This facility starts its weeks on Mondays. So I typically work Fri, Sat, Sun, Mon; have Tues off; work Wed & Thurs; then have seven days off in a row. It's a pretty rad schedule.
Report this morning: one charming lady with restless leg syndrome and chronic GERD, who had come into the ER after the most severe heartburn of her life, only to discover that she was having a STEMI.
The term “heart attack” is kind of tricky. We picture a guy grabbing his chest and keeling over, or if the TV writers are extra clever, maybe the guy has some left shoulder pain and starts sweating. The medics hook the actor up to a monitor and we see a flat line—his heart stopped! OH MY VERY FUCK, WE HAVE TO SHOCK. The nurse and doctor make eyes at each other as they paddle one million kilojoules into the patient’s nipples.
This may shock you: heart attacks on television are not usually accurately portrayed. For one thing, if your heart has stopped, you are generally not gonna have the energy to clutch your chest and manfully pretend that you’re just a little out of breath. Heart attacks—we call them myocardial infarctions because that sounds more professional and cool—may often end with cardiac arrest, but kind of in the same way that digestion ends with pooping.
“Myocardial” breaks down into two words: cardiac, which I’m sure you can figure out, and myo, which just means ‘muscle tissue’. Infarct is not a word we use often in the civilian world, although we fucking should, because it means that something has necrosed from oxygen starvation. “What happened to your boss?” “He has been… infarcted.” So myocardial infarction, MI, means that blood flow to part of the heart has been cut off, and some of the tissue has died.
The surrounding tissue is typically ischemic, which is another great metaphor word that should totally be used to describe shit like traffic jams, social isolation, and wi-fi shortage. Ischemia means that the tissue is being starved for oxygen, but hasn’t actually died yet. So in any MI, there’s usually an area of ischemia that can be rescued if you get blood flow going again.
Ischemia is responsible for the pain. Dead tissue doesn’t feel like anything much, but injured and starving tissue does. If you’ve ever sat on your leg wrong and cut off blood flow to your foot, you know how much that shit hurts. Or if you’ve attempted to run a mile because you heard it’s a good thing to do, and ended up a block and a half later throwing up into your neighbor’s hydrangeas while your diaphragm insists that it’s been stabbed in the dick—which is absolutely not something I would do of course—you know what muscle feels like when it’s pushed past its ability to gather oxygen.
Weirdly enough, biologically female bodies have different symptoms. I’ve heard various rationales for this, ranging from “smaller blood vessels” to “different enervation” to “estrogen causes clotting changes” to “uhhhh lady parts are weird.” Fact is, if you were born with a vagina, chances are good your heart attack will feel more like back pain, indigestion, fatigue, and shortness of breath than the “classic” heart attack. (This scares me, because I don’t know about you ladies, but I just call that Wednesday evening.)
I would like to see some more research done on heart disease and MI symptoms in FTM transgendered people undergoing testosterone therapy, by the way. I feel like we could learn a hell of a lot about the effect of androgens on the cardiovascular system.
But I digress. The area of ischemia and infarction is really important. If there’s just ischemia, no infarct, you get angina—transient (or not so transient) chest pain that isn’t a heart attack, but should warn you that you’re in danger. If there is infarct, but only some unimportant corner of your heart muscle dies, you can still have some nasty side effects (any dead tissue, for instance, is at risk of rupturing), but you’ll probably be okay except for the loss of heart flexibility and contraction power.
If you have a chunk of dead heart in the middle of a crucial conduction path or an area responsible for a lot of fluid-pushing, you are in serious, serious shit. The bigger the MI, the more likely you are to kill off a really critical section of your heart, and the more vital it is that you get the clots dug out of your heart , like, stat.
One of the ways we tell the gravity of the dead-heart-chunk situation is by classifying MIs as NSTE-MIs or STE-MIs. A Non ST Elevation MI typically has an area, the ST segment, in the EKG—the wavy line that represents electrical activity in the heart—that is depressed, rather than elevated. The depressed line tells us that the electricity is moving slower in that area of the heart, because the cells are stressed out and can’t exchange ions quickly (remember how some ions, like potassium, belong inside the cell, where they provide electrical impulse?). If the cells die, however, they stop being machines and become dead lumps of cell-wreckage, with ions floating around their battered husks freely. And this means that transmission of electrical impulses through that area is extremely fast, because nothing is regulating the flow, because everything is dead and therefore isn’t accessing (or even delaying) that electrical signal before it’s passed on to the next glob of cells.
This is expressed on the EKG as an area of ST elevation. An ST Elevation MI is bad, bad news, and requires immediate intervention and clotbusting. An NSTEMI can often be medically managed for a while with oxygen and anti-clotting medications and vasodilators to increase blood flow, allowing the body a chance to fix its shit without having holes punched in it. A STEMI is do or die—punch a hole in the pt’s crotch, jam a long tube up their femoral artery and aorta into their heart, dig out the clot, and put in a stent to hold the chewed-up cardiac artery open before any more heart-chunks die.
The weird thing is that, after a cardiac cath procedure, pts often don’t realize how big of a deal this is. They were moderately sedated during the procedure, and there wasn’t a lot of visible cutting, and their chest pain is all better and they’re annoyed because they have to keep their leg perfectly straight while their femoral artery heals for a few hours. All the cousins visit and bring flowers and See’s Candies. They’ll be headed home tomorrow or the day after, gotta pick up a few new prescriptions on the way, remember to call 911 for chest pain or shortness of breath, back on their feet in time to make that baseball game on Friday. It’s not like they were dying.
And yet… they did almost die. Twenty years or so ago, before we had cardiac catheterization as an option, people keeled over and died all the damn time, and even if they made it to the hospital there wasn’t a thing we could do. STEMI or NSTEMI, we dumped medications into them and crossed our fingers that enough heart muscle would survive to keep them going. They would lie in hospital beds, pale and sweating and gasping for breath, gagging on ten-out-of-ten crushing chest pain, until the MI had run its course and they could either go home and wait to die slowly of heart failure, or half their heart turned black and gooey and they died. For days.
Modern medicine is nothing short of a fucking miracle.
Anyway. All that was to say: this pt was absolutely just fine, headed for home by noon the next day, eating and walking around. She was a good pairing for the other pt I picked up.
My other pt was incredibly sick. He had been some kind of college athlete once upon a time, headed for the big leagues, scouts bothering him while he and his brand-new wife tried to move into their brand-new home. Then he was diagnosed with non-Hodgkins lymphoma, dosed with chemo, nuked with radiation, sliced open to remove his spleen, and finally proclaimed cancer-free. He played his sport the entire time, but after college his health—while fairly acceptable— wouldn’t permit professional athleticism. He still holds several records at his prestigious university.
Fast-forward a couple of decades and a couple dozen hospital stays. The radiation tore him up. His esophagus was burned and scarred, and where his spleen had been removed to stop the spread of lymphoma, he now has a hiatal hernia—a weak spot in his diaphragm—and his stomach has adhered to his belly wall. He’s had a couple of heart attacks, as his coronary arteries were so damaged by the radiation that they’re all scarred up and tear and clot easily. And recently, he started coughing up blood.
A biopsy revealed adenocarcinoma—cancer, from the radiation that once cured him of cancer. His left lung was eaten up with it.
About a week ago, he had surgery to remove the cancer. They ended up removing his entire left lung and pieces of the pericardium, the fluid sac around the heart. The tumor had grown to wrap around the pulmonary artery, which made the procedure a terrifying ordeal—a millimeter off, and the pt would exsanguinate like the Black Knight. While they were removing his lung, he suffered another MI intraoperatively, and because of the severity of the surgery and the danger of fucking up his precariously snipped-and-scraped pulmonary artery, they weren’t able to perform a cardiac cath for three days.
It was a STEMI. The right side of his heart, the side that pumps blood into the lungs (or, in his case, lung), has lost some of its function permanently.
But after the cath, he started to come around. He was extubated, and managed to talk and sit up in a chair and even have a few sips of water, although his esophageal scarring had acted up again and he had developed stenosis—narrowing—which prevented him from eating.
A few days later, he vomited. He inhaled the vomit. Things went downhill from there.
A lot of people who vomit while already weak or ill accidentally inhale it. This is incredibly bad for the lungs and can cause severe pneumonia, both from the germ content of the gut juices and from the irritation of stomach acid in the lung’s air sacs. For him, the combination of slow gut movement (after anesthesia and opioid administration, a very common effect), esophageal scarring, and adhesion of the stomach caused vomiting, and his body’s weakness combined with his scarred-up throat kept him from protecting his airway. Within twelve hours, he was reintubated.
Attempts to give him a feeding tube failed. Even in Interventional Radiology, where live-action xray imaging is used to do delicate internal work, the tube wouldn’t go the right way. Important medications, like the Plavix he takes to keep his cardiac stents open, went unadministered; other drugs, like heparin, provided some protection but still left him at uncomfortably high risk. His depression medication levels lagged.
I picked him up, noted that he was pouring gross green-gray chunky secretions from his remaining lung, and alerted the pulmonologist. I’ve seen pts cough up some outrageous things, but this looked like some kind of dead flesh liquefaction business, and smelled like fish sauce. The pulmonologist grabbed a bronchoscope and a respiratory tech, and we did a bedside swish-and-slurp of his airway, sending the results off to be examined by the lab.
There really wasn’t much down there, reported the pulmonologist, just a big chunk of sticky gray shit—which came up through suction in pieces, a chunk maybe the size of a cherry pit all told, reeking like an Icelandic delicacy—and a lot of very irritated lung tissue. We did a chest x-ray, and revealed patchy white spots that indicated fluid buildup in the lungs. The pulmonologist suspected pulmonary edema, and ordered a diuretic to see if that helped his lungs clear out… but I suspected something grimmer.
Pulmonary edema—backed-up fluid in the lung tissues—typically happens because the left side of the heart is sick and can’t pump fluid away from the lungs effectively. It’s not uncommon after a left-sided MI. But this guy had a right-sided MI, so if there was a fluid back-up issue from the heart, it should be backing up into the tissues themselves, not into the lungs.
There is another condition that looks like pulmonary edema, and is, in a way, fluid swelling in the lungs. It’s called ARDS—acute respiratory distress syndrome—and instead of fluid pooling in the air sacs, the lung tissues themselves become inflamed and brittle and start to weep. The cardboard-stiff tissues are too swollen to allow blood to flow easily, and fluid backs up into the right side of the heart, blowing it up like a balloon, and causing atrial fibrillation as the nerve fibers stretch apart and start panicking and firing at random intervals.
ARDS is not a thing you want to have with only one lung.
By midmorning we performed another bronchoscopy, this one attempting to advance his breathing tube past the split between his airway branch, the place where the left and right mainstem bronchi split, called the carina. If we could get the inflatable balloon cuff down into the right mainstem, totally cutting off the left, we could increase his PEEP, forcing some of the fluid back into his circulatory system and protecting his air sacs (alveoli) from boogering shut. (Increasing the air pressure against a freshly sewn-up bronchial tube is a bad thing, and can cause rupture, which is basically the worst.)
In the end, we weren’t able to get the cuff secured in the right mainstem, and he continued to struggle to oxygenate and ventilate. Finally, in fear and trembling, we raised his PEEP juuuust a little bit.
And what do you know, he improved! Finally a fucking break for this guy.
He was improved enough that the GI doc felt safe doing a bedside EGD to try and place a PEG tube for feedings. Unfortunately, between his hiatal hernia (stomach not where it should be), his esophageal stricture, and the adhesions, the only place that was available to stick a tube through would have gone through the wall where all the arteries are. You can imagine how excited we were at the prospect of blindly cutting into a forest of arteries on this guy. Instead, the GI doc fed a small-bore feeding tube along the scope, and just like that we had access for his pills again. Not a moment too soon—his anxiety when he woke up was out the roof. I ended up grinding a Xanax into powder and flushing that down his feeding tube.
Oh yeah—this guy is poorly sedated. We have him on a shitload of fentanyl for pain, but his hospital course has been long and ugly, and opioids don’t work as well for him as they used to. We’re also using precedex, a newer sedative that’s not supposed to contribute to delirium or cause hypotension, but which the average ICU nurse will tell you is almost as effective as plain saline at sedating a really agitated pt. I asked if we could start him on some propofol, and got some bullshit about the danger of prolonging his QT interval—the time it takes his heart to repolarize and be ready for the next beat—even though we have him on a kajillion other QT-prolonging meds. I just bolus him a huge dose of fentanyl every time I plan to do anything to him, and dosing him with all the grudgingly-metered benzos and low-level pain control meds (tylenol, toradol) I can scare up by jumping out at doctors from behind the printer.
His nausea issues have been a fucking thorn in my side. With his guts all backed up, he can totally puke around the breathing tube, although his airway will be protected… but a newish surgical incision is not a fun thing to strain against while you’re vomiting. Also, I am not a fan of all the pressure jackery that comes along with dry heaving, especially with that left mainstem all delicate. I’ve been giving him a ball-ton of Zofran, which usually helps with the nausea… but it’s not doing a lot. The docs have me giving him scheduled Reglan, which stimulates gastric movement and reduces nausea, but it doesn’t seem to be very helpful, and has the potential to interact with his SSRI (as would any of the stronger anti-nausea meds). I’m giving him some truly thorough oral care, for the most part, and trying to avoid stimulating his gag reflex any more than I have to.
In the midst of all this, I traded pts at 1500 during afternoon shift change. Somebody else got my lovely STEMI lady, and I picked up a complete train wreck of a family whose grandfather has been treated uselessly for glioblastoma, a brain tumor that has negligible survival rates. They’ve put him through everything anyway—chemo, gamma knife, you name it. He’s slowly losing control of his body. His family is of mixed faith, mostly Farsi speaking, and the faith conflict has been… incredibly tricky. As a result, he’s just lying in the ICU slowly choking on his secretions while the family fusses about him, providing tons of supportive care and love and also fucking with all his equipment and doing batshit crazy things like stuffing his oxygen mask straps with tissue paper to keep the loose elastic from irritating his face. All the air whooshes out over his forehead and he starts gasping, so they plug the edges of the mask with more tissue paper. I walked in there about 1700 and thought that poor fucker had been mummified. They had also poured medicated antifungal powder all over his body, patting it into his thick pelt of body hair until he looked like some kind of gigantic Versailles pompadour or a guinea pig making a nest in a brick of cocaine.
At one point I walked in and found three of them crowded at the foot of the bed, fighting with each other about God and about whose caregiving was the best as they clipped and filed his toenails, which were grisly. I backed out of the room and left them to it.
Their behavior is just fucking bizarre. They fight and snivel and guilt-trip each other and assume martyred postures and heave endless rubbery sighs as they make up new and ever-more-intrusive ways to take care of their grandfather, who looks more and more uncomfortable as they tape towels to his hands and smear vaseline in his eyebrows and fiddle with his foley catheter so that it pulls against this side, then the other side, then this side again, of his urethra.
Apparently a number of nurses have fired them. I am well-accustomed to families from that part of the world being very involved in pt care, distrustful of American doctors, and deeply invested in the possibility of their family member recovering even when chances are slim. That can be challenging, because American medicine is not really set up to accommodate that spectrum of cultural needs, and anybody who’s worked in a hospital can tell you that pts with a thick accent are more likely overall to have their questions and requests ignored. But it’s not really something to fire a pt for—it’s something to learn a new cultural language for.
This is totally different. These people are an unhealthy family of whackjobs with irreconcilable differences who are held together entirely by the tenuous glue of their grandfather’s chronic illness, which they use against each other as a weapon, struggling to maintain control of his condition by being the most caretaker at any given point. His body is a family battleground. Thank goodness he’s mostly zonked and doesn’t have to be awake for this bullshit.
Abd guy has been making tenuous progress. His abdomen is mostly closed except for a wound vac, and he was able to wake up during my camping trip and follow commands. As far as I can tell, nobody has checked him for methanol intoxication yet. I floated a hint to his nurse, although I’m not sure at this point it will make much of a difference. His anion gap acidosis rages unchecked. I’m impressed that he’s alive, let alone progressing; his necrotizing pancreatitis is severe. I’m not exactly holding out a lot of hope for him, but who knows?
If I had to choose only one of them to survive, I'd rather see my pneumonectomy guy live than my abd pt, which makes me feel a little guilty. They both seem like nice people, but the abd guy is a single dude with a distant family—still ignorant of his condition, none of them in contact yet—and a crippling chronic addiction problem that will make his recovery process hell for him, while the pneumo guy is just an unlucky dude who got cancer as a young adult and who has kids and a wife who will be devastated when he’s gone.
But hey, if I could choose who lives or dies, I’d throw Crowbarrens out a window and chuck his wife after him and let both of these guys live. I would be a dread god of capricious benevolence.
Crowbarrens isn’t back yet, and every day he stays gone, I’m a little more antsy. I can’t believe we sent him home last time with his wife—did I mention this? She brought him in on a Friday because all their daytime home health nurses were taking the weekend off and his wife, who performs all care for him at night and while the caretakers are gone, called the police and said that if she had to spend the weekend with him she would murder him and then kill herself. She spent the weekend on our psych unit and he spent the weekend on our ICU. AND THEN WE SENT HIM HOME WITH HER. That will go over really, really well if she actually does murder him. Or if there’s a welfare check and he tells the police what she said last time. Or, basically, if anything happens to him at all, we are getting reamed like half a lemon by Adult Protective Services.
I cornered my manager and delivered a frothy screed about risk management and liability and the extent to which I do not want to lose my job because the ICU got sued down to the baseboards and is now too poor for indoor plumbing. His eyes bugged out a little bit. I think this is the first time he’s seen me in warpaint. It’s good for him, probably. I hope he doesn’t start dodging me behind corners.
Three days on, then one day off, then two more days on. Then I go camping again, because I have a Problem.
God, I hope this one lives. He probably won’t, but I hope he does.
Monday, July 20, 2015
Sunday, July 19, 2015
Week ???? Shift ???????????
Some things I forgot to mention last time:
At 1100, shortly after I received the abdomen pt, I called up the charge nurse and politely requested to have him made 1:1. I don't ask for this often, and pride myself on my ability to balance multiple high-acuity pts safely. But part of this ability involves my recognition of when the load is too heavy for safety-- anyone can pretend they have things under control right up until a pt codes-- and when I realized this pt had hourly insulin checks, constant potassium replacements from an electrolyte replacement protocol (the intensivist declined to start a potassium-containing IV fluid despite refractory K+ levels below 2.8, the cutoff point below which the heart starts to starve and freak out, on the grounds that his renal failure would cause his K+ to skyrocket eventually), q2h labs, and 200mL+ output every hour from his NG tube (thus the potassium loss: stomach juices contain a lot of K+)... I had also just started levophed to pull his blood pressure up, couldn't find peripheral pulses in his feet, and was calling the RT in frequently to handle his ventilator-bucking. Yeah, at this point I decided he wasn’t going to be compatible with the high-need lady next door on bipap, no matter how clean she was now.
I was pretty sure he’d code by mid-afternoon.
The charge nurse came in, looked around, and agreed with me. So after 1100 he was 1:1. This came in really handy when the GI surgeon took him down for that washout.
So for the next couple of days, he wore me out. His open abdomen wept constantly through the drains in the intestine-containment bag, and every thirty minutes he required a full dressing change just to control the flow. His insulin infusion had to be cranked up from one algorithm to the next, as higher and higher doses failed to control his wild hyperglycemia. Worse, as I finally caught up on his blood sugars the next morning, his anion gap stayed wide open—the acidosis continued, and although his potassium finally caught up and began to rise as his small bowel obstruction stopped backing four liters of stomach juices out of his NG tube every day, the problem was clearly not a sugar/insulin imbalance.
Anion gap acidosis has a number of possible sources, although insulin deficiency is probably the most common. A few of them were addressed in that nephrologist’s note I quoted the other day. Another occurred to me during my camping trip this weekend, as I was studying for the CCRN test I took today (AND FUCKING PASSED YESSSS I AM A CCRN NOW). This guy is an alcoholic, and had been sick for a little while, homebound. What if he got into some alcohol that wasn’t drinkable? Specifically, methanol? It would explain some other major things, like the encephalopathy and his eventual failure to maintain pupillary reflexes.
Man I got no idea. I haven’t actually taken care of a pt with methanol poisoning, so all my knowledge is book knowledge. Methanol, aka wood alcohol, is an alcohol much like ethanol (booze), except that it turns into formic acid in your body, destroys your eyesight permanently, causes brain swelling, and tends to result in horrible death. I’ll have to look that up when I get back to work on Saturday.
Anyway. He stayed very high-acuity for the next few days; I was 1:1 with him the next day, and the day after that I was first admit, but ended up not admitting because the only person who came up from the ER was a telemetry overflow. He was one of those pts who isn’t panic-level crazy, but whose workload nurses describe to each other as “steady.” Basically, there’s something to do at least once every ten minutes, some of these things taking as long as twenty or thirty minutes and requiring multiple RNs or the help of a CNA, and you spend very little time charting because you’re constantly scanning medications or taking blood sugars or turning or changing dressings or titrating drips.
In this case, about halfway through the second day, the intensivist ordered lactulose enemas to be given every four hours, in hopes of stimulating his bowel to move. I took extreme issue with this because I could SEE the guy’s intestines and they were obviously too swollen to twitch, let alone move stool effectively, but considering that his colon was relatively un-irritated per report of the GI surgeon and the enemas were only about 250mL volume (we often give 1L-2L enemas!), I figured it couldn’t hurt. And sure enough, after the second enema he dumped a decent handful of mucoid stool, although his small intestines were obviously still not moving.
How did we administer these enemas? The traditional way involves turning your pt on their left side, sticking a tube up their rectum, and draining a bag of fluid into their butt to get the shitslide cookin’. Turning this guy onto his left side would have been… tricky, so instead I pulled the rubber tube off the business end of a foley catheter, lubed it up a bit, jammed it up his butt via the “lift balls, grope for anus” method, and inflated the balloon with a syringe of saline. Then I mixed up the enema, drew it up into a giant Toomey syringe of the kind we use to instill fluids into a GI tube (it holds about 60mL at a time), and flushed it all through the rubber hose into his colon. Between flushes I clamped it off with a large hemostat, the kind we use to clamp chest tubes shut. An hour or two later he dumped the full enema, still clear, into the bed. Time to start over.
Turning was tricky. Any time we moved him, he would grimace and his blood pressure would skyrocket—even though he was heavily sedated and receiving a pain med drip, he was clearly having a lot of breakthrough pain. His blood pressure tended to run dangerously low whenever he wasn’t in pain, though. So I would dose him with a huge bolus of fentanyl, wait about two minutes for it to kick in, watch his blood pressure start to bomb (watching in real time through an arterial line), and then do all the turning and washing and dressing changing and whatnot.
Ventilated pts also get their teeth brushed or their mouths swabbed and suctioned once every two hours, usually right before we turn them so there isn’t a drool river when we’re moving them around every two hours.
The whole time, we were hunting desperately for someone to make decisions on his behalf: a family member, a designated power of attorney, anybody. His kidneys weren’t pulling out of their tailspin, and the buildup of nitrogenous wastes in his body wasn’t doing him any favors. Before we made the huge step of initiating dialysis, though, knowing that this would be a long healing process with a huge amount of involved and intensive care, it would have been really nice to know if he’d have wanted it.
This being a weekend, and this fellow being a member of a specific healthcare group that has its own social workers and discharge nurses that aren’t available on weekends for whatever goddamn reason, I found myself doing most of the work of contact hunting. I called his job and, without being able to give them any details over the phone, asked if he had any next-of-kin numbers. None of them worked. I called his home phone, got his roommate, learned that he had a daughter he had only ever referred to as “my daughter;” received a phone call from a coworker of his who had heard he was out sick, and found out that he has a landlady who “might know somebody;” called the landlady and learned that he had family somewhere in a Middle Eastern country “who don’t speak any English and I don’t know their names;” and was finally suggested to contact a religious leader of his community, who might have access to lineage papers.
By the time I got to that point, it was Monday morning, and the social workers were back on the job. So I spent about an hour pushing them over the phone, giving them a full report of everything I’d done to seek contact, and signed off on his “call the family” duties.
Meanwhile, down the hallway, the drowned kid circled the drain for days. His lungs were torn to shreds by the lake water; his anoxic brain injury caused him to start seizing for hours at a time; his mother went completely insane before my eyes and descended from “horrified and grieving mother” to “crazy woman in filthy clothing laugh-sobbing in the end of the hallway all day and all night.” God, we all felt terrible for her. She threw a shoe at the palliative care people when they came by.
He went into a rotoprone bed, as I think I said before, and coded in it. A rotoprone bed is no minor thing in ICU practice. It’s like a huge padded coffin/cradle into which a pt can be packed, then wrapped tightly in cushions and panels and straps, then rotated until their face is hanging downward so their lungs can drain. Once they’re proned, we open the back of the bed and let them lie there, gently swinging back and forth with their belly facing the floor, letting their lungs stretch and drain and slowly recover. It’s very effective when used early, and was originally marketed for H1N1 support, since young pts who survived the initial respiratory catastrophe of that strain would recover easily enough in a week or two.
Now we use it for ARDS, acute respiratory distress syndrome, which can happen for many reasons ranging from pneumonia to aspiration to pancreatitis. In ARDS, the lungs become so inflamed that their tissues turn thin and stiff, they can’t exchange gas well, fluids weep into the air sacs, and even the blood vessels lose their pliancy and become hard and resistant to blood flow.
We use a lot of things to treat ARDS. Paralytics can help reduce the pt’s inclination to fight the ventilator, and minimize their oxygen usage; Flolan (epoprostenol) is a ruinously expensive inhaled medication that dilates the blood vessels of the lungs to allow improved blood flow; chest physiotherapy can sometimes be used to help break up secretions and move fluids around; and, of course, antibiotics and steroids and protective settings on the ventilator to prevent lung damage. And PEEP.
Remember how a bipap mask adds a kick of pressurized air at the end of the breathing cycle to keep the airways (large and small) open? PEEP (positive end-expiratory pressure) is similar to that. Cranking up the pressure helps force fluid back into the veins, keeps the air sacs open, and increases the pressure gradient of air vs blood so that air exchanges more effectively across the membranes. Usually ventilation (CO2 shedding) is harder than oxygenation, but in ARDS pts often have oxygenation just as bad as their ventilation.
I’ve seen ARDS fought effectively. I cared for a pt once who was very young, got a nasty pneumonia, spent days and days in the rotoprone bed, and was eventually transferred to the local children’s hospital to receive ECMO—extracorporeal membranous oxygenation, in which blood is drained from the body, oxygenated through a membrane, and pumped back into the body constantly. She ended up doing well, and sent us a letter about a year later to let us know that she had not only survived, she had recovered enough to walk across the stage at her graduation.
The drowned kid will not be so lucky. Even if his lungs manage to recover from the lake water problem, his brain is completely fucked from the continued hypoxia. We are, essentially, buying the family time to say goodbye.
Which is a victory, sometimes. If we define death as failure and any kind of life as success, then pretty soon our successes are often hollow—we have quite a few pts who end up suffering for a very long time and being shipped back and forth between the hospital and a long-term acute care facility—and our failures are nearly constant.
You have to look for other definitions of success and failure, here. Sometimes our victories are good deaths. Sometimes we work our asses off day and night to make sure a pt is comfortable as they’re dying. Sometimes we finally manage to talk the family into letting go; sometimes we struggle to win them the few days they need to come to terms with their loss. Sometimes we squeeze enough time to let the plane land and the taxi speed from the airport, so that the kids can be there when their father dies. Sometimes we wash our hands of a code and catch our breaths, and the corpse cools in the room while we go back over the entire crisis and realize that we did everything right and they died anyway. But it’s still a victory, just as all these others are victories: we did everything right.
But they died anyway.
And sometimes we practice our skills on a pt who has made every possible bad choice and is dying of their bad choices, knowing that our care is futile and the resources we spend are wasted, but knowing that when the next pt comes in needing that unusual procedure, we will be that much fresher in our practice. That’s a victory, if you squint.
And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.
Which is to say: when the drowned kid died, my last day before I went on that huge long camping trip and didn’t post for a while, we were all devastated. His mother cried like an animal, gagging and groaning and clawing at her arms, and we all twisted our mouths and ground our teeth and remembered that we were people and wished we weren’t.
Rachel went home again. Her younger child’s birthday is coming up.
That same day, the last day before camping, I sent my open abd guy down to have his belly incision revised. They will slowly close it until at last his intestines are all contained, giving him time for the swelling to diminish between each revision. Then, because he wasn’t expected back up before my end of shift, I took two more pts: a comfort care pt in his thirties with Huntington’s, who was starting to lose his ability to swallow his secretions and was choosing to go home to die rather than move forward with a tracheostomy, and an older fellow with severe hearing loss who had come in for a very mild GI bleed from an ulcer in his stomach.
The comfort care pt’s case was relentlessly sad. His young wife is pregnant; he is not expected to live to see the child. He declined to make a video for the baby, saying that he didn’t want his son to see him like this. His family are rollicking good-ol-boy country folk, and they all sat in his room picking on him affectionately and watching Pawn Stars. They were delightful; they had faced this monster directly, and chosen not to be destroyed by its inevitable rampage, and as a result they were wonderfully supportive and caring. They helped move his cramped arms and roll him gently when he needed to be repositioned; they joked that his stubble “looked like wanderin’ pubes.” They ate five boxes of Fruit Roll-Ups in the room (making me crave Fruit Roll-Ups), and tirelessly suctioned his mouth with a soft plastic tube so he wouldn’t choke.
We tried out atropine drops to dry up his mouth, and they worked fairly well, although he still needed some suctioning from time to time. He was just waiting for the hospice group to pick him up in the morning and bring him home, where he can spend the rest of his life in comfort, surrounded by family. He got the shittest deal on the table, but I think he’s choosing the best possible option with it.
The GI bleed old guy told me about gladiator diets (beans and porridge, with burned plants to provide magnesium?) and house paint (never just use flat white, it looks too bare!) and nail storage (lots of yogurt containers!). He was advanced from a clear liquid diet to a full liquid diet, and delighted in his tray of four different kinds of soup instead of “all that sweet stuff they’ve been trying to trick me into eating.” He called me darlin’ and ma’am and Nurse Elise. He was an absolute doll and I wish all my pts were like him. Plan was to send him home the next day.
The next day I left for my camping trip, and haven’t been back to work yet. The trip was wonderful—I moved into a hammock by Lake Crescent, out on the peninsula, one of the prettiest places I’ve ever camped—and then I came home, finished my studying, took my CCRN exam, slept for a full day, and went to Cardiology Summer School today (first of three Fridays spread throughout the summer, lectures by a popular nurse educator in the area). Tomorrow, I go back to work.
I did stop by and check on my open abd guy. He is still alive and seems to be doing well, though the dialysis nurse was in his room setting up shop when I poked my head in. I didn’t see his abdomen, though. Maybe it’s closed by now. I will check his chart tomorrow and see what all has been going on while I was eating hot dogs and smores at the lake.
And I had my ninety-day review at this facility (I worked there for three months as a traveler before hiring on full time). My manager said there have been absolutely no complaints about me, which makes me pretty giddy, but added that the charge nurses were surprised by how easily I fell asleep on my nap breaks and how often I spend my breaks napping.
I really don’t know what to say to that. I’m fucking exhausted all the time at work and I sleep like a dead rock every chance I get. I just kind of stammered something about being ex-night-shift and wandered away. I thought break naps were one of the crucial characteristics of the nursing profession in general? Maybe I’m just lazy. That is a very real possibility.
I wonder if I’ll get my abd guy back tomorrow. I guess I should head to bed soon, since I have to be up in six hours. Shit, I think I figured out why I nap on all my breaks.
At 1100, shortly after I received the abdomen pt, I called up the charge nurse and politely requested to have him made 1:1. I don't ask for this often, and pride myself on my ability to balance multiple high-acuity pts safely. But part of this ability involves my recognition of when the load is too heavy for safety-- anyone can pretend they have things under control right up until a pt codes-- and when I realized this pt had hourly insulin checks, constant potassium replacements from an electrolyte replacement protocol (the intensivist declined to start a potassium-containing IV fluid despite refractory K+ levels below 2.8, the cutoff point below which the heart starts to starve and freak out, on the grounds that his renal failure would cause his K+ to skyrocket eventually), q2h labs, and 200mL+ output every hour from his NG tube (thus the potassium loss: stomach juices contain a lot of K+)... I had also just started levophed to pull his blood pressure up, couldn't find peripheral pulses in his feet, and was calling the RT in frequently to handle his ventilator-bucking. Yeah, at this point I decided he wasn’t going to be compatible with the high-need lady next door on bipap, no matter how clean she was now.
I was pretty sure he’d code by mid-afternoon.
The charge nurse came in, looked around, and agreed with me. So after 1100 he was 1:1. This came in really handy when the GI surgeon took him down for that washout.
So for the next couple of days, he wore me out. His open abdomen wept constantly through the drains in the intestine-containment bag, and every thirty minutes he required a full dressing change just to control the flow. His insulin infusion had to be cranked up from one algorithm to the next, as higher and higher doses failed to control his wild hyperglycemia. Worse, as I finally caught up on his blood sugars the next morning, his anion gap stayed wide open—the acidosis continued, and although his potassium finally caught up and began to rise as his small bowel obstruction stopped backing four liters of stomach juices out of his NG tube every day, the problem was clearly not a sugar/insulin imbalance.
Anion gap acidosis has a number of possible sources, although insulin deficiency is probably the most common. A few of them were addressed in that nephrologist’s note I quoted the other day. Another occurred to me during my camping trip this weekend, as I was studying for the CCRN test I took today (AND FUCKING PASSED YESSSS I AM A CCRN NOW). This guy is an alcoholic, and had been sick for a little while, homebound. What if he got into some alcohol that wasn’t drinkable? Specifically, methanol? It would explain some other major things, like the encephalopathy and his eventual failure to maintain pupillary reflexes.
Man I got no idea. I haven’t actually taken care of a pt with methanol poisoning, so all my knowledge is book knowledge. Methanol, aka wood alcohol, is an alcohol much like ethanol (booze), except that it turns into formic acid in your body, destroys your eyesight permanently, causes brain swelling, and tends to result in horrible death. I’ll have to look that up when I get back to work on Saturday.
Anyway. He stayed very high-acuity for the next few days; I was 1:1 with him the next day, and the day after that I was first admit, but ended up not admitting because the only person who came up from the ER was a telemetry overflow. He was one of those pts who isn’t panic-level crazy, but whose workload nurses describe to each other as “steady.” Basically, there’s something to do at least once every ten minutes, some of these things taking as long as twenty or thirty minutes and requiring multiple RNs or the help of a CNA, and you spend very little time charting because you’re constantly scanning medications or taking blood sugars or turning or changing dressings or titrating drips.
In this case, about halfway through the second day, the intensivist ordered lactulose enemas to be given every four hours, in hopes of stimulating his bowel to move. I took extreme issue with this because I could SEE the guy’s intestines and they were obviously too swollen to twitch, let alone move stool effectively, but considering that his colon was relatively un-irritated per report of the GI surgeon and the enemas were only about 250mL volume (we often give 1L-2L enemas!), I figured it couldn’t hurt. And sure enough, after the second enema he dumped a decent handful of mucoid stool, although his small intestines were obviously still not moving.
How did we administer these enemas? The traditional way involves turning your pt on their left side, sticking a tube up their rectum, and draining a bag of fluid into their butt to get the shitslide cookin’. Turning this guy onto his left side would have been… tricky, so instead I pulled the rubber tube off the business end of a foley catheter, lubed it up a bit, jammed it up his butt via the “lift balls, grope for anus” method, and inflated the balloon with a syringe of saline. Then I mixed up the enema, drew it up into a giant Toomey syringe of the kind we use to instill fluids into a GI tube (it holds about 60mL at a time), and flushed it all through the rubber hose into his colon. Between flushes I clamped it off with a large hemostat, the kind we use to clamp chest tubes shut. An hour or two later he dumped the full enema, still clear, into the bed. Time to start over.
Turning was tricky. Any time we moved him, he would grimace and his blood pressure would skyrocket—even though he was heavily sedated and receiving a pain med drip, he was clearly having a lot of breakthrough pain. His blood pressure tended to run dangerously low whenever he wasn’t in pain, though. So I would dose him with a huge bolus of fentanyl, wait about two minutes for it to kick in, watch his blood pressure start to bomb (watching in real time through an arterial line), and then do all the turning and washing and dressing changing and whatnot.
Ventilated pts also get their teeth brushed or their mouths swabbed and suctioned once every two hours, usually right before we turn them so there isn’t a drool river when we’re moving them around every two hours.
The whole time, we were hunting desperately for someone to make decisions on his behalf: a family member, a designated power of attorney, anybody. His kidneys weren’t pulling out of their tailspin, and the buildup of nitrogenous wastes in his body wasn’t doing him any favors. Before we made the huge step of initiating dialysis, though, knowing that this would be a long healing process with a huge amount of involved and intensive care, it would have been really nice to know if he’d have wanted it.
This being a weekend, and this fellow being a member of a specific healthcare group that has its own social workers and discharge nurses that aren’t available on weekends for whatever goddamn reason, I found myself doing most of the work of contact hunting. I called his job and, without being able to give them any details over the phone, asked if he had any next-of-kin numbers. None of them worked. I called his home phone, got his roommate, learned that he had a daughter he had only ever referred to as “my daughter;” received a phone call from a coworker of his who had heard he was out sick, and found out that he has a landlady who “might know somebody;” called the landlady and learned that he had family somewhere in a Middle Eastern country “who don’t speak any English and I don’t know their names;” and was finally suggested to contact a religious leader of his community, who might have access to lineage papers.
By the time I got to that point, it was Monday morning, and the social workers were back on the job. So I spent about an hour pushing them over the phone, giving them a full report of everything I’d done to seek contact, and signed off on his “call the family” duties.
Meanwhile, down the hallway, the drowned kid circled the drain for days. His lungs were torn to shreds by the lake water; his anoxic brain injury caused him to start seizing for hours at a time; his mother went completely insane before my eyes and descended from “horrified and grieving mother” to “crazy woman in filthy clothing laugh-sobbing in the end of the hallway all day and all night.” God, we all felt terrible for her. She threw a shoe at the palliative care people when they came by.
He went into a rotoprone bed, as I think I said before, and coded in it. A rotoprone bed is no minor thing in ICU practice. It’s like a huge padded coffin/cradle into which a pt can be packed, then wrapped tightly in cushions and panels and straps, then rotated until their face is hanging downward so their lungs can drain. Once they’re proned, we open the back of the bed and let them lie there, gently swinging back and forth with their belly facing the floor, letting their lungs stretch and drain and slowly recover. It’s very effective when used early, and was originally marketed for H1N1 support, since young pts who survived the initial respiratory catastrophe of that strain would recover easily enough in a week or two.
Now we use it for ARDS, acute respiratory distress syndrome, which can happen for many reasons ranging from pneumonia to aspiration to pancreatitis. In ARDS, the lungs become so inflamed that their tissues turn thin and stiff, they can’t exchange gas well, fluids weep into the air sacs, and even the blood vessels lose their pliancy and become hard and resistant to blood flow.
We use a lot of things to treat ARDS. Paralytics can help reduce the pt’s inclination to fight the ventilator, and minimize their oxygen usage; Flolan (epoprostenol) is a ruinously expensive inhaled medication that dilates the blood vessels of the lungs to allow improved blood flow; chest physiotherapy can sometimes be used to help break up secretions and move fluids around; and, of course, antibiotics and steroids and protective settings on the ventilator to prevent lung damage. And PEEP.
Remember how a bipap mask adds a kick of pressurized air at the end of the breathing cycle to keep the airways (large and small) open? PEEP (positive end-expiratory pressure) is similar to that. Cranking up the pressure helps force fluid back into the veins, keeps the air sacs open, and increases the pressure gradient of air vs blood so that air exchanges more effectively across the membranes. Usually ventilation (CO2 shedding) is harder than oxygenation, but in ARDS pts often have oxygenation just as bad as their ventilation.
I’ve seen ARDS fought effectively. I cared for a pt once who was very young, got a nasty pneumonia, spent days and days in the rotoprone bed, and was eventually transferred to the local children’s hospital to receive ECMO—extracorporeal membranous oxygenation, in which blood is drained from the body, oxygenated through a membrane, and pumped back into the body constantly. She ended up doing well, and sent us a letter about a year later to let us know that she had not only survived, she had recovered enough to walk across the stage at her graduation.
The drowned kid will not be so lucky. Even if his lungs manage to recover from the lake water problem, his brain is completely fucked from the continued hypoxia. We are, essentially, buying the family time to say goodbye.
Which is a victory, sometimes. If we define death as failure and any kind of life as success, then pretty soon our successes are often hollow—we have quite a few pts who end up suffering for a very long time and being shipped back and forth between the hospital and a long-term acute care facility—and our failures are nearly constant.
You have to look for other definitions of success and failure, here. Sometimes our victories are good deaths. Sometimes we work our asses off day and night to make sure a pt is comfortable as they’re dying. Sometimes we finally manage to talk the family into letting go; sometimes we struggle to win them the few days they need to come to terms with their loss. Sometimes we squeeze enough time to let the plane land and the taxi speed from the airport, so that the kids can be there when their father dies. Sometimes we wash our hands of a code and catch our breaths, and the corpse cools in the room while we go back over the entire crisis and realize that we did everything right and they died anyway. But it’s still a victory, just as all these others are victories: we did everything right.
But they died anyway.
And sometimes we practice our skills on a pt who has made every possible bad choice and is dying of their bad choices, knowing that our care is futile and the resources we spend are wasted, but knowing that when the next pt comes in needing that unusual procedure, we will be that much fresher in our practice. That’s a victory, if you squint.
And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.
Which is to say: when the drowned kid died, my last day before I went on that huge long camping trip and didn’t post for a while, we were all devastated. His mother cried like an animal, gagging and groaning and clawing at her arms, and we all twisted our mouths and ground our teeth and remembered that we were people and wished we weren’t.
Rachel went home again. Her younger child’s birthday is coming up.
That same day, the last day before camping, I sent my open abd guy down to have his belly incision revised. They will slowly close it until at last his intestines are all contained, giving him time for the swelling to diminish between each revision. Then, because he wasn’t expected back up before my end of shift, I took two more pts: a comfort care pt in his thirties with Huntington’s, who was starting to lose his ability to swallow his secretions and was choosing to go home to die rather than move forward with a tracheostomy, and an older fellow with severe hearing loss who had come in for a very mild GI bleed from an ulcer in his stomach.
The comfort care pt’s case was relentlessly sad. His young wife is pregnant; he is not expected to live to see the child. He declined to make a video for the baby, saying that he didn’t want his son to see him like this. His family are rollicking good-ol-boy country folk, and they all sat in his room picking on him affectionately and watching Pawn Stars. They were delightful; they had faced this monster directly, and chosen not to be destroyed by its inevitable rampage, and as a result they were wonderfully supportive and caring. They helped move his cramped arms and roll him gently when he needed to be repositioned; they joked that his stubble “looked like wanderin’ pubes.” They ate five boxes of Fruit Roll-Ups in the room (making me crave Fruit Roll-Ups), and tirelessly suctioned his mouth with a soft plastic tube so he wouldn’t choke.
We tried out atropine drops to dry up his mouth, and they worked fairly well, although he still needed some suctioning from time to time. He was just waiting for the hospice group to pick him up in the morning and bring him home, where he can spend the rest of his life in comfort, surrounded by family. He got the shittest deal on the table, but I think he’s choosing the best possible option with it.
The GI bleed old guy told me about gladiator diets (beans and porridge, with burned plants to provide magnesium?) and house paint (never just use flat white, it looks too bare!) and nail storage (lots of yogurt containers!). He was advanced from a clear liquid diet to a full liquid diet, and delighted in his tray of four different kinds of soup instead of “all that sweet stuff they’ve been trying to trick me into eating.” He called me darlin’ and ma’am and Nurse Elise. He was an absolute doll and I wish all my pts were like him. Plan was to send him home the next day.
The next day I left for my camping trip, and haven’t been back to work yet. The trip was wonderful—I moved into a hammock by Lake Crescent, out on the peninsula, one of the prettiest places I’ve ever camped—and then I came home, finished my studying, took my CCRN exam, slept for a full day, and went to Cardiology Summer School today (first of three Fridays spread throughout the summer, lectures by a popular nurse educator in the area). Tomorrow, I go back to work.
I did stop by and check on my open abd guy. He is still alive and seems to be doing well, though the dialysis nurse was in his room setting up shop when I poked my head in. I didn’t see his abdomen, though. Maybe it’s closed by now. I will check his chart tomorrow and see what all has been going on while I was eating hot dogs and smores at the lake.
And I had my ninety-day review at this facility (I worked there for three months as a traveler before hiring on full time). My manager said there have been absolutely no complaints about me, which makes me pretty giddy, but added that the charge nurses were surprised by how easily I fell asleep on my nap breaks and how often I spend my breaks napping.
I really don’t know what to say to that. I’m fucking exhausted all the time at work and I sleep like a dead rock every chance I get. I just kind of stammered something about being ex-night-shift and wandered away. I thought break naps were one of the crucial characteristics of the nursing profession in general? Maybe I’m just lazy. That is a very real possibility.
I wonder if I’ll get my abd guy back tomorrow. I guess I should head to bed soon, since I have to be up in six hours. Shit, I think I figured out why I nap on all my breaks.
Saturday, July 18, 2015
I have no idea what week this is but it's Friday
I had Friday off. I spent it on meaningless bullshit and faffery, for the most part; my sister and I had a meeting with her new guidance counselor to schedule some aptitude testing and discuss tutoring/counseling options for the next week. She’s settling in well—learning things like “how to make a sandwich” and “how to use a bus.” I feel like I’ve been working almost every day since she arrived.
Saturday morning I assumed the role of first admit nurse, then took report on one pt, a frequent flyer who has been notorious for her poor adherence to heart failure medications and home bipap use. She is cared for almost entirely by her devoted son, who does a fine job except that she refuses a lot of care, and hits. Or did. Last time she was here we put her on a horse-tranquilizing dose of Paxil, and this time around she’s been fairly pleasant and cooperative.
Her son is a very gentle sort, a little bit Bob Ross and a little bit hapless victim, so I was quite surprised to hear him call the Paxil her “anti-bitch pills.” He said it in such a self-deprecating way that it took me a moment to realize he was making a joke. I suspect that his life has changed a lot for the better since we started her on the meds.
She hadn’t been handling her bipap well lately, though, so not only had she collected lots of carbon dioxide, but her heart failure was really acting up. Explaining this will take a little bit of pathophysiology, so buckle in.
The old ICU saying goes: if you ain’t got pressure, you ain’t got shit. Blood pressure is so crucial to survival that we’ve even changed our CPR methods to emphasize compressions—pressing on the heart to maintain some blood pressure—and decreased the whole rescue-breathing thing to “meh, if you have time, but don’t stop compressions.” Oxygenation and ventilation (remember, ventilation refers to airing out the carbon dioxide in your blood) are important, but without pressure, you can’t get the oxygen to the tissues or return CO2-laden blood from the tissues. And your body can deal with a little low oxygen or high CO2 (your blood keeps a huge amount of oxygen after its first pump-through!), but not with a loss of pressure.
But what if you have too much pressure? High blood pressure makes tiny tears in your veins, which scab and scar and become susceptible to clots. Not as damaging as high blood sugar, which is like knives in your blood, but it will definitely tear you up inside. And if your blood pressure gets too high, you might blow a blood vessel in your brain—you will typically feel a headache only once it’s too late to do more than contain the bleed. High blood pressure is a silent killer.
What about if you have a pressure imbalance? That’s what’s happening to this lady. She has an obstructive breathing disease, with nasty sleep apnea that traps air in her lungs while she sleeps. The pressure in her lungs grows and grows as her body struggles to overcome her collapsed airways, until finally the air escapes with a whoosh and she can start the process of gasping for more air. There’s a reason people with sleep apnea are always tired and shitty-feeling: they spend their nights suffocating.
Meanwhile, the right side of the heart, which pumps blood into the lungs to be oxygenated, has to pump against a huge amount of pressure. As the pressure grows in the lungs, the blood has to be squeeeeeezed in with incredible force, and eventually the right side of the heart blows out like a stepped-on water balloon, becoming weak and floppy, and struggling to empty itself so more blood can return from the body. So blood backs up in the body, and the water that would normally be peed away by the kidneys just squeezes out into your tissues instead. Usually the lower part of your body first. People with right-sided heart failure get giant, swollen ogre legs, which get so stretched out they form big bubbly scars where water is tucked away, never to be returned to the bloodstream again.
One of the most crucial treatments for this is a diuretic, a water pill that convinces the kidneys to pee extra water away while it has the chance, since it’ll take a lot more work for the body to get water all the way back around to the kidneys again. So if you are, say, a grouchy old lady who hits nurses and doesn’t believe in taking her pills, pretty soon you’re retaining more water than New Orleans in hurricane season. And if your bipap is lying in a drawer while you sleep, your CO2 rises, and you become too groggy from CO2 poisoning to wake up and breathe.
CPAP and BiPAP can help a lot with this too. CPAP gives a little boost of air pressure to keep the airways open; BiPAP uses two different pressure levels, one for inspiration and the other for expiration. The increase in pressure is absolutely minimal compared to the whole “lungs stuck shut” pressure differential, and the overall result is that the lungs stay open, the volume of air (and thus the ventilation of CO2) is maximized, and the pt is wildly uncomfortable for the first little bit and then suddenly realizes they can breathe again. Nobody wants to wear a mask over their face… until they realize they can finally sleep like a real human with the mask on.
So she came in to the hospital nearly comatose, swollen up like a marshmallow in the microwave, smelling like the inside of a hobo’s shoe. I have a personal thing about stinky pts: I want them to be clean. I will make them clean if it kills me. Under no circumstances short of immediate, life-threatening danger will I allow my pts to lie in their filth with a baguette’s worth of yeasty crust on their scalp and a gunt-tuck full of smegma the texture and color of butterscotch pudding. If you come into my merciful care and your vagina is oozing all-natural Cheez Wiz, you had better get ready to spread.
I shoved a bedpan under her head and shoulders and soaked her in warm soapy water up to the ears, periodically sloshing more over her scalp and dumping the detritus in the toilet to be replaced with more. Once the water started clearing up, I emptied half a bottle of chlorhexadine mouthwash into the next round, and let that seep through the microbial rainforest of her ratty hair until the tectonic plates of yeast-plaque gave up and let go. The scalp underneath was raw and pink and looked like a fresh pork chop with a little incidental gray hair growing out of it.
All her folds I scrubbed, with the help of the long-suffering CNA, lashing the creases with antifungal powder and lining them with folded absorbent pads. The less said about her lady parts the better, but I can’t imagine how anyone could have dustflaps that yeast-eaten and not cry like a kicked dog every time they took a piss.
Her son came in near the end of the scrub-a-thon and gaped. “She never lets me wash her,” he said. “The last time I tried, she hit me and said she’d be dead before anybody washed her hair again.”
“Well, unconscious,” I said, and added that if she really wanted to stay filthy she was going to have to make sure she took her medicine so she wouldn’t become unconscious and be at the mercy of nurses again.
Then I got a call from the charge nurse: a rapid response from upstairs would be my admit, an alcoholic gentleman who had come in with pancreatitis three days before, gone into massive withdrawal, and then become so short of breath that he was being emergently intubated upstairs.
I knew right away it was going to be a clusterfuck. The intensivist was up to his neck in the drowned kid’s case, and was in the middle of a chest tube insertion that would need to be followed by a bronchoscopy. His acute lung injury was reaching the point where he couldn’t maintain decent oxygen levels, let alone ventilate effectively. Worse, he’d started to show signs of severe brain injury, small seizures that ramped up throughout the day until (right around the time I left) he was in status epilepticus, a massive seizure storm that we couldn’t seem to get under control. Needless to say, if my guy was going to be trouble, he was going to be my trouble.
Naturally, he showed up looking like yesterday’s shit. Blood pressure tanking, legs cold and mottled, foley catheter having drained less than 5mL of urine per hour (we start worrying at 30mL/hr) for the last six hours, nostrils flaring to suck in more air even while the ventilator forced each breath in. His anion gap—a measure of his energy status on the cellular level—was incredibly elevated, along with his blood glucose, which suggested that his sugar was staying in his blood rather than being eaten by his cells. His body was acidotic, which supported that idea—starving cells shit out torrents of lactic acid—but, weirdly, his potassium levels were low.
Those of you who have been following this blog for a bit have already been bashed over the head with the relationship between insulin, sugar, and potassium, but I will explain it again for the new admits. Insulin isn’t a magic anti-sugar substance—it’s just the key that opens your cells’ mouths so they can eat the sugar out of your blood. It also lets them eat potassium, which is a positive anion that keeps the inside of the cell electrically imbalanced against the outside (where negative sodium ions and other such things float around). Between the potassium, which is the electricity that powers the cells’ pumps, and the sugar, which is the gasoline that powers their engines, insulin keeps your cells purring along like that Nissan 240Z pignose you had in college and will never forget.
(I did not have that car. I barely know what that car is. My husband had that car and still obsessively draws pictures of it, rhapsodizes about it, and laments its demise to this day. He likes engines a lot and likes to stay up late at night and look at pictures of old Soviet planes until three in the morning, hurriedly switching windows back to wholesome Miata portraiture when I stumble to the kitchen for a glass of water. This is a dumb derail and I will stop.)
If there’s not enough insulin, or if your cells have become resistant to insulin, your blood sugar will soar as your cells starve. Potassium lingers in the blood, slowly throwing off the balance of positive and negative until muscle cells—especially heart muscle cells—can’t function properly. As your cells rip themselves to pieces, looking for anything they can burn for energy, pouring out lactic acid diarrhea from eating their own garbage, your heart begins to short out and beat erratically.
So it was really weird that he was hypokalemic—LOW on potassium. Especially since his kidneys had started failing, and thus weren’t able to dump any potassium. Even weirder, his lactic acid levels were still fairly low. (I can tell you now, days and days later, that even nephrology was never quite able to pin down the reason behind the rhyme with this one. Actual quote, with warning for medical blather: “Anion gap acidosis. The large anion gap is unexplained by the minimally elevated lactate or phosphorus level. The acidosis is larger than the ABG or serum bicarb suggests since he is currently receiving 180 mEq per day of sodium bicarbonate. Doubt ketosis. Doubt salicylate at this point in hospitalization. Because of ileus, could possiblly have d lacate. No heavy lorazepam (he did have several doses IV) or other propylene glycol ingestion.”)
But all this weirdness aside, I can tell you he was sicker than shit. His abdomen was HUGELY distended and hard to the touch. It’s not uncommon for people with pancreatitis to have swollen, painful bellies—really, that’s usually what brings them in—but this was just out of control. I laid him flat to turn him, and his blood pressure bombed. His ice-cold, mottled legs had no pulses. I sat him back up and he recovered his blood pressure, and I developed a hunch.
Low blood pressure from sepsis isn’t positional. Positional hypotension usually means that either the aorta is so scarred up (usually from smoking) that the heart can’t push blood hard enough to reach the brain when you stand up, or that something is crushing your heart in one position and not in another position. I suspected abdominal compartment syndrome.
Compartment syndrome is what happens when some part of your body is so swollen that it fills up its entire "compartment" and crushes itself, preventing blood from circulating to the tissue. Compartment syndrome in an arm or a leg can result in losing the limb, and the primary treatment is a fasciotomy: a deep slash that opens the muscle sheath-- the fascia-- so the swollen tissue has somewhere to expand to.
But what if you have massive pancreatitis, and your intestines are so swollen they're crushing all your internal organs, blocking your aorta, preventing blood from returning to your heart, and blocking any blood flow to themselves at all?
One carefully worded discussion with the intensivist-- who was moving the drowned boy into a rotoprone bed, which would rock him gently face-down to help drain his lungs and keep them open-- I got permission to put in a consult by a GI surgeon. "If he's pissed," said the intensivist, "I'm gonna tell him it was the pushy nurse that put in that order." We get along well and are facebook friends, but he's testy when pressed and haaaates being told what to do.
Whatever. Put in the consult with a note of my own-- STAT PLEASE SUSPECT ABD COMPARTMENT SYNDROME-- and within an hour the GI surgeon had cleared his slate and called in the team for an open abdomen washout.
He returned three hours later with his guts still open. A plastic bag contained his bright-red, massively swollen small intestine, sutured to the edges of his incision. Gooey abdominal fluid poured from every crease and seam. His urine output picked up a little, but to this date he hasn't recovered kidney function yet. His legs turned pink again, and his breathing eased. His guts had been crushing him to death.
I had him almost stable by the time night shift arrived. I gave report, helped clean and turn and mop his juices out of the bed, and staggered out of the hospital. I was so tired I slept in my car for an hour before I could drive home.
I will tell you all more about his care and progress tomorrow, and hopefully get caught up completely, as I finally DON'T work tomorrow. For now, I will tell you that there is an actual photograph of his guts posted on my Patreon, and that shit only gets crazier.
Rachel was readmitted that day. She was having sharp pleural pains in her side, and she has a pneumothorax. She's getting another chest tube, but isn't expected to stay long. She's gained ten pounds since discharge and is as sweet as ever.
A forty-five-year-old woman died that day of sudden-onset pneumonia with hypoxia. We are all a little stressed over all these young, incredibly sick pts.
Saturday morning I assumed the role of first admit nurse, then took report on one pt, a frequent flyer who has been notorious for her poor adherence to heart failure medications and home bipap use. She is cared for almost entirely by her devoted son, who does a fine job except that she refuses a lot of care, and hits. Or did. Last time she was here we put her on a horse-tranquilizing dose of Paxil, and this time around she’s been fairly pleasant and cooperative.
Her son is a very gentle sort, a little bit Bob Ross and a little bit hapless victim, so I was quite surprised to hear him call the Paxil her “anti-bitch pills.” He said it in such a self-deprecating way that it took me a moment to realize he was making a joke. I suspect that his life has changed a lot for the better since we started her on the meds.
She hadn’t been handling her bipap well lately, though, so not only had she collected lots of carbon dioxide, but her heart failure was really acting up. Explaining this will take a little bit of pathophysiology, so buckle in.
The old ICU saying goes: if you ain’t got pressure, you ain’t got shit. Blood pressure is so crucial to survival that we’ve even changed our CPR methods to emphasize compressions—pressing on the heart to maintain some blood pressure—and decreased the whole rescue-breathing thing to “meh, if you have time, but don’t stop compressions.” Oxygenation and ventilation (remember, ventilation refers to airing out the carbon dioxide in your blood) are important, but without pressure, you can’t get the oxygen to the tissues or return CO2-laden blood from the tissues. And your body can deal with a little low oxygen or high CO2 (your blood keeps a huge amount of oxygen after its first pump-through!), but not with a loss of pressure.
But what if you have too much pressure? High blood pressure makes tiny tears in your veins, which scab and scar and become susceptible to clots. Not as damaging as high blood sugar, which is like knives in your blood, but it will definitely tear you up inside. And if your blood pressure gets too high, you might blow a blood vessel in your brain—you will typically feel a headache only once it’s too late to do more than contain the bleed. High blood pressure is a silent killer.
What about if you have a pressure imbalance? That’s what’s happening to this lady. She has an obstructive breathing disease, with nasty sleep apnea that traps air in her lungs while she sleeps. The pressure in her lungs grows and grows as her body struggles to overcome her collapsed airways, until finally the air escapes with a whoosh and she can start the process of gasping for more air. There’s a reason people with sleep apnea are always tired and shitty-feeling: they spend their nights suffocating.
Meanwhile, the right side of the heart, which pumps blood into the lungs to be oxygenated, has to pump against a huge amount of pressure. As the pressure grows in the lungs, the blood has to be squeeeeeezed in with incredible force, and eventually the right side of the heart blows out like a stepped-on water balloon, becoming weak and floppy, and struggling to empty itself so more blood can return from the body. So blood backs up in the body, and the water that would normally be peed away by the kidneys just squeezes out into your tissues instead. Usually the lower part of your body first. People with right-sided heart failure get giant, swollen ogre legs, which get so stretched out they form big bubbly scars where water is tucked away, never to be returned to the bloodstream again.
One of the most crucial treatments for this is a diuretic, a water pill that convinces the kidneys to pee extra water away while it has the chance, since it’ll take a lot more work for the body to get water all the way back around to the kidneys again. So if you are, say, a grouchy old lady who hits nurses and doesn’t believe in taking her pills, pretty soon you’re retaining more water than New Orleans in hurricane season. And if your bipap is lying in a drawer while you sleep, your CO2 rises, and you become too groggy from CO2 poisoning to wake up and breathe.
CPAP and BiPAP can help a lot with this too. CPAP gives a little boost of air pressure to keep the airways open; BiPAP uses two different pressure levels, one for inspiration and the other for expiration. The increase in pressure is absolutely minimal compared to the whole “lungs stuck shut” pressure differential, and the overall result is that the lungs stay open, the volume of air (and thus the ventilation of CO2) is maximized, and the pt is wildly uncomfortable for the first little bit and then suddenly realizes they can breathe again. Nobody wants to wear a mask over their face… until they realize they can finally sleep like a real human with the mask on.
So she came in to the hospital nearly comatose, swollen up like a marshmallow in the microwave, smelling like the inside of a hobo’s shoe. I have a personal thing about stinky pts: I want them to be clean. I will make them clean if it kills me. Under no circumstances short of immediate, life-threatening danger will I allow my pts to lie in their filth with a baguette’s worth of yeasty crust on their scalp and a gunt-tuck full of smegma the texture and color of butterscotch pudding. If you come into my merciful care and your vagina is oozing all-natural Cheez Wiz, you had better get ready to spread.
I shoved a bedpan under her head and shoulders and soaked her in warm soapy water up to the ears, periodically sloshing more over her scalp and dumping the detritus in the toilet to be replaced with more. Once the water started clearing up, I emptied half a bottle of chlorhexadine mouthwash into the next round, and let that seep through the microbial rainforest of her ratty hair until the tectonic plates of yeast-plaque gave up and let go. The scalp underneath was raw and pink and looked like a fresh pork chop with a little incidental gray hair growing out of it.
All her folds I scrubbed, with the help of the long-suffering CNA, lashing the creases with antifungal powder and lining them with folded absorbent pads. The less said about her lady parts the better, but I can’t imagine how anyone could have dustflaps that yeast-eaten and not cry like a kicked dog every time they took a piss.
Her son came in near the end of the scrub-a-thon and gaped. “She never lets me wash her,” he said. “The last time I tried, she hit me and said she’d be dead before anybody washed her hair again.”
“Well, unconscious,” I said, and added that if she really wanted to stay filthy she was going to have to make sure she took her medicine so she wouldn’t become unconscious and be at the mercy of nurses again.
Then I got a call from the charge nurse: a rapid response from upstairs would be my admit, an alcoholic gentleman who had come in with pancreatitis three days before, gone into massive withdrawal, and then become so short of breath that he was being emergently intubated upstairs.
I knew right away it was going to be a clusterfuck. The intensivist was up to his neck in the drowned kid’s case, and was in the middle of a chest tube insertion that would need to be followed by a bronchoscopy. His acute lung injury was reaching the point where he couldn’t maintain decent oxygen levels, let alone ventilate effectively. Worse, he’d started to show signs of severe brain injury, small seizures that ramped up throughout the day until (right around the time I left) he was in status epilepticus, a massive seizure storm that we couldn’t seem to get under control. Needless to say, if my guy was going to be trouble, he was going to be my trouble.
Naturally, he showed up looking like yesterday’s shit. Blood pressure tanking, legs cold and mottled, foley catheter having drained less than 5mL of urine per hour (we start worrying at 30mL/hr) for the last six hours, nostrils flaring to suck in more air even while the ventilator forced each breath in. His anion gap—a measure of his energy status on the cellular level—was incredibly elevated, along with his blood glucose, which suggested that his sugar was staying in his blood rather than being eaten by his cells. His body was acidotic, which supported that idea—starving cells shit out torrents of lactic acid—but, weirdly, his potassium levels were low.
Those of you who have been following this blog for a bit have already been bashed over the head with the relationship between insulin, sugar, and potassium, but I will explain it again for the new admits. Insulin isn’t a magic anti-sugar substance—it’s just the key that opens your cells’ mouths so they can eat the sugar out of your blood. It also lets them eat potassium, which is a positive anion that keeps the inside of the cell electrically imbalanced against the outside (where negative sodium ions and other such things float around). Between the potassium, which is the electricity that powers the cells’ pumps, and the sugar, which is the gasoline that powers their engines, insulin keeps your cells purring along like that Nissan 240Z pignose you had in college and will never forget.
(I did not have that car. I barely know what that car is. My husband had that car and still obsessively draws pictures of it, rhapsodizes about it, and laments its demise to this day. He likes engines a lot and likes to stay up late at night and look at pictures of old Soviet planes until three in the morning, hurriedly switching windows back to wholesome Miata portraiture when I stumble to the kitchen for a glass of water. This is a dumb derail and I will stop.)
If there’s not enough insulin, or if your cells have become resistant to insulin, your blood sugar will soar as your cells starve. Potassium lingers in the blood, slowly throwing off the balance of positive and negative until muscle cells—especially heart muscle cells—can’t function properly. As your cells rip themselves to pieces, looking for anything they can burn for energy, pouring out lactic acid diarrhea from eating their own garbage, your heart begins to short out and beat erratically.
So it was really weird that he was hypokalemic—LOW on potassium. Especially since his kidneys had started failing, and thus weren’t able to dump any potassium. Even weirder, his lactic acid levels were still fairly low. (I can tell you now, days and days later, that even nephrology was never quite able to pin down the reason behind the rhyme with this one. Actual quote, with warning for medical blather: “Anion gap acidosis. The large anion gap is unexplained by the minimally elevated lactate or phosphorus level. The acidosis is larger than the ABG or serum bicarb suggests since he is currently receiving 180 mEq per day of sodium bicarbonate. Doubt ketosis. Doubt salicylate at this point in hospitalization. Because of ileus, could possiblly have d lacate. No heavy lorazepam (he did have several doses IV) or other propylene glycol ingestion.”)
But all this weirdness aside, I can tell you he was sicker than shit. His abdomen was HUGELY distended and hard to the touch. It’s not uncommon for people with pancreatitis to have swollen, painful bellies—really, that’s usually what brings them in—but this was just out of control. I laid him flat to turn him, and his blood pressure bombed. His ice-cold, mottled legs had no pulses. I sat him back up and he recovered his blood pressure, and I developed a hunch.
Low blood pressure from sepsis isn’t positional. Positional hypotension usually means that either the aorta is so scarred up (usually from smoking) that the heart can’t push blood hard enough to reach the brain when you stand up, or that something is crushing your heart in one position and not in another position. I suspected abdominal compartment syndrome.
Compartment syndrome is what happens when some part of your body is so swollen that it fills up its entire "compartment" and crushes itself, preventing blood from circulating to the tissue. Compartment syndrome in an arm or a leg can result in losing the limb, and the primary treatment is a fasciotomy: a deep slash that opens the muscle sheath-- the fascia-- so the swollen tissue has somewhere to expand to.
But what if you have massive pancreatitis, and your intestines are so swollen they're crushing all your internal organs, blocking your aorta, preventing blood from returning to your heart, and blocking any blood flow to themselves at all?
One carefully worded discussion with the intensivist-- who was moving the drowned boy into a rotoprone bed, which would rock him gently face-down to help drain his lungs and keep them open-- I got permission to put in a consult by a GI surgeon. "If he's pissed," said the intensivist, "I'm gonna tell him it was the pushy nurse that put in that order." We get along well and are facebook friends, but he's testy when pressed and haaaates being told what to do.
Whatever. Put in the consult with a note of my own-- STAT PLEASE SUSPECT ABD COMPARTMENT SYNDROME-- and within an hour the GI surgeon had cleared his slate and called in the team for an open abdomen washout.
He returned three hours later with his guts still open. A plastic bag contained his bright-red, massively swollen small intestine, sutured to the edges of his incision. Gooey abdominal fluid poured from every crease and seam. His urine output picked up a little, but to this date he hasn't recovered kidney function yet. His legs turned pink again, and his breathing eased. His guts had been crushing him to death.
I had him almost stable by the time night shift arrived. I gave report, helped clean and turn and mop his juices out of the bed, and staggered out of the hospital. I was so tired I slept in my car for an hour before I could drive home.
I will tell you all more about his care and progress tomorrow, and hopefully get caught up completely, as I finally DON'T work tomorrow. For now, I will tell you that there is an actual photograph of his guts posted on my Patreon, and that shit only gets crazier.
Rachel was readmitted that day. She was having sharp pleural pains in her side, and she has a pneumothorax. She's getting another chest tube, but isn't expected to stay long. She's gained ten pounds since discharge and is as sweet as ever.
A forty-five-year-old woman died that day of sudden-onset pneumonia with hypoxia. We are all a little stressed over all these young, incredibly sick pts.
Friday, July 17, 2015
Week Five Please Send Help Too Much Work
Thursday I rolled into work around 1045, having juggled my hours to accommodate the concert. Getting out at 1500 on Wed was just enough time to let me stagger home, wash my gross self, nap for an hour, and put on some real-people clothes before the festivities commenced. Coming back in at 1100 on Thurs let me sleep in, which I desperately needed (and still need, and will always need even when I don’t get it). So I was well-rested, well-fed, and wearing my best work pajamas when I showed up at the nurses’ station and asked about my assignment.
Charge nurse put on a very serious face and asked if I would be comfortable getting oriented to hearts at this facility today.
Open hearts are a big deal, the moneymaker of any ICU that does them. Nurses that take fresh open heart recoveries are rigorously trained, tested, precepted, and even given classroom time on the unit’s dollar to make sure they’re fully equipped. Heart pts are delicate, touchy, and heavily regulated, but a really sharp RN with lots of training can keep everything moving smoothly despite the inevitable hiccups. I had not taken a fresh open heart in something like nine months, because even a few months before I left my last facility, the open-heart program became a dangerous place for a relatively inexperienced nurse.
A second-day heart pt had been assigned to a non-heart night nurse due to understaffing, with the idea that the heart-certified charge nurse would be able to back her up and keep things running smoothly. Instead, the pt lost conduction (valve replacements often do, though it’s less common for this to happen on the second or third days) and dropped their heartbeat completely. They ended up coding her for almost thirty minutes before someone thought to hook up her pacemaker, and after thirty more minutes without success they called the code.
The charge nurse was hung out to dry, and retired to PACU a few months later. The unfortunate unit nurse assigned to the pt was scapegoated roundly, despite having never been trained on hearts and therefore lacking the reflex to hook up the pacer to the V-wires sticking out of the pt’s chest. Every hiccup in every recovery for the next six months was scrutinized, written up, and presented “in a meeting” between managerial staff and the heart nurse in question. Everyone on the unit was trained in temporary pacer management, but when the heart RNs requested additional training to address the hiccups that were obviously such a big problem now, they were given no more education—just stripped of autonomy and grilled after every case.
I voluntarily removed myself from the heart list. Which is sad, because I fucking love hearts. They are a huge rush and the detail and precision and reflex required is a serious, galvanizing challenge. There’s also an element of prestige to the open heart program, which I like because I am a bit shallow and vain. Succeeding at the challenge makes me feel like a Real Nurse instead of the secret imposter I usually feel like I am.
The imposter thing is a huge deal in my life. Even writing this diary is kind of terrifying to me, because I know that I’m getting some things wrong and there are probably people shaking their heads and wondering why I suck so bad. I’ve worked ICU since 2008 and I still regularly encounter things that make me feel like a clueless kid wearing borrowed scrubs, things I should have known but didn’t, moments of dumb that make me cringe for months. I am deeply afraid of appearing stupid or uneducated or incompetent. One of the hardest things in my practice is recovering rusty skills—things I used to do well, but which I haven’t done for a while, and which I might be expected to perform competently but will probably make mistakes with. I am constantly ashamed of myself, and sometimes this makes me defensive or aggressive when I really shouldn’t be.
Mostly I channel it into fighting my innate laziness. I don’t want to look like a piece of shit nurse who can’t do anything without her hand being held, so I constantly educate myself, refresh my skills, pay attention to the details, and attend to the shitty boring jobs as well as the exciting flashy ones.
So taking this heart pt was very important to me, and although my shamepanic drive geared up for a beating, I accepted the assignment. As a psychological incentive, there was also an element of the unit really needing a few more heart nurses—my other great fear is abandonment, which means that I am at my most comfortable and secure when I feel necessary. It’s vital that I keep that impulse in check, because a hospital will chew you up and spit you out if you can’t resist the phrase “we really need you.” And nobody in a hospital is truly indispensable, so at some point in every work situation I will inevitably encounter the truth that I will never be perfect and that perfection is not required for me to be valuable. But I allow myself a few smug moments sometimes to enjoy my employers’ gratitude and/or relief, just as I occasionally remind myself that if I don’t get my job done right, I will get in just as much trouble as the next nurse down the hall.
My value is earned, and if I fuck around and make messes, other people are entitled to avoid me—which means that the approval and security I crave is a predictable resource I can expect if I fulfill certain realistic expectations, and am entitled to demand if it’s inappropriately withheld.
There was a time when I handled things with much less self-awareness. Approval and love were like an endless series of rocks thrown into the emotional well of my insecurity, each little splash a momentary fix, while the whole time I acted like a crazy person, trying to drive the source of approval away to “prove” that my fears were legitimate and that the splashes would stop coming. I was an incredibly challenging person to care about. I think the only reason I finally escaped that personality hellhole was that I got into nursing, where my value was measured in life and death and hourly wage. It’s hard to lie to yourself about patient outcomes.
I’m pretty sure nursing saved my life.
I’m also pretty sure this diary is not at its best when I’m navel-gazing in it. Lo siento, my friends.
Anyway, Mavi*, one of the best heart nurses on the unit, offered to be my second/preceptor for the day. She is a tiny Filipina woman with beastly skills, ice-cold reflexes, and the kind of gentle, humorous nursing style that makes everyone around her comfortable and happy.
We prepared the room and sat down to get me oriented to the paperwork and charting. Every fresh heart has a primary nurse (in this case, me) and a second (Mavi), with distinct roles in the recovery process—there is a hell of a lot of work to do during those first few hours. Every facility documents its hearts a little differently, and every surgeon has their own preferences and quirks, and every heart nurse needs to get familiar with the details very quickly so they can be second nature by the time they’re making decisions about which medication to start.
This surgeon doesn’t like SCDs (leg massager pumps used to prevent blood clots from forming), prefers to be texted rather than paged, dislikes high doses of epinephrine used as a pressor, and is blazing fast at his job. He also plays jazz guitar, was once an aerospace engineer (his first career), and is in active military duty through some branch or other. I was a little intimidated, to be honest. Mavi put the surgeon’s number in my phone while we looked over the procedural chart for landing a fresh heart, which she wrote a while back and which has become official paperwork because it rocks.
Off-pump call came about four hours after surgery started, which was incredible, considering that the guy had a valve replaced (requires cutting into the heart itself), a coronary artery bypass graft (CABG, requires harvesting a vein or artery from somewhere else in the body), and a double MAZE procedure (a labyrinth of burn scars in both atria to prevent atrial fibrillation). This is a whole lot of stuff to have done in a single surgery, let alone in a mere four hours of surgery.
Elevator call is typically an hour after off-pump call. Once the pt is taken off the bypass pump and their heart is restarted, the team still needs to close the chest and perform a few other little tune-ups, then watch the pt until they’re satisfied that he’s stable. Then they give one last notification to the ICU and load the whole crew into the elevator. So the pt arrived, intubated and still working off the anesthesia, with a churning nest of OR nurses, techs, and anesthetologists squirming all over him. Mavi hooked him up to monitors while I checked on his chest tubes; Mavi drew up his initial labs while I charted until my eyes started to sweat. Mavi performed foley care; I ran hemodynamics through his swann catheter, checking on the function of his various cardiac components. I listened to his heart and lungs—this is especially important in valve surgeries, since a valve problem will usually be audible as a murmur—and Mavi examined his pacer wires and vent settings.
He was atrially paced. Many valve pts come back with their pacer wires hooked up and firing, either by directly stimulating the ventricles (the big chambers at the bottom of the heart, the ones with all the kick) or by starting the electric cascade in the atria (the little chambers whose job is mostly to pack extra blood into the big chambers and stretch them out bigger so they can beat harder). Some surgeons prefer to let the ventricles fill on their own and just pace from the ventricles themselves. In valve surgery, the actual heart itself is cut and the nerves are very unhappy, especially the nerves responsible for relaying messages from the atria (where each beat starts) down to the ventricles (where the beat ends with a big push). Angry, swollen, shocky nerves don’t relay impulses well, and thus any beat that starts at the top of the heart—whether natural or atrially paced—may not get conducted all the way to the bottom.
But that atrial kick gets a lot more mileage out of each beat. Imagine holding a water balloon in your fist, and squeezing it until it pops. If the balloon was filled just by dunking the empty balloon into a bucket of water, it won’t have much water inside, and your fist will have to squeeze really hard to pop the balloon. But if you hooked the same balloon up to a water hose and filled it until it was ready to pop in the first place, the balloon itself wants to return to its original shape—it has mechanical elasticity, and your fist only has to work a little to make it pop. In this case, the ‘pop’ is the force of perfusing your entire body with blood, and the water hose is the atrial kick that forces extra blood into your ventricles. So atrial pacing is a great place to start a cardiac pt. If you lose conduction, you can always hook up the ventricular pacer wires and stimulate beats that way.
His blood pressure and cardiac output, of course, started to drop very quickly. The recently-cut heart is stiff and shocky and stressed out, and its walls don’t want to move very well. Plus, the body is reacting to the insult of being cut up and partially exsanguinated by shifting fluid around its various spaces, pulling water out of the blood into the tissues where it’s mostly useless except to swell up and make you look puffy. So we administer fluids, to replenish the thirsty bloodstream, and we administer albumin, which thickens up the blood (increases its osmolarity) to suck water back out of the tissues into the blood vessels.
To support the blood pressure, we use several different medications by steady drip. I am pretty used to using dobutamine as a front-line inotrope—that is, the first drug I turn to when I need to stimulate the heart to squeeze harder instead of faster. This surgeon, however, prefers epinephrine, aka adrenaline, which both speeds the heart (a chronotrope) and increases its contractility (an inotrope). As the pt’s recovery continued, we shifted from the fluid-moving phase to the vasodilation phase, in which the body really wants to relax its veins and dump all its fluid into the tissues. Here we started using phenylephrine, also known as neosynephrine, which is a pure vasopressor—that is, it tightens up your blood vessels, and doesn’t affect the workings of your heart. In the same way that you get higher pressure by squirting water through a straw than through a hose with the same force, tighter blood vessels increase pressure… although they resist the heart’s beats a little harder.
One of the other big bad pressors, norepinephrine/noradrenaline, is also known as Levophed… or, in ICU parlance, leave-‘em-dead. It will squeeze the living shit out of your blood vessels until your toes drop off, which is what happened to my CRRT lady a while back. If you find yourself using norepi on a cardiac surgery pt, something has gone extremely wrong. The other two pressors, vasopressin and dopamine, I will probably talk about later, when I have a pt I’m using them on.
Within about two hours of his arrival on the unit, he awakened enough from general anesthesia that he could open his eyes, lift his head, and follow commands, so we pulled out his breathing tube and let him breathe on his own. A little morphine for pain, a few ice chips for his dry throat, and he was happy as a clam in sauce.
He was also convinced that I spoke exclusively German, and was courteous enough to speak exclusively German to me. I do not speak German at all, so occasionally I would rattle back at him in hospital Spanish (I cut my ICU teeth in Texas) and he would recoil, startled. He is a world traveler and historian and as he came back to his senses throughout the afternoon he and I had many wonderful conversations in English. Any time he drifted off though, he would wake up, look at me, and start speaking German again.
Man, I don’t know. I don’t even look German. I have enormous bushy brown hair, a prominent forehead, freckles, glasses, and the kind of sloppily-assembled facial features you get from slightly inbred trailer trash that grew up in the river bottom. I look like leftover tax dodger and piney-woods moonshiner and hastily concealed ancestor ethnicity back when Irish was considered ‘ethnic’. I am white as shit, but not in the classy-lookin’ European way, is what I’m saying. Four years ago, before suffering my way through braces, I had buck teeth.
I’m not exactly pretty, but fuckin hell man, I don’t have to be. I am the apocalyptic definition of ‘personality hot’. I’m the lady equivalent of that weird-lookin fucker on TV that’s sixty years old and worryingly asymmetrical in the face parts and could bang your girlfriend in the bathroom at your favorite bar after five minutes of conversation. I am also incredibly arrogant and don’t speak a word of German. It’s quite possible that he was just telling me how my face is so gnarly it’s giving him flashbacks to WWII.
We joked a little about our respective experiences with foreign languages, and he taught me a little about the ways in which Italian deviates from Spanish. I taught him to say “qapla’.” I can’t help but feel that I got the better end of that deal.
Anyway, linguistic barriers aside, by the time we had this guy settled down and feeling pretty good, I had an imperial shit-ton of charting to get done, so Mavi watched him for a bit while I had lunch and then tore into the paperwork. The surgeon came by to see how the guy was doing, and I noticed that he was wearing an honest-to-god Starfleet insignia badge on his white coat, which after my earlier Klingon language lesson seemed like a much stranger coincidence than it probably was. We ended up having a nice chat about Star Trek, after which a couple of the RTs came up and started reminiscing about Jimmy Doohan, who apparently used to come to this hospital for pulmonary fibrosis because he lived nearby. (I would consider this HIPPA material except that it’s freely available information from Wikipedia.) He was apparently funny and personable, hated being called “Scotty,” and once left AMA because he hadn’t had any alone time with his wife in a week.
The RTs apparently thought very highly of his wife, who was much younger than him but who genuinely seemed to care about him and connect with him on a personal level. “They were great people,” said the surgeon. “I was always a little intimidated by him though.” Then he started talking about how his engineering career was spurred by his love of Star Trek, and how he missed NASA because he had felt like a member of a modern-day Starfleet there. I turned into a brick of shy-terror and finished my charting in record time.
After that, we got my pt sitting up on the edge of the bed so his feet could dangle, reminding him to hug his heart-shaped splint pillow tightly to relieve tension on his chest, then popped him back into bed and tidied up the room for the next shift. He was scheduled for at least one more major exercise activity, probably an hour sitting in a recliner, before bedtime. Exercise is critical to the early recovery phase; a pt who lies in bed the whole time will have nasty consequences. Lungs collapse and close up and fill with fluid; chest tubes clot off, and fluid builds up around the heart; blood clots up in the legs and causes pain and swelling, with a huge risk of pulmonary embolism; and the whole body misses the opportunity to tune itself up after the surgery, leading to increased swelling, decreased cardiac output, and severe constipation.
Tomorrow he’ll walk around the unit four times, and spend at least half the day in a chair. After that we’ll really start pushing. His case will be a smooth one, barring any major unanticipated events, and he’ll probably go home in a week or two. Before the surgery he couldn’t walk without collapsing because his heart was too starved for oxygen and too backed up from his scarred-up valve; when he gets home, lord willin’ and the creek don’t rise, he’ll be able to stroll around the park and even do some gentle gardening.
Other things that happened today…
The screaming lady died. Her ammonia poisoning—hepatic encephalopathy—became so intense that she could no longer speak or make eye contact, and she laid in bed thrashing and groaning in horrible garbled sentences of fragmented non-words as if demons had crawled into her skull and were eating everything inside it. Her family stopped going into the room at all, and huddled outside in knots of two and three, weeping. Palliative care approached gingerly, having been rebuffed many times before, and her closest relative made the decision without even having to be asked.
“Let her go,” he said. “She’s not even really alive anymore.”
We took the fem-stop pressure dressing off her leg, and she bled out and died within five minutes. The absence of her screams was sickening for the first half-hour; then hospital silence seeped into the cracks, a weird relief.
In the car on the way home from a shift, you forget to turn on the radio, you forget that you were going to make that phone call—you soak in the lack of alarms, the lack of dinging and beeping and chiming and clanging. It’s like breathing after you resurface from the water, at first. Your eardrums feel like somebody is pressing on them, blunting out the constant bells you know must still be ringing. Then, as other small daily sounds creep in at the edges, you forget what it was that you were supposed to be hearing. The white hum of road noise, the whoosh and rumble, disappears beneath the sounds of the car passing you in the other lane, the click of your blinker, the subvocalization of the gearshift, the creak of your knee as you depress the clutch and wonder why the fuck you can’t just give up your dignity and buy an automatic for the commute. You remember that you downloaded the new episode of that podcast, and hook your phone up with one hand, and dig that last Kit-Kat bar out of your purse to devour while you drive. By the time you reach your home, the endless litany of alarms is not only missing but forgotten.
That’s how it was with her screaming. An hour after she died, we were all cursing under our breath about the one guy whose monitor kept false-alarming. I almost forgot she had been alive just that afternoon.
We also got in two pediatric cases. Okay, teenagers. One was in a car wreck and had mashed up his legs, but was expected to recover, although his entire family was shaken and white-faced. The other was involved in a drowning incident; his mother had seen him go underwater and not come up, and although there was a nurse nearby who started CPR as soon as they could pull him up, he had inhaled a fuck-ton of lake water. His mother was a complete wreck, and understandably so, but very optimistic and desperately hopeful that he would wake up soon.
We’ve had a few drowning cases. Everyone is keeping a politely neutral face, and of course we’re doing everything we can, but (because I’m writing this a few days later) I can tell you that on Friday he had his first code blue as his lungs succumbed to the inevitable damage of lake aspiration, and that today he’s in a rotoprone bed, seizing.
He might yet make it. Maybe. It’s a long shot. Either way, I’ll be here every day through Wednesday, so if he dies I have about a 50% chance of being here for it.
Charge nurse put on a very serious face and asked if I would be comfortable getting oriented to hearts at this facility today.
Open hearts are a big deal, the moneymaker of any ICU that does them. Nurses that take fresh open heart recoveries are rigorously trained, tested, precepted, and even given classroom time on the unit’s dollar to make sure they’re fully equipped. Heart pts are delicate, touchy, and heavily regulated, but a really sharp RN with lots of training can keep everything moving smoothly despite the inevitable hiccups. I had not taken a fresh open heart in something like nine months, because even a few months before I left my last facility, the open-heart program became a dangerous place for a relatively inexperienced nurse.
A second-day heart pt had been assigned to a non-heart night nurse due to understaffing, with the idea that the heart-certified charge nurse would be able to back her up and keep things running smoothly. Instead, the pt lost conduction (valve replacements often do, though it’s less common for this to happen on the second or third days) and dropped their heartbeat completely. They ended up coding her for almost thirty minutes before someone thought to hook up her pacemaker, and after thirty more minutes without success they called the code.
The charge nurse was hung out to dry, and retired to PACU a few months later. The unfortunate unit nurse assigned to the pt was scapegoated roundly, despite having never been trained on hearts and therefore lacking the reflex to hook up the pacer to the V-wires sticking out of the pt’s chest. Every hiccup in every recovery for the next six months was scrutinized, written up, and presented “in a meeting” between managerial staff and the heart nurse in question. Everyone on the unit was trained in temporary pacer management, but when the heart RNs requested additional training to address the hiccups that were obviously such a big problem now, they were given no more education—just stripped of autonomy and grilled after every case.
I voluntarily removed myself from the heart list. Which is sad, because I fucking love hearts. They are a huge rush and the detail and precision and reflex required is a serious, galvanizing challenge. There’s also an element of prestige to the open heart program, which I like because I am a bit shallow and vain. Succeeding at the challenge makes me feel like a Real Nurse instead of the secret imposter I usually feel like I am.
The imposter thing is a huge deal in my life. Even writing this diary is kind of terrifying to me, because I know that I’m getting some things wrong and there are probably people shaking their heads and wondering why I suck so bad. I’ve worked ICU since 2008 and I still regularly encounter things that make me feel like a clueless kid wearing borrowed scrubs, things I should have known but didn’t, moments of dumb that make me cringe for months. I am deeply afraid of appearing stupid or uneducated or incompetent. One of the hardest things in my practice is recovering rusty skills—things I used to do well, but which I haven’t done for a while, and which I might be expected to perform competently but will probably make mistakes with. I am constantly ashamed of myself, and sometimes this makes me defensive or aggressive when I really shouldn’t be.
Mostly I channel it into fighting my innate laziness. I don’t want to look like a piece of shit nurse who can’t do anything without her hand being held, so I constantly educate myself, refresh my skills, pay attention to the details, and attend to the shitty boring jobs as well as the exciting flashy ones.
So taking this heart pt was very important to me, and although my shamepanic drive geared up for a beating, I accepted the assignment. As a psychological incentive, there was also an element of the unit really needing a few more heart nurses—my other great fear is abandonment, which means that I am at my most comfortable and secure when I feel necessary. It’s vital that I keep that impulse in check, because a hospital will chew you up and spit you out if you can’t resist the phrase “we really need you.” And nobody in a hospital is truly indispensable, so at some point in every work situation I will inevitably encounter the truth that I will never be perfect and that perfection is not required for me to be valuable. But I allow myself a few smug moments sometimes to enjoy my employers’ gratitude and/or relief, just as I occasionally remind myself that if I don’t get my job done right, I will get in just as much trouble as the next nurse down the hall.
My value is earned, and if I fuck around and make messes, other people are entitled to avoid me—which means that the approval and security I crave is a predictable resource I can expect if I fulfill certain realistic expectations, and am entitled to demand if it’s inappropriately withheld.
There was a time when I handled things with much less self-awareness. Approval and love were like an endless series of rocks thrown into the emotional well of my insecurity, each little splash a momentary fix, while the whole time I acted like a crazy person, trying to drive the source of approval away to “prove” that my fears were legitimate and that the splashes would stop coming. I was an incredibly challenging person to care about. I think the only reason I finally escaped that personality hellhole was that I got into nursing, where my value was measured in life and death and hourly wage. It’s hard to lie to yourself about patient outcomes.
I’m pretty sure nursing saved my life.
I’m also pretty sure this diary is not at its best when I’m navel-gazing in it. Lo siento, my friends.
Anyway, Mavi*, one of the best heart nurses on the unit, offered to be my second/preceptor for the day. She is a tiny Filipina woman with beastly skills, ice-cold reflexes, and the kind of gentle, humorous nursing style that makes everyone around her comfortable and happy.
We prepared the room and sat down to get me oriented to the paperwork and charting. Every fresh heart has a primary nurse (in this case, me) and a second (Mavi), with distinct roles in the recovery process—there is a hell of a lot of work to do during those first few hours. Every facility documents its hearts a little differently, and every surgeon has their own preferences and quirks, and every heart nurse needs to get familiar with the details very quickly so they can be second nature by the time they’re making decisions about which medication to start.
This surgeon doesn’t like SCDs (leg massager pumps used to prevent blood clots from forming), prefers to be texted rather than paged, dislikes high doses of epinephrine used as a pressor, and is blazing fast at his job. He also plays jazz guitar, was once an aerospace engineer (his first career), and is in active military duty through some branch or other. I was a little intimidated, to be honest. Mavi put the surgeon’s number in my phone while we looked over the procedural chart for landing a fresh heart, which she wrote a while back and which has become official paperwork because it rocks.
Off-pump call came about four hours after surgery started, which was incredible, considering that the guy had a valve replaced (requires cutting into the heart itself), a coronary artery bypass graft (CABG, requires harvesting a vein or artery from somewhere else in the body), and a double MAZE procedure (a labyrinth of burn scars in both atria to prevent atrial fibrillation). This is a whole lot of stuff to have done in a single surgery, let alone in a mere four hours of surgery.
Elevator call is typically an hour after off-pump call. Once the pt is taken off the bypass pump and their heart is restarted, the team still needs to close the chest and perform a few other little tune-ups, then watch the pt until they’re satisfied that he’s stable. Then they give one last notification to the ICU and load the whole crew into the elevator. So the pt arrived, intubated and still working off the anesthesia, with a churning nest of OR nurses, techs, and anesthetologists squirming all over him. Mavi hooked him up to monitors while I checked on his chest tubes; Mavi drew up his initial labs while I charted until my eyes started to sweat. Mavi performed foley care; I ran hemodynamics through his swann catheter, checking on the function of his various cardiac components. I listened to his heart and lungs—this is especially important in valve surgeries, since a valve problem will usually be audible as a murmur—and Mavi examined his pacer wires and vent settings.
He was atrially paced. Many valve pts come back with their pacer wires hooked up and firing, either by directly stimulating the ventricles (the big chambers at the bottom of the heart, the ones with all the kick) or by starting the electric cascade in the atria (the little chambers whose job is mostly to pack extra blood into the big chambers and stretch them out bigger so they can beat harder). Some surgeons prefer to let the ventricles fill on their own and just pace from the ventricles themselves. In valve surgery, the actual heart itself is cut and the nerves are very unhappy, especially the nerves responsible for relaying messages from the atria (where each beat starts) down to the ventricles (where the beat ends with a big push). Angry, swollen, shocky nerves don’t relay impulses well, and thus any beat that starts at the top of the heart—whether natural or atrially paced—may not get conducted all the way to the bottom.
But that atrial kick gets a lot more mileage out of each beat. Imagine holding a water balloon in your fist, and squeezing it until it pops. If the balloon was filled just by dunking the empty balloon into a bucket of water, it won’t have much water inside, and your fist will have to squeeze really hard to pop the balloon. But if you hooked the same balloon up to a water hose and filled it until it was ready to pop in the first place, the balloon itself wants to return to its original shape—it has mechanical elasticity, and your fist only has to work a little to make it pop. In this case, the ‘pop’ is the force of perfusing your entire body with blood, and the water hose is the atrial kick that forces extra blood into your ventricles. So atrial pacing is a great place to start a cardiac pt. If you lose conduction, you can always hook up the ventricular pacer wires and stimulate beats that way.
His blood pressure and cardiac output, of course, started to drop very quickly. The recently-cut heart is stiff and shocky and stressed out, and its walls don’t want to move very well. Plus, the body is reacting to the insult of being cut up and partially exsanguinated by shifting fluid around its various spaces, pulling water out of the blood into the tissues where it’s mostly useless except to swell up and make you look puffy. So we administer fluids, to replenish the thirsty bloodstream, and we administer albumin, which thickens up the blood (increases its osmolarity) to suck water back out of the tissues into the blood vessels.
To support the blood pressure, we use several different medications by steady drip. I am pretty used to using dobutamine as a front-line inotrope—that is, the first drug I turn to when I need to stimulate the heart to squeeze harder instead of faster. This surgeon, however, prefers epinephrine, aka adrenaline, which both speeds the heart (a chronotrope) and increases its contractility (an inotrope). As the pt’s recovery continued, we shifted from the fluid-moving phase to the vasodilation phase, in which the body really wants to relax its veins and dump all its fluid into the tissues. Here we started using phenylephrine, also known as neosynephrine, which is a pure vasopressor—that is, it tightens up your blood vessels, and doesn’t affect the workings of your heart. In the same way that you get higher pressure by squirting water through a straw than through a hose with the same force, tighter blood vessels increase pressure… although they resist the heart’s beats a little harder.
One of the other big bad pressors, norepinephrine/noradrenaline, is also known as Levophed… or, in ICU parlance, leave-‘em-dead. It will squeeze the living shit out of your blood vessels until your toes drop off, which is what happened to my CRRT lady a while back. If you find yourself using norepi on a cardiac surgery pt, something has gone extremely wrong. The other two pressors, vasopressin and dopamine, I will probably talk about later, when I have a pt I’m using them on.
Within about two hours of his arrival on the unit, he awakened enough from general anesthesia that he could open his eyes, lift his head, and follow commands, so we pulled out his breathing tube and let him breathe on his own. A little morphine for pain, a few ice chips for his dry throat, and he was happy as a clam in sauce.
He was also convinced that I spoke exclusively German, and was courteous enough to speak exclusively German to me. I do not speak German at all, so occasionally I would rattle back at him in hospital Spanish (I cut my ICU teeth in Texas) and he would recoil, startled. He is a world traveler and historian and as he came back to his senses throughout the afternoon he and I had many wonderful conversations in English. Any time he drifted off though, he would wake up, look at me, and start speaking German again.
Man, I don’t know. I don’t even look German. I have enormous bushy brown hair, a prominent forehead, freckles, glasses, and the kind of sloppily-assembled facial features you get from slightly inbred trailer trash that grew up in the river bottom. I look like leftover tax dodger and piney-woods moonshiner and hastily concealed ancestor ethnicity back when Irish was considered ‘ethnic’. I am white as shit, but not in the classy-lookin’ European way, is what I’m saying. Four years ago, before suffering my way through braces, I had buck teeth.
I’m not exactly pretty, but fuckin hell man, I don’t have to be. I am the apocalyptic definition of ‘personality hot’. I’m the lady equivalent of that weird-lookin fucker on TV that’s sixty years old and worryingly asymmetrical in the face parts and could bang your girlfriend in the bathroom at your favorite bar after five minutes of conversation. I am also incredibly arrogant and don’t speak a word of German. It’s quite possible that he was just telling me how my face is so gnarly it’s giving him flashbacks to WWII.
We joked a little about our respective experiences with foreign languages, and he taught me a little about the ways in which Italian deviates from Spanish. I taught him to say “qapla’.” I can’t help but feel that I got the better end of that deal.
Anyway, linguistic barriers aside, by the time we had this guy settled down and feeling pretty good, I had an imperial shit-ton of charting to get done, so Mavi watched him for a bit while I had lunch and then tore into the paperwork. The surgeon came by to see how the guy was doing, and I noticed that he was wearing an honest-to-god Starfleet insignia badge on his white coat, which after my earlier Klingon language lesson seemed like a much stranger coincidence than it probably was. We ended up having a nice chat about Star Trek, after which a couple of the RTs came up and started reminiscing about Jimmy Doohan, who apparently used to come to this hospital for pulmonary fibrosis because he lived nearby. (I would consider this HIPPA material except that it’s freely available information from Wikipedia.) He was apparently funny and personable, hated being called “Scotty,” and once left AMA because he hadn’t had any alone time with his wife in a week.
The RTs apparently thought very highly of his wife, who was much younger than him but who genuinely seemed to care about him and connect with him on a personal level. “They were great people,” said the surgeon. “I was always a little intimidated by him though.” Then he started talking about how his engineering career was spurred by his love of Star Trek, and how he missed NASA because he had felt like a member of a modern-day Starfleet there. I turned into a brick of shy-terror and finished my charting in record time.
After that, we got my pt sitting up on the edge of the bed so his feet could dangle, reminding him to hug his heart-shaped splint pillow tightly to relieve tension on his chest, then popped him back into bed and tidied up the room for the next shift. He was scheduled for at least one more major exercise activity, probably an hour sitting in a recliner, before bedtime. Exercise is critical to the early recovery phase; a pt who lies in bed the whole time will have nasty consequences. Lungs collapse and close up and fill with fluid; chest tubes clot off, and fluid builds up around the heart; blood clots up in the legs and causes pain and swelling, with a huge risk of pulmonary embolism; and the whole body misses the opportunity to tune itself up after the surgery, leading to increased swelling, decreased cardiac output, and severe constipation.
Tomorrow he’ll walk around the unit four times, and spend at least half the day in a chair. After that we’ll really start pushing. His case will be a smooth one, barring any major unanticipated events, and he’ll probably go home in a week or two. Before the surgery he couldn’t walk without collapsing because his heart was too starved for oxygen and too backed up from his scarred-up valve; when he gets home, lord willin’ and the creek don’t rise, he’ll be able to stroll around the park and even do some gentle gardening.
Other things that happened today…
The screaming lady died. Her ammonia poisoning—hepatic encephalopathy—became so intense that she could no longer speak or make eye contact, and she laid in bed thrashing and groaning in horrible garbled sentences of fragmented non-words as if demons had crawled into her skull and were eating everything inside it. Her family stopped going into the room at all, and huddled outside in knots of two and three, weeping. Palliative care approached gingerly, having been rebuffed many times before, and her closest relative made the decision without even having to be asked.
“Let her go,” he said. “She’s not even really alive anymore.”
We took the fem-stop pressure dressing off her leg, and she bled out and died within five minutes. The absence of her screams was sickening for the first half-hour; then hospital silence seeped into the cracks, a weird relief.
In the car on the way home from a shift, you forget to turn on the radio, you forget that you were going to make that phone call—you soak in the lack of alarms, the lack of dinging and beeping and chiming and clanging. It’s like breathing after you resurface from the water, at first. Your eardrums feel like somebody is pressing on them, blunting out the constant bells you know must still be ringing. Then, as other small daily sounds creep in at the edges, you forget what it was that you were supposed to be hearing. The white hum of road noise, the whoosh and rumble, disappears beneath the sounds of the car passing you in the other lane, the click of your blinker, the subvocalization of the gearshift, the creak of your knee as you depress the clutch and wonder why the fuck you can’t just give up your dignity and buy an automatic for the commute. You remember that you downloaded the new episode of that podcast, and hook your phone up with one hand, and dig that last Kit-Kat bar out of your purse to devour while you drive. By the time you reach your home, the endless litany of alarms is not only missing but forgotten.
That’s how it was with her screaming. An hour after she died, we were all cursing under our breath about the one guy whose monitor kept false-alarming. I almost forgot she had been alive just that afternoon.
We also got in two pediatric cases. Okay, teenagers. One was in a car wreck and had mashed up his legs, but was expected to recover, although his entire family was shaken and white-faced. The other was involved in a drowning incident; his mother had seen him go underwater and not come up, and although there was a nurse nearby who started CPR as soon as they could pull him up, he had inhaled a fuck-ton of lake water. His mother was a complete wreck, and understandably so, but very optimistic and desperately hopeful that he would wake up soon.
We’ve had a few drowning cases. Everyone is keeping a politely neutral face, and of course we’re doing everything we can, but (because I’m writing this a few days later) I can tell you that on Friday he had his first code blue as his lungs succumbed to the inevitable damage of lake aspiration, and that today he’s in a rotoprone bed, seizing.
He might yet make it. Maybe. It’s a long shot. Either way, I’ll be here every day through Wednesday, so if he dies I have about a 50% chance of being here for it.
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