's kind of the final step in admitting that your swallowing function is pretty well fucked. He and his family consulted the niece and nephew, a pair of doctors on the east coast, and decided to avoid the repeated aspiration pneumonia episodes and increasing weakness that inevitably follow when you try to keep eating even after your throat goes floppy.
Part of my job was to place an NG tube so that the docs down in Interventional Radiology could dump contrast into his stomach, which makes it easier to see the stomach on X-ray and thus to place the tube. Unfortunately, his septum was heavily deviated so his right nostril was blocked off, and as I started feeding it into his left nostril he started groaning and screaming.
It's not a comfortable procedure. I'm usually very quick about it, and I use lidocaine lube when I can so that it's not sheer misery. But it's almost impossible if your pt can't stop yelling long enough to swallow, because your tube will just end up in their windpipe. When you're hollering, your airway is open; when you're swallowing, it's closed, and your esophagus opens up instead. I used all the tricks I had and got it into his esophagus, after which he was much more comfortable... but it had coiled up in his esophagus and had to be taken out.
I called it quits, informed IR that there would be no contrast, and apologized to my pt with warm blankets and a single ice chip (which he choked on). That's two NGT fails in a row. Like any other ICU nurse, I am superstitious as shit. My next NGT placement will probably be a volunteer try on a pt who's heavily sedated or dying, so I can get the third one out of the way and/or break the streak.
Okay, I am not actually superstitious as shit. I am way into rational thinking. After a few fails at any nursing procedure, your brain starts to overcorrect and focus on changing things, with the result that you can have a much longer streak of fails that slowly destroys your brain's instinct and your muscle memory. When you start fucking up a bunch, it's time to find somewhere you can practice where fucking up won't hurt anyone, get real relaxed, and hopefully pick an easy one to do so that when you've done it you're back on track. It's amazing how quickly your brain will jettison all your hard-earned methodologies and hand movements once they miss a couple of times, and you can blow years of experience on one bad afternoon of IV sticks if you don't follow it up with an easy stick to remind your brain that the old info is still useful.
It's just much easier to package this as a superstition.
I also educated his family a lot about stroke and aftermath. For the first six months after a major brain injury, your brain is rearranging all the furniture, trying to salvage what it can and cover for the damaged places most effectively. Some days you're really working well, and some days you're barely yourself. Sometimes your brain finds a really great place for the sofa to be and you seem to have that corner of the living room wrapped up, and then the next day your brain wonders if it could push the sofa six inches to the left and fit the end table between it and the wall, and for the rest of that day you're figuratively barking your shins. To, you know, torture the metaphor. After that first six months, your brain has a pretty good grasp on where the furniture will be from now on, and works on adjusting everything a little at a time until the decor is right and the angles are all straight.
After a year, you stop having up days and down days for the most part, and you find your baseline. From there you can decline, if you don't exercise and get good treatment, or you can work on further recovery.
They seemed relieved to hear this. He had certainly been having up and down days, and they were all very frustrated with the way his progress seemed to appear and vanish without warning. It's cool, I told them, his brain remembers what worked, it's just trying to decide what else it needs to move to make this happen... and if it's worth having good speech if that means not having use of your left hand.
This is an incredibly simplified and anthropomorphized description of the brain's healing process, but as a metaphor it seems to help people very much. Sickness is supposed to be linear, in our minds: we get sick, we get better. Maybe we relapse, but then we get better again. To face a process that's fluid and ongoing, in which we make strides and then seem to slide backward... we don't like that. It reminds us of processes like piano practice, potty training, and grief.
And just as it helps to know that the numb days are just as normal as the days we spend in bed, that the accidents in the grocery store are just as normal as the days with dry underpants, it helps us to know that progress is not lost and that our bodies are doing what they should.
But that's just, like, my opinion, man.
My whole unit has been on a Big Lebowski kick. I saw it for the first time recently and, because I have a history in critical analysis, I felt like Donnie was a literary metaphor for Walter's feelings of weakness and incompetence, and that even though we see him bowling well as part of the team (functioning well as a human, in extended metaphor), we also see that nobody acknowledges him except for Walter, because to interact with him is to invite Walter's abuse to fall on them as well. It isn't until Walter's tough-guy persona is collapsing and Donnie is the only part left functioning that we finally see the Dude acknowledge him... just before he dies, allowing Walter to invite that part of his personality back into the whole, allowing him to be the one that experiences helplessness and grief. I told a couple guys on the unit about this and it turns out there's a fan theory that Donnie literally does not exist, which I feel is a bit excessive but sure, we live in a post-Fight-Club world. Since then word got around that I'm a huge fucking nerd and simultaneously everyone has watched Big Lebowski again just to see.
Wait until they find out how I feel about the Silmarillion.
PEG guy went down to have his tube placed and was gone for most of the afternoon. He came back just before shift change at seven. Fairly uneventful day with him.
HD lady did not have a good day while I was at home eating honey. Her bowels have been in a world of hurt, and although the rind sludge finished expressing the night after my previous shift, by the next morning she was oozing bile. You don't want free bile in your gut. They took her down for a CT scan, pumped contrast into her OG tube (like an NG tube but through the mouth, very common with pts who are intubated anyway), and watched the contrast feather out into all the corners of her belly. This is a very bad thing and she immediately went back down to OR for a washout and resection, where they discovered two things:
--Her entire abdominal cavity was full of liquid shit
--Her intestines were so stiff and swollen that they were like hot sausage casings, ready to blow at a touch.
It took them a lot of work just to find two places that could be sewn together, but they managed to put the whole mess back in, sew it up, and send her back to the ICU with a note that they would not operate on her again. Either she would somehow magically drop the swelling in her gut, or her intestines would dissolve. There's not much we can do to influence that. Her abdomen was, when I picked her up yesterday morning, almost completely open. She had two new drains in addition to the old one, with serosanguineous-- bloody and clear-- fluid pouring out through them. She was no longer moving her arms or blinking. Her body was so swollen with fluid that her skin had started to blister, and everywhere anyone had stuck her for the last few days was pouring clear-yellow fluid.
She was so incredibly swollen that I called immediately for an order to doppler-ultrasound all her arms and legs. Of course, she was full of DVTs. FULL of them. Our hands are tied, though-- we can't give major anticoagulants to a fresh post-abd op pt. Her platelets were beginning to drop. The doc suspected disseminated intravascular coagulation (DICs), a condition in which the body is so sick and inflamed that it forgets how to clot, and platelets spontaneously form tons of tiny clots and become useless. We also tested for heparin-induced thrombotic thrombocytopenia, in which the body reacts violently to anticoagulants and dumps all its platelets. She came back negative for both. Her belly stayed taut and distended.
She probably has cancer from the original pelvic mass in her bones, or somewhere else. The cancer won't kill her-- it'll be the bowel thing that does her in.
We dialyzed her and gave blood and albumin (a blood protein related to egg whites in structure, which gives blood its tacky sticky qualities and acts like an osmotic sponge to suck water back in from the tissues to the bloodstream). Her blood pressure was much more sensitive this time and I was forced to turn her levophed way the hell up, even with the albumin. Her family sat by the bed, grim-faced; her husband stared at the monitor, red-rimmed and hollow, until dialysis was finished and I sent them all home for the next two hours so we could pack up the machines and clean the room before shift change.
Her gown was soaked again from all the oozing, so I grabbed a fresh one and started stripping the old one off. Beneath it, all her drains were full of fecal material.
The incision site smelled strongly of bile and feces. I opened it up and found trickles of brown and dark green pouring from between the loose staples. I emptied the drains and they refilled instantly. The whole room stank of shit and death, the smell of inevitable defeat.
I cleaned her up as best I could, because it was the last thing I could do for her. Her blood pressure was holding for now, but I knew that within an hour the poison would spread and she'd be back on pressors. I washed her body and put gauze over the blisters, lined her gown with absorbent pads, swaddled the drains in towels to hide their contents, and paged the doctor to let him know. Then I called her family and told them to come back to the hospital, because she'd taken a nonspecific "turn for the worse" and they should be at her bedside.
By shift change time an hour later, I came out of the PEG guy's room with my polite smile still in place, sanitized my hands, muted the alarm that told me her BP was dropping, and started cranking up her levophed. She was still alive when I left the hospital, but I know for a fact that she died last night.
Meanwhile, Rachel passed her swallow evaluation and had her first sandwich in a month-- chopped bacon and avocado on rye, specially ordered from the cafeteria. Her nurse gave her a little of the birthday cupcakes, which they had saved in the freezer. I went in the room once to help her with a bedpan, and when that was finished she pressed her trach valve button and said: "Thank you." This is the first time I've ever heard her voice. She has an Eastern European accent.
Plan with her is to move to a rehab facility later this week. Her last chest tube had, at that point, been water-sealed for 48 hours, and the doctors wanted to pull it out today. Her one-year prognosis, if she avoids pneumonia, is extremely good-- the docs think she might be back to near baseline within two years.
I have the next five days off, and I'm not back at that facility until next weekend. I might not see her again. I hope she writes, later, to tell us how she is. Some pts do, some pts don't. When we get a letter we post it on the wall in the break room and read it over and over again for literally decades. I think if Rachel writes us a letter we will frame it.
The other woman with the perforated bowel is doing better today. She received a total of nine units of blood yesterday, but her bleeding has stopped and the bowel repair seems to be holding. I didn't get to see her much, but her prognosis is good, so I'll probably catch up on her case next week.
I don't know how much updating I'll have for you guys on days I'm not working. I typically work three to four twelve-hour shifts per week. I also don't know how long I'll keep this diary thing going, but I do promise that I'll give fair warning before I stop, because nothing pisses me off more than when somebody just randomly ditches their blog right after I started reading it. And thank you all for the encouraging comments-- it's really neat to know that people are reading and enjoying my torrents of unfocused rambling. You are great.
Now I'm going to have a nap.
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