Week 8 Shift 4 (I picked up an extra shift)

I didn’t sleep well after that last shift, and coming back in the next morning was an act of sheer will. This summer has been broiling hot, and I moved out of Texas for a reason, namely that for humans to live in Texas is an act of defiance against the great god Ra, and that if the away team of the Enterprise were to visit Texas in the summer they would refer to this entire world as a “desert planet” and four redshirts would die of fatal solar radiation. I did not move across the continent to a cooler climate so I could sweat like a wrung dishrag all day and all night.

One of my pts was exactly to my tastes: somnolent and needing very little intervention. She lives in an assisted living facility, where she’s mostly independent and hooks herself up to his peritoneal dialysis every night before bed. For the past few nights, though, she’s been “sick,” and hasn’t been running her PD, which has only made her sicker.

Hemodialysis involves sucking your blood out, running it through a machine the size of a Volkswagen that scrubs and washes and concentrates it, and pumping it back in to pick up more trash and water from your overloaded tissues. Peritoneal dialysis is a much less common form of dialysis, and one that doesn’t work for everyone, but which can be much less troublesome if it works right. A PD catheter is inserted through the wall of the pt’s abdomen, and dialysate fluid is pumped in and out, washing toxins from their body and blood through the permeable membranes of their gut. The fluid typically contains sugar, so pts have higher blood sugars on PD, but if it works for the pt… well.

After HD, a pt is typically sick as shit, often confused and shaky, usually weak and exhausted, and frequently nauseated. Regularly dialyzed HD pts tend to go in for a scrub three times a week, and with each round of HD the pt can count on being completely wiped out and useless for the rest of the day. This tends to really interfere in little things like “having a job” and “functioning for a majority of the week,” and that’s before travel time and expenses, interacting with health care staff (I will be the first to admit that we are terrible company), and having to rub elbows with other gross people from your medical community while hoping that they aren’t crawling with MRSA. So if you have the option of doing dialysis in the privacy of your own home, while you’re sleeping, and waking up the next morning ready to go about your day… PD is a total godsend.

The learning curve is a little high though. The pt needs to be thoroughly educated on how to maintain sterility, how to use and troubleshoot the machine, and how to recognize when something has gone wrong. A pt who skips days, who doesn’t follow up on appointments, who cuts corners—that pt is likely to have some really nasty outcomes. A PD catheter is a fast way to fill your belly with all sorts of microorganisms if you aren’t safe and clean with the thing.

Anyway, she had a UTI, which explains both the “sick” part and the reason she, a normally very sharp and independent older lady, made the very bad decision to stop doing dialysis rather than going to the doctor. Those of you with vaginas have likely experienced the burning agony of the UTI, with its bloody boiling lava piss and its ability to leave you feeling like you slept in a dumpster and were picked up by the trash truck before dawn. Sad fact: that shit is a blessing, because you think to yourself: gosh, I have a UTI, I should go get antibiotics. Older women are less likely to have the burning pee sensation, and sometimes their earliest clue to the presence of e.coli in their bladder is the fact that they lose their ever-loving goddamn minds.

That’s right: old ladies with bladder infections go fucking crazy. I’ve seen sweet grandmothers cursing and biting at their descendents, calm-faced knitters who turned into screaming paranoid kung-fu masters, and even a deacon’s wife railing about shit-eating demons crawling into her body and jacking off into her belly button from behind. Forgetting to plug in your advanced medical equipment is kind of tame in comparison.

But hey, no matter how well you handle a pelvis full of creepy crawlies, a few days without dialysis will absolutely make you loopier than a tatted doily, and sicker than shit to boot. This poor lady had no idea where she was or what was going on, except that she was nauseated and unhappy. I came into the room, scrubbing my hands with Purell and offering a chipper greeting, and she groaned and leaned over and barfed corn chowder down her shoulder and off the side of the bed.

There’s this thing, right, where you see or hear someone puking and you feel like puking too, right? I guess the evolutionary advantage is that, if your fellow cave-dwellers start horking up last week’s mammoth, you can get a head start on the mammoth evacuation process before the salmonella poisoning really gets a grip on your duodenum. Being a nurse for more than a few months will completely destroy that impulse. My immediate instinct when someone starts throwing up is to grab the nearest wad of laundry and jam it into the flood to keep it from spreading.

The last time my husband ate bad sushi, I nearly ruined our feather duvet.

God, the best thing about working in a hospital is that so much of the really gross shit gets done where I don’t have to see it. Laundry absolutely saturated with a grainy flood of shit? Put it in the big white bag and throw it down the chute and forget it! Pt took a whiz over the bedrail and threw his dinner into the results? Mop up what you can, and call the long-suffering housekeepers to do a bleach mop. I swear to god, I am not anywhere near this obsessively clean in my daily life, and I am 100% sure it’s because I can’t just page someone for backup whenever shit gets literal. I hope to sweet sainted fuck that the laundry is done by soulless aluminum launder-bots. I have this awful hunch, though, that it’s not, so I’m that picky nurse loser who separates all the plastic padding from the cheap muslin to minimize the necessary sorting before the blankets go in the wash.

But lord almighty, it is so good to be able to get rid of the stench immediately and start forgetting I ever smelled it.

A dose of Zofran and a housekeeping call later, the corn chowder was a distant memory and my pt was sleeping like your dad in church. On her left side, of course. The right lung is set at an angle that makes it easier for inhaled food and puke to slide down the right mainstem bronchus before you can cough it up, which means you want the right side elevated if your pt is at any risk of throwing up and drowning in it. Left side fetal position is often called the “recovery position,” because if you’ve had CPR or had a seizure or been very close to death, you’re likely to throw up at some point in the immediate future and you might not be awake enough to make sure it leaves your mouth and goes all over your nurse’s arm like it’s supposed to. (There are some other benefits to this position too, but my god, how much do you guys really want me to talk about hemodynamics right now?)

My other pt was a gentleman in for placement of an AICD, an automatic implanted cardioverter/defibrillator, which functions much like a pacemaker except that instead of reminding your heart to beat (although some of them do this too), it listens for your heart to have a dysrhythmic freakout and shocks the shit out of its unruly ventricular ass like a neighbor banging on the wall during a party. Pts who frequently go into dangerous dysrhythmias (also called arrhythmias), like ventricular tachycardia, or whose heart damage from MIs and heart failure puts them at high risk of deadly arrhythmias, get AICDs put in so they don’t suddenly die. If parts of your heart are especially irritable or not getting good communication with the rest of the heart, they panic and assume that they’re going to have to run the whole heartbeat show, and start yelling disorganized orders over the actual heartbeat signal. This can cause the whole heart to spasm and lose track of what it’s supposed to be doing, preventing it from actually moving any blood—this is called cardiac arrest. A good jolt of electricity stuns the panicked parts, giving the normal heartbeat a chance to pick itself back up.

That freakout is called fibrillation. The shock is called defibrillation. It’s one of the best tools we have for fixing deadly arrhythmias.

If the AICD shocks you, you know it. We get a lot of pts in because they were having Thursday night dinner when their AICD went off and kicked them facefirst into the meatloaf. Very uncomfortable and sticky.

So this guy had suffered a major heart attack that left part of his heart withered and necrotic—a part that, unfortunately, carried a lot of electrical impulse. As a result, one little area of his ventricles is now deaf to the electrical marching orders of the rest of his heart, and occasionally it gets the idea that it should be doing something and starts barking its own confused orders at its neighbors. He’s gone into ventricular fibrillation several times already, and had multiple rounds of CPR. Fortunately, since he’s been on the ICU hooked up to a heart monitor, we’ve been able to shock him immediately each time; the sticky electric-shock pads that we use to defibrillate him are just staying on his chest at all times now, until the AICD goes in. Because the defibrillation is happening very quickly and he’s only had to rely on CPR for circulation for a few minutes total, his organs haven’t really taken a lot of damage and he’s had good outcomes each time.

Despite three code blues this week with accompanying chest-crushing CPR, this guy is in good enough shape to be sitting in a chair, grumbling because he can’t have breakfast this morning. (No breakfast before surgery—anything in your stomach when you get anesthesia is going to be ejected at some point, and you definitely can’t spit your barf out while you’re unconscious, so breakfast before surgery leads directly to aspiration pneumonia and ARDS.)

When I walked into the room, he greeted me with one of my absolute least favorite quotes: “Hellooooooo nurse!”

Now, I get that it’s meant to be a compliment in some backward way. I understand that if you’re white and male and sixty-five you probably think the highest praise you can give a woman is aesthetic; you might even, if you’ve been reading a lot of noiresque literature, assume that complimenting a woman on her looks is a way of acknowledging her power and independence. But man, I got two problems with pts expressing attraction to me:

--I am pretty obviously not here to look hot. I am wearing pajamas, no makeup, an expression of exhausted patience, and about a pound of someone else’s bile. If you tell me I have lovely eyes with an earnest tone, I will probably accept that gracefully, because while I may check you extra-thoroughly for delirium I can at least appreciate that maybe you have strange tastes. If you react to my entrance like you’ve just been offered a hayjay by Jessica Rabbit, I’m gonna assume that your compliment is the disingenuous flattery of someone who thinks they’re gonna win my favor by introducing a sexual element to our professional relationship, and who intends to milk it for morphine.

--I am far from the most experienced nurse on the unit; I have about five years of ICU under my belt and I showed up for work in critical care two days after my NCLEX with dewy eyes and a trembling chin. But I worked obscenely hard to get where I am, both in my personal and in my professional life, and I am a formidable member of an elite team of life-saving medical staff, and to have that hard-earned accomplishment reduced to a catcall is absolutely intolerable. It reeks of disrespect and inappropriate sexual aggression.

This guy has had several rounds of CPR this week, though, so I gave him the benefit of a quick boundary: “That’s pretty inappropriate, would you like to try a different greeting?”

“Come on over here, little girl, and I’ll give you a different greeting.” Ugh. Uuuuuugh. At moments like this I just remember that I get paid not according to how many lives I save but according to how Disneyland-pampered my pts feel. I picture the dollar signs and bar graphs and ratings, and I grit my teeth and remind my pt that I’m here to provide him with medical care and that I’ll come back in a bit when he’s able to get his behavior under better control.

I’ve learned to be very comfortable with varying degrees of confrontation. I was raised, like many women, to think that the scale goes from “everyone is acting like nothing is wrong” directly to “EVERYTHING IS TERRIBLE” the moment a hint of conflict is introduced. Nursing has taught me that a little conflict in a conversation, like a little pepper on your scrambled eggs, is not only an acceptable thing but even a delicious thing—a thing to be savored, a thing that makes relationships and interactions exciting instead of bland.

I still have the instinct to flee, to placate, to absorb the unpleasantness and smile right through it. And I do keep my smile, and behave politely; but I also have learned to say, That’s super awkward of you, aren’t you embarrassed, and to tilt my head and smile with my eyes and watch that asshole twist.

This was a theme throughout the day. It got very tedious.  

My PD lady continued to vomit, and the doc ordered her an MRI with contrast, which meant I had to take her down to MRI for a full forty-five-minute scan without letting her drown in her vomit. I loaded her with Phenergan, popped a scopolamine patch behind her ear, and borrowed a subglottal suction catheter so I could keep her mouth empty if she vomited while I couldn’t reach her.

Then we moved her down to the MRI chamber and loaded her into the tube. The suction system in the MRI chamber was doing something really weird—like most hospitals, ours has been forced to prioritize its expenses, so some non-critical systems are a bit primitive—so I hooked a big syringe up to the subglottal catheter and stood by her feet as she went into the tube, watching and listening for any signs of vomiting so I could hand-suction her mouth.

The MRI is so loud. I was wearing earplugs and the sound went through me like a bore hole to the terrestrial mantle. If you’ve never heard this sound, I urge you to hit up youtube and have a listen, because no words can do it justice: clanging and crashing, and an all-consuming power-chord thrum of metallic force: DAH DAH DAH DAH DAH. DUM DUM DUM DUM DUM. DRRRR DRRRRR DRRRRRRR.

 It jarred my teeth. My feet ached with the force of the noise. There is an arcane quality to it, a rhythmic intent of pure alien purpose that wants nothing of your sanity and only stops to breathe when it’s finished its task.

While I was in the MRI, my annoying pt was shuffled off to have his AICD placed, and as I returned to the unit the charge nurse told me he would go to the special care unit after the procedure.

So by the time my PD pt was settled, I was ready to take another pt: a craniotomy who had fallen in her home and developed a subdural hematoma. After surgical evacuation of the blood blister inside her skull, they brought her up to me intubated and sedated with a C-collar to keep her spine immobilized. We hoped that the pressure damage to her brain wouldn’t be fatal, but there’s really no way to tell yet, so we’ll wait and see how the swelling goes, and support her medically until then.

She has fake breasts. They are extremely rigid and strangely shaped. The CNA and I noted this and carried on; we see many pts with breast implants and other surgical reconstructions, and I have long since learned that as soon as you start judging a pt for some seemingly voluntary aspect of their looks, you’ll discover that they had reconstructive surgery for cancer or some other thing that makes you feel like shit, and deserve to.

So we made sure that everything on the bed was arranged in such a way that visitors couldn’t see either her nipples poking through the gown, or the unnatural rigidity and wide placement of the breasts themselves. I’m certain that this woman spent a great deal of effort in making her breasts look natural, and it would be cruel and spiteful to let the secret out if she hadn’t already told any of her guests.

It feels very strange to carefully pad a pt’s breasts, let me tell you. I felt a little gross and intrusive. But even if she got them for purely cosmetic reasons, it’s her body, and I wouldn’t leave an embarrassing tattoo out for the neighbors to gawk at either.

The MRI showed no signs of anything wrong in the PD lady’s belly. Thank goodness, she just needs lots of dialysis and antibiotics; we can have her fixed up and home by the weekend. The dialysis nurse dropped by just before shift report and started her on her nightly PD, and I hope that by morning she’s closer to her normal self.

During report, my pt from the last two shifts, the sepsis pt with liver failure, died. An estranged sister had got in contact with us and given us the okay to allow him a natural death according to his wishes, and they turned off the drips, loaded him with painkillers and benzos, and pulled the breathing tube. He breathed on his own for ten minutes, then slipped away gently and comfortably at last.

I am glad for him. He earned his rest.

And after this shift, I’ve earned mine too.

Week 6 Shift 2

I walked onto the unit and was greeted with perplexed stares. “What are you doing here,” said the charge nurse, frozen in place, still holding her pager six inches from the countertop where she was reaching. Everyone who wasn’t already giving me a funny look turned and joined the crowd.

“Uh,” I said. I hadn’t had any coffee yet. “I work here?”

“You aren’t scheduled today,” said the charge nurse. “The book says you’re on vacation.”

I considered this for way, way longer than I should have. I was leaving the next morning at the crack of dawn, headed out to the Olympic Peninsula for a weekend of camping with my husband, one of my closest friends (whose wife, my other closest friend, was stuck in town for the weekend with houseguests), and my friends’ ridiculously adorable kid, the 2.5yo. I hadn’t packed yet, had done minimal food prep, and hadn’t slept worth shit for a week because I was worried about Tiberius.

“So… should I go home?”

“No no no no! Don’t go anywhere! Can you stay? You’ll get your pt back. Don’t go anywhere.”

Just then my unit manager arrived. “What’s all the shouting about,” he said, then spotted me and pulled a double take. “I thought you were camping!”

“That’s tomorrow,” I said. “If I stay until three, can I go home?”

So I ended up working a measly eight hours today, which was a blessed relief, because Tiberius was gearing up for a Hail Mary surgery first thing tomorrow morning and needed every delicate fine-tuning touch I could give him. The pulms and CT surgeons agreed: the repeated chest tube occlusions and stump perforations were taking far too much of a toll on his limited resources, and the still-sort-of-open thoracotomy was starting to dehisce. The ARDS is beginning to retreat, but he’s still hanging on the edge, and his cardiac output is consistently in the trash because of the insane pressure differential in the various parts of his chest.

My job today was to give him every inch of gained ground I could fight for. I titrated down his pressors with extreme care, just low enough to give wiggle room in case they had to crank ‘em up in surgery, not low enough to challenge him. I talked plans with the pulm, and got orders for albumin (to pull water in from the tissues) and Lasix (to shed the water, reducing the heart’s afterload, the amount of back-pressure it’s pushing against as it tries to perfuse the tissues). I timed them with exquisite care and pulled this stunt three times in a row without rocking his vital signs, before finally chickening out of Round 4 because his heart rate went up ten points.

And I started working really hard on his bowels.

Tiberius was backed up as all hell. I think I mentioned before that his distended colon was causing pressure issues with his heart and his venous return; I took it on myself to get that shit out of there, and championed the cause of poop until I’m pretty sure Dr Sunny worried about my sanity. I dosed him with bowel meds; I administered enemas; I finally, in a fit of desperation, gloved up to the wrists and performed digital disimpaction and stimulation of his rectum.

This is, if anything, less fun than it sounds. You basically glove up, slather your fingers with lube, and work them up the pt’s back end until you encounter stool. Scoop what you can, work anything loose that you can, and stretch out the rectal muscle to stimulate the body’s “rectum full, evict tenants” impulses. Tiberius couldn’t be turned on his side for this, so I had to hoist up the boys, so to speak, and jam my hand back in there from the front side.

As I got to work, I felt floppy skin lap over my wrist, local anatomy returning to its accustomed position. Well, it’s not the first time someone’s balls have posed me an inconvenient barrier to their ass. This job can be undignified. I just didn’t look—this procedure is all about proprioception and sense of touch.

I got a handful on my first fishing trip. A little dig stim, and his rectum refilled; I pulled out pebbles and chunks and lumps shaped like knucklebones and tiny flecks of shit-granite the size of rice krispy cereal. My shoulders cramped up and my wrist was on fire by the time I took a break; at my side, the bucket I’d allotted for captured items contained a good double fistful of rock-hard desiccated shit.

An hour later I went digging again. This time I got pebbles with a little slushy liquid. Things were breaking free.

An hour after that I got nothing with the finger sweep, but during the dig stim portion he started having a tremendous bowel movement. I’m talking liters of liquid shit. It flowed and poured and could not be contained, and with each surge of excrement, his blood pressure rose and his heart rate fell.

All told, I think he shit about a gallon, roughly four liters. Enough that I was able to turn him when it was time to clean him. Enough that his family, who have a high tolerance for medical grossness after decades of hospital stays and multiple family members who’ve suffered terrible diseases, blanched and gently shuffled out of the room.

It’s weird to write about that, because I so frequently write about shit torrents with the perverse delight of someone sharing that video from The Ring, but in this case the endless bowel movement has a totally different meaning. It means less pressure on the heart, less vomiting, less compression of his remaining lung, less risk of crashing and even death when we move him. It means the surgery can be performed with better access, since he can lie on his side without his guts crushing the breath out of him. It means Tiberius has a fighting chance.

Slowly his blood pressure continued to improve, reaching a plateau where it took about two-thirds the amount of pressors to keep him trucking along. Slowly the color came back into his cheeks. I worked up a genuine bouncing excitement.

Let me tell you, though, at the end of this stretch of shifts, all the extra moving and turning—all the tight attention to detail and moment-by-moment control-freaking—and, oh my god, the emotional support for family? I was so exhausted I slept over the end of my break and, an hour later, told my neighbor to watch my pts while I took a dump… then slept on a sheet in the bathroom floor, something I haven’t done since I was a night shift MICU nurse in Texas.

In Texas, which has no nursing union, breaks are “if you’re lucky” and “thirty minutes per twelve-hour shift” and “absolutely no leaving campus to pick up a burger at the all-night fast food joint, stay in the break room.” The unit I worked on, bizarrely, had a strict no-sleeping policy to boot, which meant that if you were nodding off at 0300 and you found someone to cover your pts so you could wolf your lunch in the thirty minutes you were allotted, you still had to stay awake in the tiny stuffy closet-sized break room the whole time. Falling asleep could mean a severe reprimand, or even an immediate termination. I don’t know how the fuck they expected patients to survive with their nurses either nodding off at the syringe or cranked up on stimulants nastier than caffeine.

I spent a lot of ten-minute dump breaks passed out on a bathroom floor. I will never live in Texas again.

When I moved to my current state, which is unionized, I came back from break still chewing my salad, only to be given a weird look and instructions from my preceptor to go back and take the rest of my break. Turns out, that facility usually takes a fifteen-minute morning break and a forty-five-minute lunch break; others keep the lunch break at thirty minutes, but add a fifteen-minute afternoon break. Night shifters often pool their breaks to get an hour, or even an hour and fifteen minutes if your facility rolls that way. And you can sleep. God, you can sleep.

So I sleep on most of my breaks, even now that I work days. I steal five-minute chunks with a coworker keeping an eye on my pts, cram my food into my mouth, then take a proper break to snore and drool on the break room sofa. It’s amazing.

But man, Tiberius wore me out.

Since I was only working an eight, I wrapped up early, and at afternoon shift change I started giving report while the evening RT went in to check his vent settings. A few minutes later his alarms started going off: oxygen desaturation, bombing blood pressure, volumes and pressures on the ventilator messed up. I had removed his lidocaine patch from his left shoulder a little while before, so I was freshly familiar with that part of him, and I immediately spotted the way his shoulder was ballooning up.

The tension pneumo was back with a vengeance. Air was pushing up through his flesh, inflating him with tiny bubbles that crackled where I pressed his skin; his chest tube wasn’t tidaling at all. (Tidaling refers to the rise and fall of water in the tube’s suction chamber, which shows that there’s a pressure change in the tube as he breathes in and out—that is, that the tube is still sucking air appropriately.)

The prickly pulm who’d been stripping his tubes wasn’t around today. The current pulm was not comfortable stripping the tube, especially considering that he didn’t know exactly how she’d done it before, and didn’t know that things would continue to work that way. I called the CT surgeon, and soon the one who’d done the initial pulmonectomy was at the bedside with the lanky PA, Pilgrim, to place another chest tube.

Just as this happened, the charge nurse asked if I could admit in the room next door. “Extremely no,” I said. “I’m supposed to be clocked out. Do you know where the chest tube cart is?”

The flex RN, a sort of all-hands troubleshooter who (at this facility) works like a dog all day, ended up landing that pt. I don’t even remember what her deal was, although I took report on her while the flex wrapped up her other duties, then passed off report during the chest tube insertion. I think she was hypotensive.

They had paired him with a second pt for the night shift nurse, which seemed cruel and unusual, since the other pt was having confusion and agitation issues and needed a sitter. The night sitter hadn’t shown up yet—was late, I think—and the day sitter had to leave to pick up her kids, so the oncoming RN sat with (and blasted with Haldol) the agitated pt while I dove in with the chest tube team.

I was okay with this, because if things started going south, I wanted someone there that knew the little nuances of his issues and could milk his pressors and sedatives for all they were worth. And I wasn’t done giving report on him yet.

Pilgrim pulled the old chest tube, and they popped in another, which released the pressure with a huge pink-spattered whoosh before I could hook it up to the atrium. Tiberius tolerated all of this remarkably well, and the duo marveled as they cleaned up that they couldn’t believe he’d made it through this latest setback and had halfway expected him to die while they were putting in the new tube.

I thought about the bedful of shit and felt extremely smug.

Then I finished cleaning the room, because CT surgeons performing a bedside procedure tend to tear up your room like a teenager’s mom looking for skin mags, and lurched out into the hallway. The family was in the middle of an impromptu conference with the pulm and CT docs, white-faced and tightly nodding.

“We’re going to finish the thoracotomy tomorrow morning at seven,” said the pulmonologist. “He can’t take many more setbacks. I think he’s about as good now as he’s going to get, and if we don’t do this tomorrow, unfortunately he will decline and probably die within the next few days.”

His wife took a couple of deep breaths before she could speak. “What are his chances in surgery?”

“About fifty-fifty. Unfortunately, he’s had a very hard course with this disease and I don’t think we can give him better than that.”

Physicians use the word ‘unfortunately’ a lot. Like ‘discomfort’, it’s a way of recognizing that someone is suffering when you’re so accustomed to human suffering that it’s hard to get a good perspective on this particular case. Unfortunately, ma’am, your son passed last night. Is that a bad thing? I don’t think he suffered much. Were you expecting it? Was it kind of a surprise? God, I have no idea. He’s dead, unfortunately.

I packed up my stuff, checked on Tiberius, clocked out, checked on Tiberius again, and left through the waiting room, where his family was gathered. I don’t like hugging pts or their family, because generally the hospital is a gross place and I have issues with being hugged by people I haven’t learned to trust, but I hugged them all. They were all crying, and I may have shed a few tears on my way out.

I made it home with a blank face, listening to podcasts about charlatan magicians, and started chopping vegetables and rolling them up in foil to be roasted over the campfire all weekend. You’re not supposed to take your work home with you, because it will make you crazy, but sometimes you really can’t avoid it.

You’d think it’s the tragic cases, the young people unceremoniously cut down, or the old folks dying alone and slow because their family can’t translate their love into letting them go; but man, the ones that get to me are the ones where I put in real work. His chances are slim to none, but by God I’ve squeezed those chances for every drop of advantage I can get, and it’s been exhausting and terrifying and edge-of-my-seat the whole way. I haven’t even let his family see, really, how close he is to death at every moment, how often some small setback has made me scramble. They know he’s not likely to make it; no reason to torture them with the constant surge and retreat of miniature battles and victories and losses. But every moment in that room, for me, was a challenge: not to panic when things went wrong, not to lose focus when things became tedious, not to slack off and cut corners and take risks, not to forget to be a person and care for the family as well.

And now he’s out of my hands. I will be out in the woods, out beyond phone reception, for the next five days. I am going from the front lines to a position of complete helplessness, and it put jagged edges on all my chopped vegetables and set my molars grinding. For a few hours, standing in my kitchen, I got to experience the corner of what his family must be feeling—he is in such a precarious place, teetering on the edge, and I have to rely on others to be conscientious and critical and skilled for his sake.

I have to remember that, even if everything goes perfectly right and everyone performs flawlessly, he will probably still die.

I don’t know how I’m going to sleep tonight.

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.