I slept until 0900 this morning, laid in bed playing Monument Valley on my phone until 1045 (I have legitimately not played this game at all despite all my friends telling me I would love it), then convinced myself that brunch and a shower sounded better than just lying in bed forever. The shower was amazing because it took place in the middle of the day with no time constraints and I could shave everything and spend plenty of time staring at the wall and thinking about absolutely nothing. Showers are usually ten minutes of scrubbing, shampooing, and telling myself aloud: "Come on, come on, you're okay." They usually take place at 0530.
This shower went on so long that I made my husband bring me hot tea with milk and sugar, which I drank in the shower, setting it on the little shelf between sips. He stuck around and sat on the (closed, hopefully) toilet and told me about the airplanes he saw at the flight museum restoration hangar last week. We haven't seen much of each other this week, so while I care very little about airplanes, it's nice to hear him talk about things he likes.
Then I had a fucking decadent brunch before time for him to head to school. Now I am sitting in a nest of blankets and pillows on the sofa. The coffee table is arranged with the accoutrements of another couple of dumb hobbies of mine, different types of tea in several french presses and teapots + an honest to god thirteen jars of different kinds of honey. I had a weekend in Hawaii recently and bought YET ANOTHER sampler set of honey and I like to sit with my tea and my honey and a pile of chopsticks and compare the different flavors. If I had a shit-ton of different kinds of cheese this setup would be perfect. Hi, yes, I am the most boring person you have ever met.
The point of all this is: I will write up this report in extreme comfort.
Yesterday morning I took report on my CRRT pt, whose renal replacement therapy had been turned off overnight in preparation for the day's dialysis, and another pt who was preparing for discharge after having a cardiac stent placed. I made sure the first pt was comfortable and all her drips were stable-- she was still requiring a little bit of norepinephrine to keep her blood pressure up-- and then settled in to discharge the stent guy in record time. (Different stent guy from the previous shift. That dude was still checked in down the hallway, ringing his call bell constantly to ask if random tiny things meant he was dying. I answered a few of those calls while his nurse was busy, and reassured him that a random itch on his foot, a mild headache, and a restless feeling in his legs were not in fact signs of imminent death, though I was a bit more tactful about it.)
Taught the stent guy about his new blood-thinning medications and blood-pressure medications. He had a lazy eye that wandered around as I talked to him. Very difficult not to attempt normal eye-contact interactions with the lazy eye. Very polite and personable fellow, I just have a weird thing about lazy eyes that I have to compensate for so as to keep from being an asshole. Finished the discharge, pulled out his IV, and called the transporter to come wheel him down to his wife's car.
Caught up on my lady next door, whose blood pressure was kind of labile. Part of it was that I'd been measuring her BP mostly by an arterial line, which is a notoriously finicky process. I suspected she was also having breakthrough pain even under sedation. Turned up her fentanyl and crossed my fingers that I wouldn't bomb her pressure, and voila, she evened out. I don't blame her. The semi-open abdomen thing looks like hell. Her colon rind drainage was significantly reduced in volume and more liquid today. Her toes still look like shit-- she had very high doses of norepinephrine (also known as levophed) to keep her alive during the height of her illness, and norepi is well known for constricting your blood vessels until your toes turn black and drop off. Pt's family kept massaging the gross purple-black toes, trying to bring back circulation. Educated them on the importance of not dumping dead-tissue toxins into the bloodstream. Yes, she will probably lose most of her toes, although she stands a decent chance of living, so stop trying to milk rotten toe-meat back into her arteries, we cool?
Her toenails were solid lumps of fungus. Family was bare-handing that shit. I must just be squeamish from hospital work but I wanted to throw up just watching it.
Got caught up, oh my god, and went to help out down the hallway, where another nurse was landing a complete clusterfuck of a situation from the operating room. Her pt was an attractive lady in her fifties, wearing the kind of makeup you see on real estate agents, bleeding like a Tarantino extra from all her holes with her gut laid wide open under a delicate sheeting of saline-soaked gauze. Apparently she had been at work earlier and felt something 'pop'. Perforated small bowel, plus during surgery the MD had discovered a previously stable renal-aortic aneurysm which began to dissect under the stress. Deeply sedated and intubated, of course, but the room was a disaster area and the nurse was frantic. I called lab for her to make sure they'd started processing the pt's stat hematocrit, which they had not because uh, oops, then drew more labs, read blood, and generally did scut work for about half an hour until things started to calm down.
One 'reads' blood by verifying all its information against the pt's armband, the computer's cross-checking sheet, and the various stickers on the bag of blood itself. Giving a pt the wrong blood can be swiftly and horribly fatal. Two RNs are always required for blood checks.
Bailed out of that room to attend rounds for my lady. Rounds involves an assortment of hospital professionals, the care team, who circulate through the ICU in the morning and check up on all the pts to make sure nothing is missed. The intensivist, pharmacist, nutritionist, charge nurse, physical therapist charge, respiratory technician charge, and occasionally others like the infection control specialist or the social worker all gather up with their rolling computer carts and surround you, and you give report and talk about any concerns or plans for the day.
Code blue by the front nurses station, yesterday's first heart-surgery pt. The pt's daughter came screaming and jumping out into the hallway, having pressed the code button herself. She was apparently an RN herself. The code team swarmed in and found that he wasn't dead dead, he was just having a massive vagal response from bearing down hard on the shitter while his heart was still stiff and shocky after surgery. Sigh of relief all around-- he wasn't an open-heart valve repair, just a triple bypass, so he didn't have pacer wires still installed (we keep them in the valve pts for a long time because valve surgery often disrupts the nerve pathway through the heart, resulting in sudden drop-dead moments like that one guy the other day) and therefore wouldn't have been an easy fix (seriously, nothing is easier than bringing back a valve pt with a pacemaker).
The housekeeper came by to stat clean the now-empty room where the stent guy was before. Why a stat clean, I asked her? Oh, she said, you're getting a patient in this room. Me specifically? That's what the charge nurse said. WHAT THE FUCK. I call the charge nurse and ask if this is true, and sure enough, I am getting a femoral-popliteal bypass case from the OR in about thirty minutes. Oh, I didn't tell you? I'm sorry.
The lack of communication is killing me. Toward the beginning of this run of days I was caring for three telemetry-level pts (a step down from ICU critical care), preparing one for a routine cardioversion, which for tele pts involves the team carrying them down to Special Procedures and bringing them back when they're finished. Instead, the whole team showed up at the bedside and asked me where the paralytics were. Turns out, somebody had decided to intubate the pt, perform a trans-esophageal echocardiogram (heart ultrasound from inside the esophagus), and cardiovert (shock the heart to break the pt out of a dangerously fast rhythm) AT THE BEDSIDE. Assurances that the pt would be made critical-care status. I ended up demanding that the flex RN take over that pt one-to-one, and I'm glad I did, because she turned out to be an utter disaster and there was nobody to take my other two teles.
And after the previous shift's CRRT ambush, I really was not feeling good about the communication level with that charge nurse.
Turns out though that she was just trying to make sure I got the easier of the two incoming pts, and had been delayed in telling me because the RN getting the other pt needed a lot of help setting up. Not excused, but understandable.
Elevator call: my pt was on his way up. Out of nowhere, code blue. A pt on the other end of the unit who had been on a balloon pump-- a sausage-shaped balloon in his aorta that helped pump blood with each heartbeat, really cool tech but very risky-- had gone into cardiac arrest. The whole unit poured into that room to bring the guy back to life, leaving me to admit the new guy alone. This sounds worse than it is, mainly because the new guy was super nice and his wife was super nice and everything had gone without a hiccup. His potassium was very high, because his kidneys were chronically insufficient and he couldn't shed potassium very well, so I gave him a medicine to drink that gives you insane diarrhea but dumps all your potassium through your butthole. He was not happy about this, but he understood. We looked up all of his meds together and made sure everything else was right.
He kept asking to pee, but he had a foley catheter in-- a tube that goes up your dick into your bladder to drain it. I kept telling him to pee whenever he needed to, but honestly, foleys are uncomfortable as shit. His leg looked great where the closed-off arteries had been bypassed and his pulses were strong. The incisions were minimal. I told him he'd be bikini-ready in six weeks and he laughed and spilled his cranberry juice everywhere.
The balloon pump pt survived, but was for some reason immediately moved into full airborne precautions, the kind we use for tuberculosis. I still have no idea what that was about, but the nurses involved in that disaster were totally isolated for the rest of the shift, wearing bubble helmet respirators and gowns in an airlocked room at the end of the unit. I can't even imagine taking care of a fucking balloon pump pt while under full airborne precautions. I am a sucker for high-acuity pts but that just sounds exhausting.
Dialysis nurse showed up in the next room. I love it when my pts go on dialysis because they get a dedicated nurse to run the machine, which means I don't have to watch as closely because somebody with at least half a brain will let me know if anything's changing. Sure enough, as soon as he hooked her up, her blood pressure on the arterial line dumped. We both panicked a little and tried a few things, but nothing was touching that shitty blood pressure. I noted that the dialysis catheter was accessed on the same side as the brachial art line, suspected that the arterial outflow through the HD cath was sucking pressure away from the art line, and put a BP cuff on her other arm. Sure enough, her BP was fine. Maybe a little on the high side. Fuck yes, dialysis go.
Helped a nurse the next room over with bathing and prettying up her pt. I have taken care of this pt frequently over the month she's been on our ICU. She's in her thirties, a mother of two and part-time special-needs tutor, with a sweet-faced husband at her bedside constantly. She was very healthy before this, got strep pneumonia that turned into necrotizing pneumonia, had half her right lung cut out, held a fever of 38.9C+ for two weeks, coded twice, nearly died more times than I care to count, swelled up into a water balloon, lost all the water and is now sunken and sallow, now has a tracheostomy and a chest tube, and has generally been so much work to keep alive that we rotate on and off so nobody gets completely worn out on her. She's been better this week, though. Her husband didn't want to bring her kids in while she was super sick, for obvious reasons, and they're like two and five anyway so it's not entirely safe to have them on the ICU.
This was her older child's sixth birthday, so we arranged a surprise for her. Her husband went home "for the afternoon" like usual, to pick up the kids, and her nurse and I washed her hair and generally made her presentable and even pretty while the charge nurse ordered cupcakes from a nearby bakery (with extras for staff because fuck yeah, petty cash). We sat her up in the chair and she was watching a little TV when her husband returned with a pile of presents, a slice of birthday cake, and her now-six-year-old son wearing a paper crown. He started screaming as soon as we let him in the room, and she cried and managed to hold her arms up long enough to hug him. The whole fucking unit's worth of staff was gathered around that room, let me tell you.
The kid showed her his new spiderman doll and his books, opened a couple of presents and discovered a spiderman backpack and a candy bar, jumped around the room with delight, and could NOT stop telling his mother everything that had happened that week at school. After a while her crying started to really confuse him, and he asked: "Why are you sad?" Climbed into her lap (nurse at hand to keep the chest tube from getting kicked) and started fucking wiping the tears off her face. Then he started crying too, wiped his own face, and announced in bafflement: "I'm not sad!"
Look, we don't get a lot of great stories like this on the ICU. Most people die, or have long slow shitty recoveries, or are 107 and should have died anyway, or are just here for a quick cardiac stent and go home the next day without realizing they totally clipped Death's elbow in the cath lab elevator. We are all cynical assholes who don't get our hopes up. Most of us hate children. This shit made every last one of us cry like morons. Fuck. Moving on.
She's supposed to go to rehab next week after the chest tube comes out. Prognosis is pretty good at this point.
Back to the lady on dialysis. I did her dressing change, packing saline-soaked gauze into the open places on her belly and covering it with dry dressings. The colon-rind liquid coming out of her drain was starting to clear up a bit, and had the texture of hot sauce rather than ketchup. Her left arm, where the blood pressure cuff was squeezing her forearm below her PICC line, was incredibly swollen, like the whole thing from fingertips to shoulder. Oh god, she's totally getting a DVT.
PICC lines, because they're long IV lines that follow an entire vein back to the heart, are prone to gathering clots around them. A big clot in a large deep vein-- a Deep Vein Thrombosis-- can be a major issue. I took off the cuff and helped the dialysis nurse lock and pack her dialysis catheter-- she was done with the run and had tolerated it well-- and prepared the room for report to the next nurse. I realized I couldn't remember whether the opthamologist came by today; she was supposed to get her eyes checked to make sure that her fixed upward stare isn't a sign of nerve damage, like a yeast-clot stroke behind the eyes. All in all, though, I felt pretty good about the day; my fem-pop guy was having great pain control and excellent pulses and a nap after dinner, my HD lady was down 3.5 liters of fluid and a bunch of toxins and will start losing some of her swelling soon (hopefully), the lady next door was wrapping up the world's most tearjerky birthday party, and the open-gut lady down the hall was starting to pull out of her tailspin.
I left the hospital about thirty minutes late, had home-cooked dinner with my friends and their disastrously cute 2.5yo kid, listened to podcasts about birdcalls because one of them is really into podcasts (fuckin nerd lol), and don't really remember how I got home.
Saturday, July 11, 2015
Friday, July 10, 2015
Week 1 Shift 2 (technically 6 of 7)
Today started off much better than yesterday. Got my pts back; the little old man with bradycardia recovered overnight and was able to go home by 0930 without having to get a pacemaker. He was delighted and I was also glad for him, not least because getting discharged to home from the ICU almost never happens before lunch. I am a discharge beast though. Spent maybe twenty minutes after his discharge quietly charting in the end of the hallway where the lights hadn't been turned up yet. The suction canister in the empty room created a strange auditory illusion, as if I were sitting near a pond full of frogs all chiming at once. The dim light and weirdly outdoor sound is very soothing and I am relaxed as I drink my first coffee of the day and finish documenting that my patients are still alive and functioning.
The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.
Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain.
He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.
Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.
He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.
After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.
Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.
"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."
"Why can't I eat what I want? I'm sick, I need comfort food."
"Sir, you just had a heart attack."
He looked at me like I had just started speaking Urdu. "...And?"
Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.
Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.
Darwin is coming for you, sir.
At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.
At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.
Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.
Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die.
I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.
I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.
The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.
I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.
She really is getting better. I think she stands a chance.
There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.
I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.
The neurodegenerative guy was amazingly improved by the administration of pain meds overnight. Even his swallow was stronger (or else, quite possibly, he's so fucked up that he can't tell when water slides into his lungs and doesn't bother coughing), so tomorrow he's gonna get a barium swallow study-- swallowing barium-enriched fluids in front of an X-ray-- and if he passes that he can eat again. Crossing my fingers for you, dude.
Also got a PICC line in him, which is a long IV that goes all the way up your arm into your heart, allowing us to give you much stronger and more concentrated medications without injuring or burning your veins-- things like potassium, which is very painful given through a peripheral IV, and total parenteral nutrition aka IV food. Palliative Care came by and talked to his brother about his end-of-life wishes and the possibility of transferring him back to his adult family home on hospice, where he can live out the rest of his days with his treatment focus being comfort rather than recovery. Physical Therapy has a hard time working with him because he has so much pain.
He apologizes every time he asks for anything, or anything is offered to him. He is pathetically grateful and wary in a way that reminds me of an abused dog, and I asked the social worker if anything needed looking into. We agreed to defer any investigation until the psych team came by to see him, since he'd had no psych meds for days and is technically schizophrenic. Sure enough, he was having a massive onslaught of hateful and abusive voices telling him that he was a bad patient and deserved to die and that the people here were waiting for him to go to sleep so they could hurt him. Jesus motherfucker. We started him on orally-dissolving cheek-absorbed olanzapine to help him. It's really easy for things to slip through the cracks, but I could kick myself for not pushing sooner for other psych med vectors.
Meanwhile, I replaced my old bradycardia dude with a new guy from the cath lab, a fifty-year-old man with a history of morbid obesity, prior V-fib arrest, two cardiac stents, heart failure, diuretics and sodium restriction, diabetes, chronic renal insufficiency, and a pacemaker. He and his whole family reeked of cigarette smoke and not one of them weighed less than a Ford pickup. "Genetics," he said. "My bad luck. Dad had a bad heart too." I mean, no. It's not genetics. You might be a nice dude, but you're also fat as hell and it's literally killing you. Your blood is so sugary it's shredding your heart from inside out and your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta, and THAT, my friend, is why you're dying.
He had another stent placed, a 98% OM occlusion roto-rootered out. Lingering reperfusion pain. Nitroglycerin, morphine, and a nice neighborly dose of ativan fixed him right up. Still had the arterial sheath in his groin where they'd gone in, done up nice and neat with a syringe of heparin taped to it and the line clamped, presumably full of anticoagulant. Orders to remove it two hours after the last bit of anti-clotting agent went in. He complained nonstop about having to keep his leg straight, which I understand sucks, but also which I understand is LESS horrible than 10/10 crushing chest pain with blue-lipped shortness of breath. Maybe my priorities are fucked.
After that it was just putting out fires for a while, but sooo many fires. The next pt down the hall was receiving continuous renal replacement therapy, a sort of constant bedside low-grade dialysis that requires a one-to-one nurse who can constantly monitor and adjust it. Nobody else on the floor besides that nurse was checked off to handle CRRT, but I've done it at other facilities a million times, so the charge nurse asked if I could break the CRRT nurse for lunch. No big, done. Then gave another nurse a break-- I've had both of her pts before and knew them well enough to need very little report.
Stent guy wanted lunch, but declared that he hated hospital food. Family offered to go get him something to eat. "I want one of those bacon crab mac and cheese plates from Cheesecake Factory and an order of crispy egg rolls," he said.
"I'm so sorry," I cut in, "but both of those are definitely off the menu. Let's see if we can come up with something better for you."
"Why can't I eat what I want? I'm sick, I need comfort food."
"Sir, you just had a heart attack."
He looked at me like I had just started speaking Urdu. "...And?"
Family left with orders not to bring him ANYTHING and a very pointed hint that they might want to attend his meeting with the nutritionist tomorrow.
Pt ordered a burger from the hospital menu for dinner. Did not want light mayonnaise. Angry that the burger would not include cheese. Asked if he could have three burgers, hold all the veggies. Dietary declined and pointed out that this would put him far over his daily salt intake limit. Pt stewed for an hour, then called his mother and asked her to sneak him a cheesecake.
Darwin is coming for you, sir.
At this point, exhausted, I went into neuro guy's room to give him a tylenol (paracetamol) suppository, his IV antibiotic, and his IV metoprolol. The cheek-dissolving schizophrenia med was nowhere to be found; I messaged pharmacy to have it sent up. Everything was due at 1400, an hour before shift change for the eight-hour nurses (not me) at 1500, so there was a line for the drug machine. He was pooping in his bed, and his previous IV medication wasn't done yet, so I figured I would go take a lunch nap for thirty minutes and come back at 1445 to finish everything.
At 1440 the charge nurse woke me up and told me I would be taking the CRRT pt at 1500, checked off or no, because that nurse had to go home and there wasn't anyone else to cover. Fuuuuuuuuck. I went and gave report to the oncoming nurse, apologizing for the state of things, putting the cheek-dissolving medication from the tube station straight into her hand, and helping her clean and turn the guy (who had finished pooping). Then I dashed over and took the world's most intense report on the CRRT pt, who was preparing to have her CRRT run ended so that tomorrow she could have normal dialysis. CRRT is mostly the same wherever you go, but the charting varies a bit.
Oncoming nurse for my other pts comes into the room, raging. She is very upset that I left her so many chores to do. The room was messy, the meds weren't given on time, the orders weren't cleaned up, etc etc. I stare at her in bewilderment. Did I not tell her explicitly that I got ambushed with a pt exchange? I walked her through all of this, I know I did. I helped her clean up the guy. What is happening.
Oh. That sheath I was going to pull at 1500, the one that was heparin-filled to keep it from clotting? Oh, this facility (where I have been working for six months) doesn't use heparin. All its arterial sheaths have to be hooked up to pressure bags to keep them from clotting. I am utterly horrified-- turns out nothing clotted and he was fine-- and then humiliated beyond reason. The charge nurse comes into the room and asks if I have much experience with sheaths. (Basic sheath management is taught in nursing school and learned hands-on during the first week or two of any ICU career, since every ICU with a cath lab gets thirty of them a week.) I stare at my hands, face burning, and wait to die.
I insist on writing up the incident report with the charge nurse. I kind of want to puke. The other nurse comes back every five minutes to tell me about another thing she found that I did wrong/didn't do/should have cleaned/should have told her in report. Some of the stuff is truly piddling. She's angry, but rightfully angry, because she got shafted. I also got shafted. I look out the window, where some kind of fluffy tree is shedding its down into the breeze, where it drifts lazily through the air over the highway and makes the world outside look hot and slow. The hospital seems to be immersed in golden brilliant syrup, an ocean of something too heavy to inhale. If I stepped out into it and held my breath, I would gradually ascend to the surface, a big human bubble rising through viscous light.
I shake myself out of it. Day six of seven is full of weird little moments like this. I am very tired and I want to breathe air that isn't filtered. The CRRT machine beeps and I empty its four-gallon bag of pee.
The pt has a drain tube in her abdomen that collects oozing, gloppy tan stuff as it pours from her abdomen, where her colon suffered two recent surgeries after a perforation. (The subsequent infection is why her kidneys are so fucked up.) I can't tell if it's pus or not and I'm a little worried. I page the GI physician's assistant, and am treated to an amazing story: apparently the colon, when shocked, forms a thick brown crust around itself called a rind, which later liquefies and oozes away. Since she's starting to recover, the rind is dissolving, and the halfway-open incision on her belly is giving it a place to drain to, mostly into the drain itself. The sixty mLs of tan phlegm I've been pouring out every hour are, apparently, liquefied traumatic colon rind. I know what I'm naming my next garage band.
I educate the pt's family extensively on renal health and infection processes. They all look tired and bruised. I bring them coffee and very gently ask the daughter to take her father home and have him get some sleep. He agrees to go, and kisses his wife's forehead goodbye. She squeeze his hand back, the first purposeful movement we've seen since she got sick. He cries hysterically and kisses her hand over and over. Their daughter guides him carefully out of the room to the waiting transport wheelchair that I've called to carry him to the car. I promise to call if anything changes, and he says he will be back in two hours. The daughter quietly tells me that if he falls asleep, she won't wake him up unless I call.
She really is getting better. I think she stands a chance.
There is a potluck in the break room. I manage a ten-minute break, load up on quinoa salad and lettuce salad and hummus, and quietly mourn the huge pancit feasts of my previous facility. Food's pretty good though. I cram it down, bitch a little about my day, get back to work. As i leave the break room a coworker comes in with a flan in a cake pan, which he dramatically inverts onto a plate. It's not a flan at all, it's a butthole-textured, donut-shaped jelly cushion used in surgery to keep pressure off patient's faces while they're lying face down. I laugh so hard I fart.
I give an uneventful report, change all the CRRT bags, and stagger to my car. My sister, who is in nursing school, has texted me: her friend from her rock-climbing days in Yosemite died yesterday in a failed base jump. I call her up and listen to her work through it as I drive home. She's a CNA when she's not in class, and she's calling me from the break room at work, crying. Ten minutes later somebody comes to get her because one of her pts has had a big bowel movement. I remind her that I'll see her at the end of the month and we say goodbye, neither of us admitting that today all our goodbyes feel a little like freefalls, because death and horror have become so familiar to us that we only notice them when they happen suddenly at the end of a plummeting drop.
Thursday, July 9, 2015
My terrible posting spree continues
A heartwarming tale of hospital fun!
This was recorded ages ago by some brave souls from Starfleet Dental, who listened as I got drunk at 0300 and told them the beautiful story of a man whose body overcame a terrible disease by sheer willpower alone. Or, wait, no, I think he actually died horribly while rotting. Either way, I'm sure this will lift your spirits.
Do not listen to it while eating.
This was recorded ages ago by some brave souls from Starfleet Dental, who listened as I got drunk at 0300 and told them the beautiful story of a man whose body overcame a terrible disease by sheer willpower alone. Or, wait, no, I think he actually died horribly while rotting. Either way, I'm sure this will lift your spirits.
Do not listen to it while eating.
Diabetes 101, or Put Down the Fucking Candy
Edit: This page seems to be getting a lot of traffic, which is unexpected, and I wish now that I'd done a better job of explaining some things about diabetes, both Type I and Type II. I certainly never expected this to be passed around as a PSA!
For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.
So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.
___________________
A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.
So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...
...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)
We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.
That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)
Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.
On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.
But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.
Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?
To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)
So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.
This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.
Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.
Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.
If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.
DKA is a horrible way to die.
---
Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.
For those of you just visiting, this blog is a meandering mess of rants and stories about my experiences as a nurse, and the health education aspects are intended to help readers understand a little more about what I handle at work and what it means when I say my pt is "in DKA" or "doesn't take their insulin." I initially made this blog for a pretty small audience of people who were already familiar with my forum posts, and nothing here has been edited or really even thought through. I'd say half of it was written after at least one round of gin & soda.
So what you'll find here may be useful if you're trying to grasp the very basics of hyperglycemia and what it does to the body, but I strongly suggest: if you find this interesting at all, go find some other sources and do more reading. There is SO much more to this topic, and this page-long rant barely begins to scratch the surface.
___________________
A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.
So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this...
...so it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)
We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.
That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)
Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.
On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.
But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.
Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?
To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)
So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.
This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.
Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.
Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.
If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.
DKA is a horrible way to die.
---
Addendum: Type 2 diabetics get a similar thing, hyperglycemic hyperosmolar nonketotic syndrome, which does basically the same thing as DKA, but with even higher blood sugars and a lower chance of survival.
Week 1 Shift 1 (technically five of seven)
Let me tell you about my days.
Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.
I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.
Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.
Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.
The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.
The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.
A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.
The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.
Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.
Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.
The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.
Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.
Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.
Today I took report initially on one pt, a man with a neurological disorder that has left him wheelchair-bound and epileptic. Recently he seized during a wheelchair transfer and broke his hip. Now, after hip surgery, he remains unable to swallow, massively incontinent of urine and stool, and extremely forgetful. He wants oral swabs soaked in water, because his mouth is dry-- we are giving him IV water and food, but this doesn't keep your stomach from growling or moisten your throat-- but he can't remember when he's had them, and he presses his call light every twenty seconds. I almost never take a call bell away from a pt, but I took this one away. I feel vague guilt, and also this increases my workload since I now have to ask him every fifteen minutes if he needs anything. The answer is always "swab." I can only give him one every thirty minutes; he chokes on even that little bit of water.
I attempted to start a feeding tube earlier but it just made his nose bleed, which kept me at the bedside suctioning him until the bleeding stopped so he wouldn't choke. That can take a while, since you can't put pressure on the bleed.
Meanwhile, took an admit from an urgent care clinic, a little old man whose heart is too slow (bradycardia). He will get a pacemaker today. However, the night doc was caught up in a Code Blue, and failed to put in ANY orders before staggering out of the hospital to (I'm guessing) die quietly in the parking lot of exhaustion. The day doc had no time to put in orders for a full 1.5 hours after admit. I just started dopamine and crossed my fingers, as the urgent care clinic had already tried atropine.
Paging the night doc got me written up. My initial response was not exactly polite, but hey, a thirty-six-hour shift will make any doc kind of cranky.
The rest of the shift was fairly uneventful. The old man's heart converted back to a more stable rhythm (sinus bradycardia is better than junctional bradycardia) so they're holding off on his pacemaker until tomorrow.
The neurological disorder guy just made me sadder and sadder. His brother brought in his dentures so he could chew food, even though he can't even swallow his spit. He constantly begged for water, but choked on even the few drops from the mouth swabs I gave him every thirty minutes.
A little investigation revealed that he's been on hydrocodone every six hours for the last thirteen years, but since admission hasn't received a single pill of it-- or any of his psych or anti-seizure meds-- because he couldn't swallow after surgery. Whether this is because of advancing neurodegenerative processes or because the intra-operative intubation process damaged his throat, he stil needs the damn drugs. Plus he had fucking surgery, he needs pain meds. I threw a fit and got IV morphine, then finally got it switched to a PCA (patient-controlled analgesia) pump so he could dose himself at need.
The dentures were time-consuming. They had to be cleaned and stored, the container labeled, their presence noted in the chart, etc etc. Paperwork.
Another nurse asked if I could do a sign-off with her. This facility requires sign-offs on all cardioactives, sedatives, and electrolytes, in addition to the universal two-RN blood sign-off. Her pt looked shitty, pale, drenched with cold sweat, and gray-mottled all over. I hovered for a few minutes while she listened to the pt's chest for some fucking reason, waiting for my chance to sign off on whatever drug or bag of blood she needed me for.
Then she nodded briskly, walked back to the computer, and entered all this into the "clinical death" flow sheet. Fuck, okay, no wonder the guy looked bad. Guess we were just hanging out with a dead body.
The reason I had to sign off on the pt's death is that apparently once an RN had a dying old person hauled off to the morgue before their heart was quiiiite done. This is easier than you might think, because the heart keeps slight electrical impulses for a while after death, and a weak pulse isn't always palpable. So two RNs are supposed to listen to any dead pt's chest for two minutes straight to make sure we can't hear any beats (ie valves closing). I mean, at the point where your heart beat is debatable, your brain is getting no perfusion and you are already brain-dead, but recent corpses do enough weird shit like breathing and farting that it's a bit much to risk em having a heartbeat as well.
Not that I actually listened, since I had no idea the guy was dead. If I had been reading off blood or checking a drip that had a chance of hurting a living pt, I would have had to go back and check the whole thing... but honestly, if I know you're a decent nurse and you tell me your pt is dead, and I've been standing there for five minutes and not seen them breathe at all and noticed that they look like three-day-old waterlogged ground beef, I'm probably going to trust your assessment.
Cleaned up, gave report, drove home, passed out. Tomorrow will be day six of seven, and I'm tired as shit.
Introductory blatherings
My name is Elise. I am an ICU nurse, and I'm here to tell you what it's like in the disgusting, heartbreaking, obsessive, foul-smelling world of intensive care.
First off, I'm gonna come clean: sometimes I change details in my stories. Nothing to interfere with the mundane horror of the stories, of course, but you wouldn't be able to recognize any of these people from the info I give. Dates are altered; shift end reports are offset by varying times. I work in one main hospital, which is an amazing facility; I've also worked in six other hospitals in this city, and two others in a different state, which means that from time to time I will be dropping in tales from other facilities and past shifts when things are running dry.
If you really wanted to find my main workplace, you could, although I would appreciate it if you didn't. They might not understand.
If you wanted to find me, you probably could, although you're better off just dropping me a note.
If you wanted to find one of my pts, you shouldn't be able to.
If you are one of my pts, and you want a story removed, I will do so immediately-- just let me know. I will ask you for some verification, since with the identifying details stripped from my stories, it could very well be someone else's story you're recognizing.
---------
I will post anywhere from three to five shift stories per week, depending on how many shifts I work.
I will not embroider anything to make it more sensational or more dramatic. ICU work is dramatic enough without any yarn-spinning faffery to tidy up the edges. Where I change details, I will stay true to the spirit of the story; where those details are improbable, I will clarify whenever possible, so that you can trust what I write here.
I will respect my coworkers, my pts, and their families. Where I have a conflict with another person, I will not sugarcoat it-- but I will hide their identity even more thoroughly, and approach their story with empathy. I see people at their most vulnerable, at points of high stress, in moments of crisis and terror, in contexts of immediate tragedy or chronic suffering. I can't promise to like everyone, but I can promise to treat everyone with humanity, compassion, and dedicated care.
I will indulge in stupid derails, frothy diatribes about pathophysiology, and occasional rants about the things I like or hate. I will use clear language whenever possible, and clarify whenever I've been confusing. I will make disgusting metaphors about food and inappropriate jokes about death. I will mess up my details and fuck up my patho and drive everyone crazy with my profane explanations for basic medical matters. I will take requests. I will take criticism. I will not take bullshit.
See you guys at the end of shift.
First off, I'm gonna come clean: sometimes I change details in my stories. Nothing to interfere with the mundane horror of the stories, of course, but you wouldn't be able to recognize any of these people from the info I give. Dates are altered; shift end reports are offset by varying times. I work in one main hospital, which is an amazing facility; I've also worked in six other hospitals in this city, and two others in a different state, which means that from time to time I will be dropping in tales from other facilities and past shifts when things are running dry.
If you really wanted to find my main workplace, you could, although I would appreciate it if you didn't. They might not understand.
If you wanted to find me, you probably could, although you're better off just dropping me a note.
If you wanted to find one of my pts, you shouldn't be able to.
If you are one of my pts, and you want a story removed, I will do so immediately-- just let me know. I will ask you for some verification, since with the identifying details stripped from my stories, it could very well be someone else's story you're recognizing.
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I will post anywhere from three to five shift stories per week, depending on how many shifts I work.
I will not embroider anything to make it more sensational or more dramatic. ICU work is dramatic enough without any yarn-spinning faffery to tidy up the edges. Where I change details, I will stay true to the spirit of the story; where those details are improbable, I will clarify whenever possible, so that you can trust what I write here.
I will respect my coworkers, my pts, and their families. Where I have a conflict with another person, I will not sugarcoat it-- but I will hide their identity even more thoroughly, and approach their story with empathy. I see people at their most vulnerable, at points of high stress, in moments of crisis and terror, in contexts of immediate tragedy or chronic suffering. I can't promise to like everyone, but I can promise to treat everyone with humanity, compassion, and dedicated care.
I will indulge in stupid derails, frothy diatribes about pathophysiology, and occasional rants about the things I like or hate. I will use clear language whenever possible, and clarify whenever I've been confusing. I will make disgusting metaphors about food and inappropriate jokes about death. I will mess up my details and fuck up my patho and drive everyone crazy with my profane explanations for basic medical matters. I will take requests. I will take criticism. I will not take bullshit.
See you guys at the end of shift.
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