My splenic rupture pt had a rough night. It’s not uncommon for people over the age of 70 to get confused at night when they’re in a strange place, sick, covered in tape and wires, and this can lead to some really risky situations. In her case, she pulled out her PICC line, which was put in yesterday to replace the internal-jugular central line she pulled out the night before. I came in to find her wrists strapped down and her nurse sitting at the bedside, gently talking to her to keep her occupied and soothed.
Used to be, as soon as you started acting like you might pull something out, you got your wrists strapped down with restraints. These days, we pay a lot more attention to delirium, and restraints dramatically increase both the incidence and severity of delirium. The night nurse who cared for her while I was sleeping is a damn good one and I trust him, so when I saw the soft bracelets on her wrists I knew things had gone to shit.
She’d pulled her PICC while making eye contact with him, holding his hand with her free hand, and saying that she felt pretty good. Grab and rip. After this she pulled two peripheral IVs, removed her oxygen a dozen times, and tried to pull out her foley catheter. The night nurse felt that restraints were the only way to keep her IV access in, so he sat beside her for the rest of the night, talking to her to keep her from going completely crazy.
Sunlight is the usual cure for this kind of delirium, which is so common we call it “sundowning” and expect it with certain age groups. Once the sun comes up, you can usually transition the pt from wrist restraints to puffy mittens, then open the fingertip part of the mittens, and finally free their hands entirely. Sometimes it’s even quicker than that.
Delirium is very different from dementia. Often, severe acute illness will combine with other factors like dehydration, sleep deprivation, and unfamiliar medications to make a patient forget where they are and what day it is, possibly even thinking they’re in a different country or it’s 1970 or that I’m a Nazi captor in a WWII prison. (This is depressingly common in older folks from Europe, many of whom were terrified as children that they would be captured and tortured by enemies of war.) We call that confusion, initially, but if confusion has an acute onset (they aren’t like this at home), the pt can’t focus long enough to follow a brief set of instructions (“I’m going to spell a few words, and I want you to squeeze my hand whenever I say ‘A’.”), and they can’t get their bearings enough to answer simple questions (“Will a stone float on water?”), they’ve moved past mere confusion and are delirious.
In a state of delirium, a pt is likely to hurt themselves—falling, pulling out tubes, etc—and is at very high risk of having weird delusions and hallucinations. These are a big deal because, in the delirious state, your mind can’t really differentiate between reality and the bizarre ideas that come with confusion and delirium, and it processes these as if they’re fact. You can end up having intense, vivid PTSD flashbacks to things like being smothered by aliens, raped and tortured by Nazis, shoved into a box and left there for hours, and burned alive—even though none of these things actually happened. The flashbacks and mental fuckery can last for literal years afterward. People who become delirious in the ICU generally have cognitive issues for a long time after discharge. (We see this a lot in re-admits, who aren’t quite themselves when they leave and return a month later completely whacked out.)
Perhaps most immediately worrying, delirium can disguise other major signs of danger, like altered level of consciousness, pain, and feelings of impending doom.
So I progressed her pretty quickly from restraints to mittens to open mittens. Too quickly—she pulled out one of her IVs. She has another, though, so I stopped the bleeding and let it rest. I feel like her mental status is one of the most vulnerable aspects of her health right now, and it would be awful if she (an independent woman who teaches music) ended up in a nursing home when she leaves here.
Anyway, as the shift progressed her lethargy continued, and she had trouble articulating almost anything she said. Head CT from yesterday was totally clean, neuro checks negative except for lethargy and verbal difficulty, blood sugar and hematocrit stable, abdomen stable, and finally we just settled in to “watch and wait.” I asked her son if she wears glasses, because although she claimed not to, she also didn’t know what state she lived in… Son brought in glasses and a novel she’d been reading, and a little later in the afternoon she came around just fine.
Still a little worried about her. Drowsiness after a splenic rupture is usually a sign that the pt is about to take a turn for the worse. But she had plenty of time to make that turn, and instead finished up my shift with a quick trip to the bedside commode and a bit of worrying-aloud about whether she would be able to get up the stairs at home. (She will be strong enough to get up the stairs by the time we send her home-- physical therapy opens almost every intial interview with, believe this or not: "Do you have stairs in your house?" This is a goon joke.)
As for my pt with the GI bleed, she was quite thoroughly recovered. She was downgraded to medical status halfway through the day, and after a bit of consultation with the blood bank, the doctor decided to go ahead and top her off with the last unit of matching, prewashed blood they had on hand, then send her home in the morning. Her family came in to visit during the afternoon, and her kids were so excited to see her that they literally jumped up and down, in place, for almost thirty minutes. One of them would settle down, and the other would kind of chill out, and then the first one would start bouncing again, and pretty soon they'd just be hopping in place, talking three hundred mph in their weird little shrieking voices. Kids are basically insects, is what I'm saying.
At three, afternoon shift change time, I traded out-- GI bleed passed off to a nurse with a group of other medical/telemetry overflow pts, new pt picked up. This guy was still critical care status, having been extubated around 1030, and he had a very distinct set of challenges to present me.
He is a developmentally delayed man, about forty, mentality between six and eight years old. Very polite-- turned his face and covered his mouth when he coughed, waved at everyone-- but easily frustrated and, for obvious reasons, very stressed out. He had been at his adult family home, eaten a bunch of dinner, aspirated it somehow, and gone into respiratory-cardiac arrest. 911, CPR, intubation, bronchoscopy with washout, extubation the next day. Really good outcome, no neuro deficit from baseline.
His lungs were still pouring sputum in response to the dinner invasion. Listening to his chest was like sticking your stethoscope into a washing machine full of shoes. Every few minutes he would cough up huge rippling mountains of sputum, which he had a very hard time managing and would suck back down his windpipe maybe one out of three times, causing another coughing fit. He did NOT like having the suction catheter in his mouth. He also wanted dinner, and some soda, and the speech therapist unsurprisingly made him strict NPO (nil per os, aka nothing by mouth) because he genuinely couldn't swallow his own spit without choking.
He'll probably get that functionality back, to a degree, but we still have to assess what made him aspirate in the first place.
In the short term, I got a packet of honey from the condiment drawer, smeared a trace of it on the suction cath (also called a yankauer, a plastic wand for sucking things out of the mouth and upper throat), and offered it to him as a "honey straw." He loved it. There wasn't enough honey to cause any trouble, and honey doesn't come off easily, so I wasn't worried about choking... and it encouraged him to keep it in his mouth almost constantly, coughing up crap and immediately jamming the "honey straw" back in his mouth. I refreshed it every hour or so and he cleared his airway wonderfully the whole time.
The real challenge came from his severe chronic constipation. An abdominal CT performed yesterday on admit, for his hugely distended belly, revealed that his colon was PACKED with shit. Cecum to rectum, dilated to a terrifying degree, crammed full of poop that hadn't seen the light of day in months. They loaded him with a truly amazing volume of bowel meds, and the night before he had started out with a few semi-liquid stools-- the kind of thing that manages to seep through the shit tunnel gridlock and keep you from backing up so hard that you die.
And he was backed WAY up. He kept burping and it smelled distinctly of shit. His OG tube, pulled out with the breathing tube when he was extubated, had been pulling something that the doc initially worried about because it looked a little like coffee grounds (a sign of gastric bleeding)... but which, when the OG tube came out, was pretty clearly just backed-up shit. Shit from his STOMACH. That is not supposed to happen and is a very bad sign.
Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets.
As I sloshed through that cleanup, trying not to breathe more than strictly necessary, I realized that this shit had been inside him for one hell of a long time. The smell had that intense death-rot odor you get when you've been hoarding that particular nugget for quite a while. That corn wasn't last week's veggie side at the cafeteria, dude. I bet you a dollar he gnawed that shit off the cob at his grandma's house for Christmas.
The fecal journey continued with inspiring diversity. One delicately-jointed, bubble-textured oblong came out looking like a Baby Ruth bar. One delivery was thick and slushy, but contained crumbly elements that glued themselves to everything they touched and pilled up like a hoodie in the dryer.
We attempted to get him up to the bedside commode at one point, hoping to catch the bounty in a bucket rather than the bed, but as he prepared to sit down he suddenly decided that there was a better potty out in the hall somewhere, and took off running with his gown flapping behind him. Two steps into his flight, his sphincter lost control. Spatters and ribbons festooned the tile in a pseudo-Farsi calligraphic scrawl. The CNA and I caught him before he could open the room door; she guided him by the shoulders back to his plastic throne, and I cupped my hands under a washcloth to form a towel-cup that I clamped to his backside, catching the steaming runoff to prevent any more modern art.
After a while, he exhausted himself on the bucket, and we got him back into bed. Five minutes after that he had another coughing fit and ripped a gargantuan chunky fart right into his disposable bed-liner. I heard the expulsion lap up against his thighs like the bubbles popping in a pot of boiling oatmeal. The pulmonologist came up to ask me a question and started coughing at the smell.
Some days are just like this. I passed that guy off to night shift with sincere condolences and warnings.
It occurs to me that I would not want to eat anything honey-flavored while in the room with a smell like that. But this pt happily smacked away on his "honey straw" even while his gut was blasting out everything he'd eaten this year, not so much as blinking. You know what? Whatever makes him happy. That's what.
The only real upside is that, being developmentally delayed, he could be convinced that this shit was hilarious, and wasn't really offended when we acknowledged that his shit stank. Some people get really upset if you don't manage to keep a straight face as you clean up their poop; some people just get incredibly embarrassed and feel horrible, and my heart goes out to those people, because I can't take a dump if anyone in the building knows I'm taking a dump and I would rather pretend at all times that I don't actually have bowel movements. (This is probably a leftover of my upbringing somehow, but I don't care to examine it too closely.)
You just gotta be really good at keeping your poker face strapped on. Gross wound? Learn to smile through it. Gallons of liquid shit? Reassure the pt that you've seen so much worse. (You have.) Crusty vadge plopping out cheese curds the size of thumb joints while you're trying to scrub the area for a catheter? Keep your face pleasantly neutral and talk about something else.
This job is allllll about winning people's confidence. It's much harder to care for someone whose guard is up, who distrusts you, or who feels awkward when you walk into the room. If they can relax and feel comfortable, if they can trust you, they have a much better experience and will tolerate a lot more of the pain and indignity that comes with a hospital stay, knowing that you're not doing this shit for fun either and that you won't judge them for anything that happens.
A particularly weird aspect of this is the importance of not reacting to anything with shock, panic, or visible distress. Like if you stub your toe and they see you wince and hop around, they're going to be wondering: is she gonna hurt me by accident too? Is she really in control of the situation? Can she be distracted at a critical moment, and possibly let me die because she just jammed her thumb in a drawer? These aren't conscious assessments, they're just part of the natural human reaction to being powerless and needing a team member you can trust. So one of the reflexes I've cultivated as a nurse is keeping a straight face when I bang my elbow, stub my toe, or otherwise remind myself that my body is pretty vulnerable and these hospital rooms are fucking crowded. If I drop something on my foot, I'm gonna politely excuse myself to another room before I descend into hissing and cursing.
I don't want my pts to ever feel like they have to comfort or protect me. I don't want to seem physically or professionally vulnerable to a person whose life may depend on my capability and strength. I want questions to be surface-level, where I can encourage my pts to articulate them and have them answered. I want to avoid situations in which my pts have to assess the situation without full access to relevant information, which means that even if my toe-stubbing happens because I'm focused on their cardiac output, I don't expect them to be able to explain my priorities of attention to themselves and decide that I must have been looking at something more important.
I am probably a fucking nutjob. I overthink things. I am paranoid and obsessive. This might make me a better nurse, or it just might make me a crazy person thinly disguised as a medical professional. Either way, I am probably the only person most people will ever meet who can make them feel safer just by smiling noncommittally as I wipe their ass.
Three days off after that shift. My kid sister moves in this evening, and will probably absorb most of my time for a couple of days.
Thank you guys so much for the encouraging messages and stuff. I get really shy sometimes when people praise my writing and I have to sit in a quiet place and squeak and drink tea, and eventually I muster up enough resistance to reply en masse while turning red and occasionally pausing to mash my hands against my mouth. You are all way too nice to me.
Thursday, July 16, 2015
Week 3 Shift 3
Arrived to find my assignment slightly shifted. The unfortunate peritoneal dialysis guy spent all morning waiting to see if they could stent him this afternoon, so he was super low acuity and they paired him with a very high-acuity pt down the hall, a different guy who required a sitter to keep him from pulling out all his lines and tubes. As a result, I only interacted with him as the next-door nurse, filling in cracks for the nurse officially assigned to his care. In the meantime, the patient patient (hurr hurr) twiddled his thumbs until cardiology decided that they would brave his awful vasculature and many allergies, and dig out whatever was clogging his heart.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Oh yeah, did I mention the many many allergies? This dude is allergic to BENADRYL. He’s allergic to everything that can be given to control an immune response. I am assuming that his vascular badness is probably related to an autoimmune issue, because god damn, this poor schmuck is allergic to his own eyebrows.
This will make his cath procedure very tricky, because he’s anaphylactically allergic to iodine dyes and most other radiopaques used in angiography. This will make it difficult for the cardio folks to tell what they hell they’re looking at while they’re trying to suck the clot escargot out of his arterial butter sauce. Or whatever gross, snail-related metaphor you care to use.
The cardiologist finally decided that there’s no fucking way anyone can be violently allergic to antihistamines and steroids, and decided to take the gamble that Benadryl and prednisone were given to him to control an already-occurring reaction and therefore got swept up with the whole ‘anaphylaxis’ thing. It’s much more likely, after all, that during his episodes of anaphylaxis from –mycin antibiotics, he got a bunch of anti-allergy medications that didn’t fully control his reactions, and assumed that the reactions were to the medications as well.
It’s a stiff gamble. Some people really do have horrible reactions to prednisone. We performed a scratch test, dipping a needle in the offending substance and nicking the back of his hand; then, seeing no reaction, we administered a quarter-dose very slowly; then, still seeing no reaction, we finished the dose and started over with the other anti-allergy medicine. Turns out he isn’t allergic to Benadryl OR prednisone. Huh.
So down he goes for his cath.
My pts, the ones I was actually taking care of, were a little less anticlimactic. As I sat down to get report, the night nurse informed me that my pt from yesterday, the woman with the GI bleed, would be having a procedure done at 0730. As I took report, the endoscopy nurses were cramming the room full of scope supplies and monitors and such. The pt was stable last night, received four units of blood, and was looking a little more pink in the cheeks, but still had huge esophageal varices, so she would be getting an esophagogastroduodenoscopy to pinch off some of these little throat-hemorrhoids so they wouldn’t keep bleeding.
(We typically refer to this procedure as an EGD, for obvious reasons.)
So at 0730, I pumped her full of versed and fentanyl, then held her hand and kept an eye on her vital signs while the GI doc snaked a long thin tube down her throat, sucked each hemorrhoid (varicele) up into the end of the tube, and popped a little rubber band off the outside of the tube over each one to pinch it off. This is called banding, and is very effective for most pts—the band eventually falls off, but by that time the varicele has clotted off and either healed or turned into a chunk of scar.
She tolerated the procedure very well, and afterward got to drink cranberry juice while we chatted about her iron-deficiency anemia (I advised her to start cooking in a cast-iron skillet) and how hilarious it is when guys assume that women will freak out about blood. Then I gave her some pain meds for her crazy-making sciatica and she took a chair nap while I scrambled around over my other pt.
The other pt was admitted under the diagnosis of probable sepsis. She presented like somebody who was about to crater: massively elevated white blood cell count, severe anemia and hypotension, confusion and weakness, and a lactate of fucking 10. My eyes bugged out of my head when I saw that number, let me assure you—4 means something is really wrong, and 6 often corresponds with impending death. Mind you, I was getting this patient while preparing for an EGD in the next room.
She had also gone nuts on night shift and pulled out her central line. Her husband had apparently called 911 because he got home from work and found her sitting on the couch, raving and screaming about dead relatives. I went into that room ready for Armageddon.
Instead I found a cute little old lady lying very peacefully in bed, where she greeted me politely and answered all my questions with ease. She looked way too healthy for somebody dying of sepsis. Her hands were wrapped up in mittens to keep her from pulling lines, but before the EGD nurses had arrived, I already had the mittens off. She was completely aware and alert and cooperative.
Other things didn’t add up. All her white blood cells were mature, suggesting that this wasn’t an acute massive response to infection. She was afebrile; she was bruised all over her side; she was having massive left shoulder pain, and her belly was tender. Her confusion had completely disappeared, and she had received a total of two units of blood, one liter of lactated ringer’s solution, and a round of antibiotics. The doctor wasn’t buying sepsis any more than I was, so we agreed to redraw a lactate to see if something had got crossed up.
This lactate came back 1. That is a totally normal lactate and it’s also physically impossible for lactate to drop from 10 to 1 in the space of three hours. I assume somebody drew it upstream of that IV of LR she got downstairs. The pt also informed me that the tourniquet was left on her arm “for like ten minutes” during that blood draw, so if that’s not hyperbole, it could have absolutely caused the lactate to draw up abnormally high.
Not sepsis. Electrocardiogram came back clean; why the shoulder pain? Pain at the point of the shoulder is often a result of phrenic nerve stimulation… and she was complaining of abdominal tenderness… and she was covered in bruises. We took a chest X-ray and were absolutely boggled to discover what looked like a serious left-sided pneumothorax—no reason for her to have air in her chest cavity outside of her lungs. No broken ribs. What the hell? We prepared for a chest tube placement, but decided to check again just in case. Additional X-rays showed that the ‘pneumothorax’ was a skin fold on her back, showing through the lung to mimic an air pocket. That is just bizarre.
And told us almost nothing. Finally a CT scan revealed that nothing was fractured, but her spleen was enlarged and had somehow ruptured. A slow ooze from her popped spleen was filling her gut with serous and sanguineous fluid. Well, shit. That would explain the phrenic pain. Why was her spleen enlarged? Why was she so loopy to begin with? Why the unconvincing markers of infection?
If you’re a medical professional, you may already be wincing in sympathy. She’ll need a biopsy to confirm it, but we’re reasonably certain this unfortunate woman has leukemia. Her white blood cells are reproducing out of control, causing her spleen to enlarge and preventing her from making enough red blood cells to keep her energy and oxygenation within brain-satisfying parameters. While her husband was at work, she had developed tremendous weakness, and apparently she slipped and fell and ruptured her swollen spleen, but wasn’t able to remember or report this by the time her husband came home.
Her hematocrit continued to drop throughout the afternoon, so around 1500 the team came to haul her off to IR and attempt to embolize her spleen, to stop the bleeding, and if necessary to remove the thing altogether.
While she was gone, most of the MD team got together to talk to the screaming lady with liver failure and explain to her that she had run out of options, and to press her and her family to shift their focus from recovery (now impossible) to comfort (such as can be given). Constant drug-induced diarrhea has kept the woman’s ammonia levels low enough that she can sort of interact, but she doesn’t seem to understand that her status has progressed to terminal, and her family isn’t willing to make the decision. She is in agony. I can’t even imagine what it must be like, lying in a hospital bed, convinced that you’ll be okay in the end if you just make it through another day—another week—another month of suffering, and screaming constantly because you hurt so much and your brain is so poisoned. Nobody deserves that kind of death.
Well, maybe a few people. But judgement like that isn’t mine to make.
I wonder if it would really fuck a kid up to name them Karma. Would they feel like it was their duty to dispense justice? Would they become some kind of self-righteous asshole, delivering their brand of Batman justice (most likely in snide youtube comments and e/n threads)? Would they resent the implication of responsibility, and refuse to accept the burden of making the world right? Would they just roll their eyes and wonder why the fuck their parents named them something so stupid?
Definitely gonna name my hypothetical future offspring Hatshepsut and Hypatia and Sagan. You know, cool names that won’t get them beaten up. I should not be allowed to have children.
No real news from Rachel today. She’s just chilling at the end of the hallway, smiling and waving at people as they walk past.
Two of our nurses are leaving. They are a married couple; one is starting nurse practitioner school in Utah, and the other will be working at a hospital near the school. We had a huge potluck for them today, and one of the CNAs brought a massive pile of utterly flawless raspberry mini-macarons. I have never experienced such emotion over anything in any hospital, ever. Literal tears of rapture were shed. Everyone in the room was uncomfortable and I don’t care.
Favorite memories of the two departing nurses:
--One showed me a video of her kids jumping off a low bed and faceplanting on the carpet, over and over. The younger one shrieked with laughter each time and kept jumping and laughing even though she bit her lip and was bleeding freely. The older one sobbed, but kept doing it, because apparently she is a competitive lil shit who can’t let her sister outdo her at anything. The nurse laughed at this video until her on-screen self appeared and put a stop to the festivities, while obviously struggling to contain her laughter. “It’s good for them,” she said. Her kids look happy and ferocious and beautiful.
--The other is the nurse who brought the fake flan to the last potluck. He is the only male nurse who will still willingly work with Crowbarrens. A couple of admits ago, he walked into the room where our albatross had just landed, and instead of addressing him directly, he looked into the mirror and chanted: “Crowbarrens, Crowbarrens, Crowbarrens” at his reflection. Then he wheeled, pulled a huge startled double-take at the guy, and shouted FUCK.
Crowbarrens laughed so hard his vent circuit popped off. I laughed so hard I had to take a breather in the equipment room. Every ICU needs a complete nutjob nurse with a younger-uncle sense of humor.
The only downside to this potluck, which is amply compensated for by the macarons, is that with everybody carousing in the break room I’m having to steal my naps elsewhere. Worse, I’m having to compete for nap space. So every time I try to steal a ten-minute snooze in the family-conference room where the short uncomfortable sofas are, there’s somebody pumping breast milk in there, or sleeping on a sheet on the floor, or having an actual family conference (the nerve). I ended up picnicking a couple warm blankets on the bathroom floor, locking the door, setting my alarm for ten minutes, and passing out on the padded tile. It’s not gross if there are blankets, right?
I used to do this a lot more often when I worked in Texas. The unions in Washington are very pointed about nurses getting their breaks, but in Texas I was lucky to get a thirty-minute lunch split in two, confined to the tiny break room with its two wire-backed chairs. I worked nights, so when I hit the wall around 0300 I would pretend to take a dump, and instead sprawl out on the bathroom floor on a stolen sheet and take the edge off with five minutes of shut-eye. It’s not terribly comfortable, but nothing is less comfortable than sleep deprivation.
Back then, I was sleep-deprived because I worked mandatory overtime, drove an hour each way to work, and had to sleep during the hottest part of the day when even the air conditioning couldn’t get my bedroom below 90F. Today, I’m sleep-deprived because my sister left yesterday and I miss her, and because on Sunday my other sister (I am the oldest of five recovering creationist-homeschoolers) is coming to live with me and my husband in our one-bedroom apartment for the summer while she gets her GED. She is 19 and has been sorely held back by my well-meaning mother’s inability to parent and educate a homeschooled, isolated teenager in a farmhouse in the woods fifty miles from the rest of humanity. I am pretty worried about the possibility that she won’t adjust well, won’t be able to get through the GED/internship program that I’ve found for her, and will end up living on my dime until I find something to do with her. Sometimes this results in insomnia, which is a nasty thing to have between shifts.
She’s a good kid. She’s better than I was at her age—she’s already managed to drop the ingrained homophobia and sexism she was brought up with, and is a lovely, articulate, hilarious person. I think she’ll do well. I’m just a selfish snot who gets all whiny about having to share my living room. And tonight I’m gonna pop a Benadryl before I sleep.
Hopefully I won’t die of anaphylactic shock.
Anyway. The splenic embolization was a grand success, and my pt returned high as a kite on pain meds and sedatives, not even minding that she had to keep her leg straight for the next four hours and that I had to poke her sore crotch-wound every fifteen minutes to make sure she wasn’t bleeding. My other pt spent the afternoon sipping Sprite, walking around, and generally looking about a thousand times better than she was last night. The guy down the hall got his stent, and is back on his ipad playing internet poker. Rachel wheeled around the unit in a transport chair pushed by a tech and high-fived an RT. Screamer lady has been drugged into oblivion and it seems to be finally catching up with her.
If it seems like a lot of these pts vanish into thin air after I’m done writing about my shift, well, that’s a thing that happens. ICU staff rarely gets the whole story—the rehab after the acute illness, the full recovery, the death at home surrounded by family, even the shift to comfort care a week later on the medical floor, all of that stuff is lost to us. We know very little about our pts before they arrive, unless they’re frequent fliers, and even less once they leave, unless they come back. So most of the stories I see, I glimpse in passing—a few scenes from the movie, a few illustrations from the book. When I leave, I disappear from the story that’s consumed my day, and I fall into a strange different story where I eat chicken teriyaki and watch Netflix and taste different kinds of honey and read science fiction and scrawl terrible essays about Tolkien and imagine that someday I will be an actual writer, as if the real story weren’t going on all around me in the places where my shifts end and beyond the hospital where I’ll be tomorrow whether my pts are still there are not.
There might be happy endings. I’m sure there are generally endings of one variety or another—endings of lives and the chapters in them, endings of nightmares, endings of doomed hopes, who knows? I get to see sad endings (she’s still screaming, and will scream until she dies); I get to see a certain brand of happy endings (down the hall a man I don’t know is gently dying, with his grandchildren holding his hand, never having to suffer the indignity and pain of a breathing tube); I get to see strange endings that are nearly happy (they leave, and I never know what became of them); and I get to see endings that are only segues into the next chapter (Crowbarrens is, as I write this, sitting in the ER waiting to be admitted).
My stories are short stories. My endings are reports at the end of shift.
Wednesday, July 15, 2015
Liver Failure 101, or How That One Family Member Will Actually Die
Why do alcoholics bleed to death?
In order to explain this, I'm gonna have to get a little pathophysiological, as I promised in an earlier post.
Most chronic alcoholics die shitting or vomiting blood. It seems like a weird connection, especially if (like most people in a non-medical arena) you're not totally clear on what the liver does exactly. Something to do with poisons, right?
Well, yeah, but not just poison. A lot of things come into your body through your mouth, and you can feel free to insert your own dick jokes here, in much the same way that you insert dicks into your mouth. That shit ranges from "inadvisable and kind of sweaty-tasting" to "straight-up block of pesticides" and your stomach and intestines give no shits about this. If you swallow a mouthful of jizz, as far as your stomach is concerned, you just had a teaspoon or two of protein supplement, and your pancreas will happily bathe it in flesh-dissolving enzymes so your intestinal bacteria can chew it up and shit it all over the absorptive walls of your intestines. Directly outside of those gut walls, blood vessels happily pump away the acid-bathed, pancreas-liquefied, bacteria-digested jizz protein for your body to make into more of itself.
Hold the fucking phone, you say. That jizz was probably nontoxic, but what about the other nasty things we eat every day without realizing it? The 2.5 spiders you swallow in your sleep every night-- where does their venom go? That waxy shit on the outside of cucumbers that tastes like Raid? The shampoo you got in your mouth last time you showered? (I know I'm not the only person who has this problem.)
And worse, even if you assume that the intestinal walls have some pretty strong filtration powers to separate the shit from the food, what happens when you get horrific diarrhea and your insides get raw? What if you eat too much corn and you scrape up your gut? What if you have hemorrhoids and your body is constantly insisting that you have to squeeze fist-sized turds directly over the open wound that your asshole has become? Oh my god, you are going to have shit blood poisoning and die.
So here's the trick: your body has two separate blood-circulating systems. One of them is systemic, and full of delicious clean blood with lots of carefully sterilized proteins and freely-available sugars floating happily through it, ready to feed your heart and brain and other assorted bits without subjecting them to anything gross at all. The other is intestinal, and it's a fucking junkyard of sloppy proteins that still look a little like the sperm you chugged to begin with, plus all the other poisonous chemicals you've splashed in your mouth recently, plus all the perfectly natural nitrogen waste that comes with living and is incredibly disruptive to brain activity, plus any traces of shit that are scraping their way into your bulging assgrapes. Fortunately, this complete wasteland of trash is outfitted with a couple of critical defenses.
First, you have tons of lymphatic drainage in your intestines. I'll cover the lymph system later sometime, but it's like an alternate circulatory system, a set of loose-mouthed leaky veins that pick up extra water and trash and scour it with macrophages that live in the nodes.
Second, the intestinal system is on a closed circuit that only returns to the rest of the body through, you guessed it, the liver. Inside the liver, the jizz proteins are reduced and converted to more usable proteins; chemicals are scrubbed and pumped back into the shit chute for dumping. The hepatic portal (literally the "liver door") refers to the tiny straw-like filters through which all your blood has to squeeze on its way in and out of the intestinal circuit. All of your blood goes through here, and the pressure gets pretty high.
Alcohol and other liver toxins scar up these tubes and make them stiff and tight, forcing your blood to squeeze through smaller and smaller spaces. Healthy liver tubes are flexible and have a little bit of give; scarred tubes are about as flexible as particleboard. Cirrhosis-- liver scarring-- results in portal hypertension, or excessive pressure on either side of the liver-door. On the systemic side of the door, backed-up blood bloats into hemorrhoids in the esophagus, which eventually burst and bleed, often catastrophically. On the intestinal side, so much blood builds up that the extra fluid is forced to ooze out into the abdominal cavity, forming that stretched-out, water-filled liver-failure belly you see in liver pts and chronic alcoholics. This is in addition to similar ready-to-pop situations in your intestines, which can blow out at any time.
Adding insult to injury, the liver takes all these proteins and food particles and makes all your blood clotting factors out of them. A failing liver, or one continually taxed by alcohol or tylenol/paracetamol, is too busy struggling to filter and repair to be effective at making clotting factors. And, being in a prime position to monitor your nutrition status, your liver has control of your body's access to its food stores-- control that's mediated largely through proteins.
The thing about proteins is that they're basically specialized wrenches, low-tech thing-grabbers designed to grab the thing they're made to grab and move it however it needs to be moved. They CAN be broken down for energy, but they're terrible energy sources, and the more protein your body has, the more wrenches it can build. And what builds your wrenches? Yeah, it's totally your liver.
And while you probably know about platelets, and with a little brain-poking you can probably figure out that those are blood cells and come from inside your bones, you should also know that platelets don't do much more than grab broken areas and then group-hug. They really aren't a fix for a torn blood vessel. Fortunately, once they're group-hugging your wound, they can secrete chemicals that activate the wrenches around them-- things like fibrin, which helps you heal and build scar tissue, and which forms the bulk of a dry scab.
Platelets by themselves don't last all that long and can't make a decent scab. But if they have the tools, they can build huge structures to protect your blood from wandering off. And what are these hammers and wrenches?
Proteins.
And what makes your proteins?
Yeah, you get the idea.
So if you start bleeding and your liver is shot to shit, good luck. Your body is going to forget how to clot very quickly. And that is why alcoholics die bleeding from the throat.
In order to explain this, I'm gonna have to get a little pathophysiological, as I promised in an earlier post.
Most chronic alcoholics die shitting or vomiting blood. It seems like a weird connection, especially if (like most people in a non-medical arena) you're not totally clear on what the liver does exactly. Something to do with poisons, right?
Well, yeah, but not just poison. A lot of things come into your body through your mouth, and you can feel free to insert your own dick jokes here, in much the same way that you insert dicks into your mouth. That shit ranges from "inadvisable and kind of sweaty-tasting" to "straight-up block of pesticides" and your stomach and intestines give no shits about this. If you swallow a mouthful of jizz, as far as your stomach is concerned, you just had a teaspoon or two of protein supplement, and your pancreas will happily bathe it in flesh-dissolving enzymes so your intestinal bacteria can chew it up and shit it all over the absorptive walls of your intestines. Directly outside of those gut walls, blood vessels happily pump away the acid-bathed, pancreas-liquefied, bacteria-digested jizz protein for your body to make into more of itself.
Hold the fucking phone, you say. That jizz was probably nontoxic, but what about the other nasty things we eat every day without realizing it? The 2.5 spiders you swallow in your sleep every night-- where does their venom go? That waxy shit on the outside of cucumbers that tastes like Raid? The shampoo you got in your mouth last time you showered? (I know I'm not the only person who has this problem.)
And worse, even if you assume that the intestinal walls have some pretty strong filtration powers to separate the shit from the food, what happens when you get horrific diarrhea and your insides get raw? What if you eat too much corn and you scrape up your gut? What if you have hemorrhoids and your body is constantly insisting that you have to squeeze fist-sized turds directly over the open wound that your asshole has become? Oh my god, you are going to have shit blood poisoning and die.
So here's the trick: your body has two separate blood-circulating systems. One of them is systemic, and full of delicious clean blood with lots of carefully sterilized proteins and freely-available sugars floating happily through it, ready to feed your heart and brain and other assorted bits without subjecting them to anything gross at all. The other is intestinal, and it's a fucking junkyard of sloppy proteins that still look a little like the sperm you chugged to begin with, plus all the other poisonous chemicals you've splashed in your mouth recently, plus all the perfectly natural nitrogen waste that comes with living and is incredibly disruptive to brain activity, plus any traces of shit that are scraping their way into your bulging assgrapes. Fortunately, this complete wasteland of trash is outfitted with a couple of critical defenses.
First, you have tons of lymphatic drainage in your intestines. I'll cover the lymph system later sometime, but it's like an alternate circulatory system, a set of loose-mouthed leaky veins that pick up extra water and trash and scour it with macrophages that live in the nodes.
Second, the intestinal system is on a closed circuit that only returns to the rest of the body through, you guessed it, the liver. Inside the liver, the jizz proteins are reduced and converted to more usable proteins; chemicals are scrubbed and pumped back into the shit chute for dumping. The hepatic portal (literally the "liver door") refers to the tiny straw-like filters through which all your blood has to squeeze on its way in and out of the intestinal circuit. All of your blood goes through here, and the pressure gets pretty high.
Alcohol and other liver toxins scar up these tubes and make them stiff and tight, forcing your blood to squeeze through smaller and smaller spaces. Healthy liver tubes are flexible and have a little bit of give; scarred tubes are about as flexible as particleboard. Cirrhosis-- liver scarring-- results in portal hypertension, or excessive pressure on either side of the liver-door. On the systemic side of the door, backed-up blood bloats into hemorrhoids in the esophagus, which eventually burst and bleed, often catastrophically. On the intestinal side, so much blood builds up that the extra fluid is forced to ooze out into the abdominal cavity, forming that stretched-out, water-filled liver-failure belly you see in liver pts and chronic alcoholics. This is in addition to similar ready-to-pop situations in your intestines, which can blow out at any time.
Adding insult to injury, the liver takes all these proteins and food particles and makes all your blood clotting factors out of them. A failing liver, or one continually taxed by alcohol or tylenol/paracetamol, is too busy struggling to filter and repair to be effective at making clotting factors. And, being in a prime position to monitor your nutrition status, your liver has control of your body's access to its food stores-- control that's mediated largely through proteins.
The thing about proteins is that they're basically specialized wrenches, low-tech thing-grabbers designed to grab the thing they're made to grab and move it however it needs to be moved. They CAN be broken down for energy, but they're terrible energy sources, and the more protein your body has, the more wrenches it can build. And what builds your wrenches? Yeah, it's totally your liver.
And while you probably know about platelets, and with a little brain-poking you can probably figure out that those are blood cells and come from inside your bones, you should also know that platelets don't do much more than grab broken areas and then group-hug. They really aren't a fix for a torn blood vessel. Fortunately, once they're group-hugging your wound, they can secrete chemicals that activate the wrenches around them-- things like fibrin, which helps you heal and build scar tissue, and which forms the bulk of a dry scab.
Platelets by themselves don't last all that long and can't make a decent scab. But if they have the tools, they can build huge structures to protect your blood from wandering off. And what are these hammers and wrenches?
Proteins.
And what makes your proteins?
Yeah, you get the idea.
So if you start bleeding and your liver is shot to shit, good luck. Your body is going to forget how to clot very quickly. And that is why alcoholics die bleeding from the throat.
Week 3 Shift 2
After six days off to hang out with my middle sister, the one who works as a CNA, and get my social life on (it's very sad and lame and involves babysitting and eating teriyaki), I went back to work this morning for a stretch of three days.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Not a half-bad shift. I took report on a man who kept having recurring pleural effusions-- buildups of fluid in the space between the lung and the chest wall-- and who had, because of a history of facial lymphoma that made docs suspect possible cancer, undergone a VATS procedure a couple of days ago. VATS is a Video-Assisted Thoracoscopic Surgery, and can be used for everything from chopping out part of your lung to fixing a hiatal hernia. In this case, surgeons had burrowed a camera into this guy's chest, scraped out chunks of lung and lung-lining, and gnawed open a little window for the gooey effusion fluid to leak out of so it won't squish his lung. This procedure actually comes with quite a bit of pain, and often requires chest tubes for drainage afterward, which continues the pain factor until the chest tube is pulled out.
Your body doesn't like having anything shoved between its ribs and/or into its thorax. Nothing that digs around in your chest is going to feel good.
This poor dude had a genuine sensitivity to opioids. You know all those pts who insist that they're allergic to all pain medications except that one that begins with D? It's virtually impossible to be allergic to all opioids except one. All of anything except one, really. It's like being allergic to all beef except filet mignon. In this guy's case, every opioid we'd tried on him resulted in tremendous nausea and vomiting, so we were keeping him tanked up on tramadol-- an opioid-like painkiller that often spares its victims the side effects of morphine, although it isn't as effective against severe acute pain-- and tylenol (paracetamol), which potentiates the tramadol and provides a bit of pain relief on its own. As a result, he was hurting.
The biopsy came back while we were having a walk around the unit: no cancer. The walk around the unit wasn't much fun for him, though. After a thoracic surgery it's crucial that patients walk around and keep moving, or else their lungs's little air sacs collapse and they get pneumonia, and fluids build up instead of sloshing around where the chest tube can drain them, and in time even the heart's output drops dramatically. The human body is kind of like a car: if it sits in the garage, it's gonna be useless pretty soon. Even a few hours without breathing exercises and a brisk walk can earn a post-surgical pt a fever, which is the body's natural response to having its lungs close up.
So a lot of times my job is to make my pts miserable by flogging them up and down the halls to keep them from dying. They hate this, by the way. Moving is painful, no matter how much pain medication I give; walking is exhausting, even with the cardiac walker that lets you lean on your arms instead of your hands. One of the hardest-earned skills in an ICU nurse's repertoire is the combination of energy, sweet-talking, brutality, and limit-watching perceptiveness it takes to get a hurting, pissed-off, six-and-a-half-foot-tall man out of bed when he wants to watch the news instead.
This dude, though, propped himself up on the cardiac walker and took the full unit circle at damn near a sprint. He panted and sweated, but he insisted his pain was manageable, and his chest tube dumped a good 50mL of fluid while he was huffing his way down the hall like he'd stolen the oxygen tank he was sucking down at four liters per minute. The cardiothoracic surgeon passed us in the hall, did a double-take, and downgraded the guy to telemetry status then and there. So I got to hand him off to a tele nurse in time for the 1500 shift change.
My other pt was a frequent flyer of the pleasant variety-- all the dialysis nurses dropped by to say hi as his assigned dialysis nurse took him off peritoneal dialysis for the day. He really got the short end of the health stick. Before he was fifteen, some unknown genetic disease had shredded his kidneys and started in on the rest of his vasculature; after this he received a transplant, which failed, and then had two dialysis fistulas fail, had a series of myocardial infarctions (MIs, generally known as heart attacks), got stents on his stents distal to his other stents, and finally was deemed so sick he needed bypass surgery before the age of forty-five.
I got him the day after the surgeons had gravely informed him that he wasn't eligible for a bypass surgery, because none of the other veins in his body were in good enough shape to use on his heart. Instead, the plan is to attempt yet another stent placement in the morning to relieve his intense chest pain with any exertion. He was pretty vacant, mostly playing mobile games on his ipad and sleeping, and I don't blame him. I think that whether the stent works or not, his next step may be to get evaluated for a donor graft, in which some generous dead person contributes a major vein to keep this guy's heart pumping.
Anyway, he gets peritoneal dialysis now, since conventional dialysis is a much more complicated option for him than it used to be when his veins worked. He essentially gets fluid pumped into his abdominal cavity, where it soaks up pollutants and sucks imbalanced electrolytes out of the blood, after which the fluid is pumped back out and discarded. It makes his blood sugar skyrocket, for reasons I haven't researched (it's not a thing I do, although now I'd like to know why it does that), so he was critical care simply because he needed an insulin drip with hourly blood-sugar checks.
The day was very quiet for him, apart from an ultrasound of the femoral arteries to see if the surgeons would be able to stent him in the morning. We'll see how that turns out.
Finally, after losing the VATS guy, I picked up another pt-- a very young woman in her thirties, a mother of three, whose autoimmune disorder had attacked her liver and caused massive cirrhosis. She was quiet and friendly and polite, but she'd been throwing up blood for three days after running out of Protonix (which she took because she had a history of ulcers), and her blood levels were disastrously low. With a hemoglobin of 4.2 and a hematocrit of 12.8, she was white as a sheet and her blood was watery when I stuck her finger to check her sugar levels.
Worse, her immune issues meant that she was IgA deficient, requiring any blood she received to be carefully washed in the blood center forty-five minutes away... and she had an unusual antibody, which has to be identified at the blood center, and which may severely limit the amount of blood that's available to her. So she was just lying there in bed, too weak and pale to do anything but shift her weight off her left hip (which was killing her because her sciatic nerve has been inflamed since her last pregnancy), waiting for blood to show up.
She wasn't throwing up any blood, so the doctor was hesitant to stick a scope down her throat, lest a scab scrape off and start the bleeding all over again. But if she bleeds again tonight, she'll be getting scoped. I won't find out until morning. I hope she's okay.
Spent a good hour of her admit time on the phone with hospital IT trying to figure out what the fuck was going on with Epic today. Man, hospital IT, talk about a fucking thankless job. If you do everything right, you're completely invisible and nobody cares that you exist; if you change anything you get a furious blizzard of kickback no matter how necessary the change is or how seamlessly it's implemented; if you offer technical support you get snapped at and huffed at and terminally eye-rolled; and even after the person who called is sick of the problem and ready to ditch it and rig a makeshift solution and move on, you have to go back and fix it ANYWAY because there is a REPORT.
Frankly, I'd rather handle poop.
Rachel is doing well today. She keeps having setbacks on her discharge, but she was moved to the big room at the end of the hall, where her panoramic window gives her views of mountains instead of boring downtown glass. She was able to stand up today for a few seconds, but is still incredibly weak and easily made short of breath. Her son visited again the other day, and they wheeled her down in a recliner to meet her daughter in the lobby, so she got to hold both her babies and give them kisses.
The woman who's been bleeding after her liver failure is still bleeding. They put the femoral pressure thing back on her today. She has a huge pressure ulcer on her groin from the fem-stop crushing her constantly, but it's the only way to keep her alive. Her abdomen is increasingly distended and there are worries that she's bleeding into her belly, but we can't drain her with a needle because that's one more place to bleed from. The doctors have been trying desperately to talk her and her family into focusing her care on comfort and family interactions rather than on these continual, painful, brutal, even disfiguring treatments we're doing to her to keep her alive while she turns yellow and exsanguinates.
I wonder how long a blood bank takes to cut you off.
She screams pretty much constantly. Pain medications just don't work for her, because her liver is so fucked. It's very disturbing to staff as well as family and other patients. I don't think I could stand to do CPR on her, knowing that she's Hep C positive, spewing blood everywhere, and fatally ill even if we bring her back from one death. I guess I'll find out soon enough what my moral boundaries there are.
Liver failure is one hell of a way to go.
Week 3 Shift 1
I totally expected to get Crowbarrens back today, but I guess some other poor sucker got that assignment. I heard him yelling as soon as I got on the unit—I CAN’T BREEEEEATHE—but I ended up at the other end of the hall from him.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
One of my pts is a lady with severe COPD from years of smoking. Her burned-out, scarred-up lungs barely open when she tries to breathe, and gross germy crap builds up in all the crevices and now she has pneumonia. Between her baseline COPD (which forces her to wear an oxygen cannula at home) and her plugged-up lungholes, carbon dioxide piled up in her body until her blood became acidic and her brain started to shut down from as a result.
It is actually pretty easy to keep your oxygen levels livable. Oxygen exchange from the little air sacs in the lungs to the blood vessels that snuggle up to them is really efficient, and even depleted air and blood have enough oxygen to keep you going for a little while. The hard part is getting rid of carbon dioxide, which is what actually triggers your breathing impulse—your oxygen level at normal health stays totally steady between breaths, but your CO2 rises and falls as you breathe, and between each breath the CO2 makes your blood more acidic until your brain triggers the next breath. Breathing is your body’s primary method of controlling its acidity, which is why I roll my eyes at fucking “alkaline diets” because a variation of a few tiny points of acid buildup can make you gasp like a carp.
I mean, yeah, you can make your whole body heavily alkaline if you puke/shit/breathe too much acid away. You can make yourself alkaline by hyperventilating. We call it ‘hyperventilating’ and not ‘hyperoxygenating’ because what makes you feel dizzy and sick is not too much oxygen, it’s too little carbon dioxide, and the process of removing poison gasses from an area is called ventilation.
Cancer and other major diseases tend to cause your blood to become acidic. This is because they are expensive for your body to maintain and compensate for. Cancer is hungry (all those cells multiplying out of control) and infections take tons of energy to fight, and when your body starts to get depleted of its energy sources, it’s forced to rely on a backup mechanism of energy production that produces tons of lactic acid. Which, of course, raises the acidity of your body. Making your body alkaline somehow would just mask the symptoms of the acidosis, if you could actually achieve it without your body just adjusting your breathing rate to maintain equilibrium.
At high acidity levels, many of your body’s proteins—that is, the power tools of your body, enzymes that look like molecular wrenches made for specific tasks—are unable to operate properly. Your brain fogs up and your organs start to take damage. Enough carbon dioxide, and you enter a state of narcosis and can’t be awakened.
When this happens because of carbon dioxide retention, we start by improving the ventilation. This usually means pressure-supported breathing, to force open the little air sacs and prevent them from collapsing during expiration, which would trap all that newly-CO2-laden air down in the lung where it can’t escape and be replaced with oxygenated air. Sometimes this means intubation, which allows us to tightly control pressure and volume; sometimes it means a bipap mask, which puffs air at two different pressures during inspiration and expiration, but is uncomfortable as all hell if you aren’t used to it.
So this lady is wearing a bipap mask to clear out her CO2, and is sleepin’ it off. She has restless leg syndrome, and apparently restless-everything syndrome, because at baseline she twitches constantly while sleeping (per her medical record) and let me tell you, she’s in there jerking around so hard her arms and legs keep flopping out of bed. She looks like a cat dreaming about fifty mice in a box.
My other pt I will give you only minimal information about, because they and their family members are likely to sue the hospital. Their radiology reports after a traumatic accident seem not to have been read correctly, and somehow everyone missed a large fracture, which caused them incredible pain for days before someone reviewed the case and discovered the fracture. One major surgery later, they are finally improving, but one of their relatives is an MD specialist and every time I go in the room I get cross-examined about medications, procedures, and test results. They are clearly looking for conflicting information to contribute to their lawsuit, and it is really unpleasant and pointless.
Pointless because when they take this case to court, they have everything they need to make their case—the exact number of times the pt used their pain-medicine button today (Patient-Controlled Analgesia is rad) really doesn’t have much bearing on whether the hospital is liable for the delay of care last week. I can’t give them any of the information they would need for legal purposes, and they have full rights and access to their entire medical record on request anyway. All I’m allowed to tell them is what I’m doing and what I’ve done—not what previous shifts have done, not what the doctors think, not what the full plan of care is—because as a nurse it’s outside my scope.
This is not exactly bolstering my pt’s trust in me as a caregiver. It sucks real bad.
Fortunately the social worker here is an angel clothed in human flesh and she spent about an hour in the room talking to the pt and their family. We are kind of teaming up to help make sure the “little things” get taken care of—parking validations, a chair for the family member on the phone by the hall window, calls to insurance companies and whatever else we can do. We’re not trying to cover up the fact that legal discussion is totally appropriate for their case (if I were them I would be looking for an attorney too), just trying to help them find some dimension of care that they don’t have to feel totally on guard about. This might sound disingenuous, but the fact is: after a bad outcome, the breach in trust between provider and patient can be incredibly detrimental to the pt’s further recovery. There’s a lingering fear that you might recognize from the last time you had to send back a dish at a restaurant: now that I’ve spoken up, even though I was in the right, will the servers spit in my food?
Which means that the little things, the pampering and attention to detail, are especially important for pts who have, or feel that they have, had wrongs done to them. It’s emotionally strenuous to be lying in bed with an awful disease or injury, thinking about how someone dropped the ball and caused you more pain and suffering, and wondering if the other staff will neglect or injure you as soon as you let down your guard. Like, even if you’re fucking crazy and nobody did a damn thing to you, your anxiety is gonna spike out the roof and you’re going to drive your caregivers crazy trying to monitor their every move… which sometimes means you’re cruising WebMD at the hospital because you feel like you need to provide your own care.
And, I mean, that loss of trust is sometimes legit. If somebody lops off the wrong leg or injects your kid with poison, you’re going to be extremely distrustful of medicine in general for a while, and nobody can fucking blame you. But you’re still in that awful helpless position of knowing that you still need medical care, and there’s the rub.
So if your immediate care providers, your nurses and other staff, can win your trust back a little at a time, and give you a little bit of a chance to relax, that’s a big deal. If you get every medication explained, bottomless ice water that never seems to hit empty, advance notice every time anyone touches you, and the question what else can I do for you every time anyone leaves your room, you start to forget that you’re supposed to be on guard, and you get to feel for a little while like someone is genuinely watching out for you again.
Is this time-consuming in the extreme? You fucking goddamn bet. Are you gonna get the Disney treatment if my other pt is on the verge of coding? No fucking way in hell. Am I still going to meet your basic care needs and tell you what’s going on in excruciating detail, even if I don’t have time to fluff your pillows and make caring faces at you? Well fuck, I’m writing all this.
Anyway. The day got better once that connection was made. The family is sleeping now.
A pt down the hall came in crazy—an alcoholic who quit in the ‘90s by switching to speed and who has recently been using lots of PCP. His adult son apparently got a weird phone call earlier today and went by to check on him, found him seizing, and called 911. Earlier this shift the PCP guy woke the hell up on full sedation, self-extubated, kicked his son in the head, bit a nurse, and gave himself a head laceration by beating his face against the side of the bed. The son came staggering down my way, shaken up pretty hard, terrified that his father would die and livid that his father was putting him through this mess again. He shored up at my end of the hallway and told me the whole story of his father’s sad and miserable life, while I charted and let him vent.
I mean, I got a shitty family too. Not angel-dust punch-a-nurse shitty, but shitty enough that I know what that helpless anger and fear feels like, and how useless it is when people try to give you advice or even really react emotionally to the situation (which just makes you feel ashamed of Dear Old Dad again). All I want when I’m venting is for somebody to laugh incredulously at how dumb Dear Old Dad was this time around, and acknowledge that the whole situation is shit but what can you do. I hope it’s the same for this dude. He certainly seemed to feel better after getting it off his chest, and by the time the RT team (plus five adorable duckling students) got his dad re-intubated, he was back on his metaphorical feet.
It sucks, man. The dude looked a little like Chris Pratt with an extra twenty pounds. I could definitely put myself in his shoes and I wish I could fix his dipshit dad for him.
About an hour later somebody called me down to Crowbarrens’s room to “talk to him,” which is both the highest possible praise and the worst possible fate. We had a nice conversation and then I spent about twenty minutes trying to teach his nurse for the day about limit-setting and boundaries. I think I really scared him the other day when I lost my cool at him, though. He was very upset that I wasn’t his nurse (see: unhealthy dependence as patient management tactic) and even more upset when I told him (this is a lie) that I deliberately didn’t take him today because I was really bothered by the way he yelled at his wife, and that if he could earn back my trust I’d be glad to take him as a pt again. He nodded eagerly. No idea whether this will impact his actual behavior in any meaningful way, but wouldn’t it be nice?
He only wants me as his nurse because I made him think that he “earned” my positive regard, and now he fears losing it. This is a shockingly effective tactic with patients who suffer—and make staff suffer—with control issues. I learned it from my mother’s second husband, who was a prison guard for a while, and I have used it with a number of really difficult pts. I feel ethically conflicted about it, but honestly, by the time somebody reaches the point that you have to make them worry about losing your respect so they won’t punch you, they probably aren’t capable of having healthy human relationships.
(This will backfire violently if Crowbarrens actually shapes up, because then I will be his nurse forever in perpetuity until he dies, which will probably be three days before I start collecting social security. Albatrosses live forever.)
Another fun pt story that’s been going on here lately: a woman with a history of ETOH (the polite way to say alcoholism) who is in catastrophic liver failure and keeps bleeding out. She had some transfemoral procedure—I think a liver embolization for a major bleed—and the insertion site at her groin has re-bled five times now. Violently. Spurtingly, even. She has almost no platelets, negligible clotting factors, and hepatic encephalopathy so intense she thinks she’s in Guam being tortured by insurgents (??????). Today she was transferred back from the medical/surgical floor with another rebleed, a softball-sized hematoma in her groin that pulsed like an alien egg sac. I wonder how much longer until the blood bank cuts her off—she’s had something like, what, seventy-five blood products in the space of a month? And she’s end-stage liver failure and an active drinker, so she’s not eligible for a transplant. This will not end well.
On the bright side, all the suction modules in her room will get a nice thorough cleaning, because she spurted blood everywhere in that general vicinity. Nobody goes in that room without every piece of protective gear they can find—she’s also Hep C positive.
Remind me some time to go into the mechanisms of alcoholism and liver failure and how it makes you bleed, especially from the throat and the intestines. I am too tired to keep typing anymore.
Tuesday, July 14, 2015
Week 2 Shift 3
Today I worked at my other facility, where I used to be a full-time night-shift ICU RN and am now working per diem shifts on days. This hospital and I have some bad blood because their method of handling conflict and "incident reports" involves a lot of stewing and poor communication. Like I might be a bitch to that CNA I chewed out, but by fucking god I talked to her about it, and after this I plan to discuss it again after a few more shifts with her (to see if our initial agreements smooth things over) and if necessary seek mediation from a higher-up. ICUs have too much shit going on to let drama grout up the corners.
This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.
Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.
Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.
One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.
Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.
Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”
The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside).
Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies.
While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.
The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.
"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."
I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.
Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.
I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.
Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.
Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.
The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.
A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.
This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.
Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.
Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.
This hospital and I also have some very fond memories, and I still work PRN there because I would miss the staff too badly if I really left. They have some good days.
Just as I have some bad days. Today wasn't, like, incredibly bad, but I did three major embarrassing things, which I will explain to you in due time.
Today I was floated from the ICU (the shift I signed up for) to the SCU, the special care unit (aka telemetry). This is not a problem; SCU is great and the people there are, for the most part, lovely. The level of care is lower, but (in my humble opinion) not low enough that the pt-to-nurse ratio of 4:1 isn't a complete nightmare. SCU nurses work so fucking hard it's ridiculous, and this is coming from a person whose job sometimes involves cramming her whole hand up a fat guy's ass to dig out all the little pellet poops. So a float there is a serious nursing workout with a strong team, and I really enjoy it.
One of my pts had undergone atrial cryoablation yesterday-- his heart wouldn't stop going into rapid atrial fibrillation (I will have many more opportunities to explain this in-depth, so I'll just say "fast irregular heartbeat" for now) so they burned away the angry chunks of nerve inside his heart with a balloon full of liquid helium. Today the plan was for him to discharge home. He had absolutely minimal needs as a pt and honestly there was a space of about an hour where he was asleep after lunch and I forgot about him. His ride home wouldn't be available until after 1700 anyway.
Another pt also had a-fib, which he had gone into because of the stress on his body from pneumonia. He was an absolute dear and his heart rate was well under control by the time I picked him up-- still irregular, but not speeding out of control. His care was unremarkable-- giving meds, giving breathing treatments because the RT was swamped, and charting.
Speaking of charting, the best thing about working at this facility is that we use Soarian, which is probably the third-worst charting system in the medical world. Soarian is made by Siemens—a German company that has its roots in WWII, when parts of its monopoly were shut down for war crimes involving “using concentration camp labor” and “using that labor to make gas chambers.” The point is, there are few things more satisfying when you’re sick of charting than calling your system a “piece of nazi crap made by literal hitlers.”
The third pt (this unit often assigns four, but today I only had three) was a comfort-care pt preparing to go home on hospice, an incredibly unfortunate old lady with a history of stroke that had rendered her aphasic. She was in for a horrific fungal epidural abscess that was not responding well to antifungals, plus a giant left-thigh abscess that left her in tremendous pain. The pt's two daughters were sweet but anxious, struggling to get their brains around the skills and information they would need to bring their mother home to die, not really quite understanding that the hospice nurse would be taking care of most of it. Bonus: a stepsister was also in the picture, but we were not allowed to give out any information to her, nor was she allowed to visit. Apparently she suffered from "being super crazy" and liked to pick screaming fights with the dying woman. This resulted in some tense phone calls with the estranged stepsister, who wanted to come see her mother "before she had a chance to work things out," but who claimed that she couldn't possibly come visit her once she was on hospice (that is, with the daughters both at the bedside).
Pain control was the biggest issue. We needed to get her pain under control, and we had to test out the oral medications (fast-absorbing mouth-dissolving morphine tablets under the tongue) to make sure they worked sufficiently. It ended up being a tremendous parade of too much, too little, too much, not nearly enough. I hope they get it worked out soon, so she can go home before she dies.
While I was applying a lidocaine patch to the area around her abscess, an older woman came in, well-dressed and well-groomed, and was immediately moved to tears by the dying woman's condition. "You've been through so much," she said, and helped me arrange her pillows to accommodate the lidocaine patch application. She watched the process with interest, so I did my usual thing and started educating. I explained that we were applying the patch to give local relief of pain, which would sort of overlap the central relief of pain offered by the morphine and the fentanyl patch, and hopefully give her better pain control.
The woman was looking at me very strangely by this point, and looking confused as hell. Undaunted, I plunged onward in my usual progression: if the student is still confused, use simpler language and more accessible metaphors. "This medicine is like the stuff you put on a toothache to make it go numb," I said, and she cut me off.
"I'm Dr. Novak*," she said. "Her clinic doctor. I'm not wearing my badge right now, but I do know what lidocaine is."
I stammered an apology and turned red to the ears, then remembered to give it a decent spin and managed to flutter on about how, not knowing who she was, I was just instinctively giving her the same education the pt and her family were receiving. She lightened up a bit at that, but I had a few minutes in the supply closet gathering myself back up.
Then at three they had me give up my pts and pick up two actual ICU pts next door, because one of the nurses was going home.
I picked up a developmentally-delayed woman, an ex-Special Olympian who had been coming down with increasingly frequent cases of aspiration pneumonia. The plan is to make her a diverting tracheostomy-- completely separating her esophagus and trachea so she can never choke on food again, and breathes entirely through a stoma-- on Monday. We extubated her at the beginning of my four-hour shift with her, and she was very unhappy about that. Fortunately she was one of the lucky souls who responds well to Precedex, a completely imaginary sedative that usually just serves as a self-extubation in an IV bag, but which occasionally is very soothing and sedating to certain folks. I left her on a little of that and it worked like a charm.
Unfortunately, about an hour after extubation, she had so many oral secretions that we had to nasotracheally suction her: a thin rubbery tube inserted down the nose to suction out the trachea. Try as she might, she just could not swallow the stuff, so she was choking on it. I held her hand and soothed her as best I could while the RT did the job, and stayed there patting her forehead and shushing her for a while afterward... until the RT explained to me that the one thing the pt hated more than anything else was having her head and face touched. Well, fuck. Strike two.
Strike three came when my successor dropped by from SCU and explained that the atrial-ablation lady had been given some kind of weird communication-only discharge orders at noon, and I had just missed them because they were comm orders instead of actual ORDERS. Fortunately I had already done most of the discharge work, and it wasn't quite five yet, so nobody was inconvenienced.
The other ICU pt was entirely unremarkable except that she was convinced that every hospital has "at least one nurse who's killing all their patents." I tried to soothe her fears, but for a moment I felt like that nurse, considering that I'd made so many mistakes today.
A frequent flyer at this facility came back today, a woman who tries to leave AMA (against medical advice) almost every admit, and can only be convinced to finish dialysis by bribing her with pain medications. She has had multiple revisions of her AV fistula (a surgically-created site on the arm where arterial and venous blood come together in a single huge vein that bleeds easily) due to poor care and her general failure to show up at dialysis on time... which causes her to be readmitted to the hospital regularly, because toxins build up in her blood and she calls 911 as she's starting to feel really dangerously sick. She has a grotesque circumferential surface leg wound; the doctors are at a loss, and have suggested several times that she just go for an amputation. She is a sex worker, somehow, even with that reeking leg wound, multiple transmissible diseases, and general appearance of somebody slowly pickling in nitrous waste from the inside out. I don't think she's very happy in that career.
This time she had, again, nearly died of being un-dialyzed. Her leg wound had spread significantly; she'd been totally noncompliant with diabetes care since her discharge, and was really upset because she had shot up in her AV fistula and it wouldn't stop bleeding. They removed her homegrown dressing and instantly the whole room and half the hallway was covered in blood. She got a surgical re-revision of the thing.
Also, the fire alarm went off today. Some old person in Geropsych must have pulled the fire alarm. That is two buildings away so I wouldn't care if it burned to the ground.
Okay. Two more shifts this stretch (Friday's is only an eight-hours). See you on the flip side.
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