Week 7, Shift 1

Well, I definitely got the crazy little lady this morning, and no, my attempt at jinxing her didn’t work. But more on that in a bit.

My adorable pt with the screaming hearing aids had really bad sundowners last night, and spent all morning groggy and slow to communicate. Even after I put in her hearing aids, she mostly just lay in bed napping, drifting off mid-sentence every time I tried to have a conversation with her. Somebody had given her a bump of dilaudid last night for an episode of back pain, and she apparently processes opioids slower than I process an entire brick of cheddar cheese, so she was completely zorked most of the morning.

Her family came in and stood around the bed, morose, watching her mutter in her sleep. “She’s really gone downhill,” said her son. “Yesterday she was so bright and awake, and she was up in the chair for hours… Today she barely wakes up to say hello. What happened?”

I explained about the pain medicine and our plan to closely limit her opioid administration from here on out, and added that her labs were all improving and her vital signs were solid, and that I was recommending to the MD for her to be transferred to a unit with a lower level of acuity. The family was uneasy, and I don’t blame them—I was keeping a weather eye out for weirdness myself, because while I had a pretty good explanation for her behavior (or lack of behavior), any time family says their loved one is different, I pay attention. I can’t tell you how many times I’ve caught something that would have gone unrecognized—a heart attack, a stroke, a major status change—just because I pay attention when family is worried.

(Sometimes I have to completely ignore worried family, when their worry is pathological and they’re doing themselves and their families no favors… more on that later. And yet, if the family is worried, even if it’s just because they’re always worried, I stay at a higher level of worry all day. Not necessarily about the pt, especially if I can look at them and tell that they’re doing fine, but I have plenty of my own shit to worry about and if we’re having a party anyway, heeeey!)

In this case, I was definitely watching her closely, especially when family brought in some edible and drinkable treats to try and coax her into eating. I was concerned that, despite her passing her swallow eval earlier, she would (in her current groggy state) fall asleep while chewing and end up with a hamburger in her lung. I hovered by the bed while her daughter leaned over and bellowed in her ear: “MOM. DO YOU WANT SOME DIET DR. PEPPER.”

And man, her face lit up like Mardi Gras in Las Vegas. Her eyes popped wide open and she levered herself upright in bed like a vampire popping out of the coffin. “Do you have any?”

After that, she was still prone to drifting off, but now she had a vested interest in staying awake. Family? Pssshhh, you can see them anytime. Diet Dr. Pepper? Now that is worth feigning alertness.

Fortunately, she really wasn’t in need of a lot of care, and the doc agreed around 0900 to downgrade her acuity to telemetry. I say ‘fortunately’ because my other pt Martha*, the crazy lady from last night, demanded almost all of my time.

Her history of bipolar disorder has provided her with a history of lithium use, and last year she attempted suicide by taking all of her lithium pills at once. The ways in which people attempt to kill themselves just horrify me. Taking two bottles of Tylenol? Finishing off your Wellbutrin in a single go? Jesus, are you trying to make sure you suffer on your way out? I mean, I sincerely hate the idea that anyone has to deal with the utter bleakness of chronic depression and the spiral that leads down to suicide, and I wish to god nobody killed themselves at all, and I hate that our society makes mental illness such a hush-hush no-funding issue that people can reach that point of suffering without having the resources they need to escape… But the shit that people do to themselves trying to kill themselves, that shit is like an Eli Roth porno. Even handguns fail frequently enough; it’s not uncommon for a person to attempt suicide, fail, and have an entire lifetime of medical fallout to deal with… or six weeks of pure torture in the ICU before they finally manage to actually die.

And of those who succeed in slow motion… they all want to live by the time they die. It’s awful.

Please don’t fucking kill yourself. Entirely aside from the fact that you’ll miss all the movies of the next few decades, that you’ll miss the chance to fake your own death and escape to a South American country and become the mysterious foreigner who lives in the jungle, that you’ll leave behind a body that somebody has to clean up… you have a pretty significant chance of ending up in a nursing home, just conscious enough to feel pain and humiliation, for the rest of your life.

Give it another year. Do something different. Talk to somebody about it. Don’t end up on my unit with ARDS from inhaling your own vomit when the pills kick in. If the Huntington’s is closing in and you really gotta go before you turn into a slack-lipped veggie on a vent, plan that shit out and have your family by your bed. If you don’t think you could convince someone to sit by your bedside while you die, it’s not time for you to die yet.

Anyway, that’s a grim little side note. The point is, this lady took all her lithium pills, and after a major round of dialysis, she ended up with a seizure disorder, diabetes insipidus, and maybe about two-thirds of her original IQ. This time around, she’s in the hospital because a week ago she tripped and fell at home, broke most of her ribs on the left side, and ended up with a hemothorax—a big pool of blood in the space her left lung was trying to occupy—plus pneumonia from her immobility and from being unable to breathe deeply and cough without pain, plus dehydration from the DI, plus a UTI.

Diabetes insipidus is a totally different animal from what we usually refer to as ‘diabetes’. Diabetes mellitus—those of you with some base in languages may recognize the root of ‘mellitus’ to mean ‘honey’—is sugar diabetes, which I have ranted about at length here. Type 1 diabetes mellitus means all the insulin cells in your pancreas were devoured by your immune system in a bizarre childhood autocannibalistic orgy, and you probably need an insulin pump; Type 2 diabetes mellitus means your body is growing resistant to insulin and your pancreas is maybe not pumping out as much as you need, often because you have a genetic predisposition or (more likely) your fat cells are overstuffed and trying to tell you to lay off the cheesecake.

It’s called ‘mellitus’ because your kidneys are dumping sugar, and your piss turns sweet. Doctors used to have to taste their pts’ urine to see if they were diabetic. It’s never been a good career for the mentally well.

Diabetes insipidus, therefore, means that your urine is insipid instead of sweet—it’s bland and watery. Lucky doctor. The problem here is that, inside your braincase, your pituitary gland (yes, the gland responsible for dragging you through puberty) has become fucked up somehow. In addition to hairy-armpit hormones, your pituitary gland regulates your water balance, secreting a hormone called vasopressin to remind your body that it actually needs water to survive. (In higher doses, vasopressin also causes your vasculature, your blood vessels, to constrict and increase your blood pressure… thus the name ‘vasopressin’. We use a synthetic version of this regularly on the ICU to raise blood pressure in septic pts.) So if you have a pituitary tumor, or massive brain trauma, or certain types of toxicity like lithium… you will constantly gush gallons of dilute watery fifteenth-beer piss, even though you’re dehydrated and dying of thirst and could really, really use all that water you’re filling your Depends with.

So this woman was constantly in desperate need of a trip to the ladies’ room, which is hard to manage when you’re completely deranged from a urinary tract infection, your entire left chest is hamburger on the inside, and you aren’t firing on all cylinders to begin with. She couldn’t bring herself to use a bedpan, and initially she was too dizzy and sick to get up to a bedside commode, so she would try to hold it until she just couldn’t, then fill the bed with a liter of water-pee and start screaming. Nothing we said to her made any sense to her. She hit and kicked and screamed, and it took her daughter and a sitter to keep her in bed and safe and calm.

Her daughter looked familiar. I’d seen her last night in the hallway, but now that I was in the room with her, she looked really familiar. After the first ten minutes of introductions, I recognized her with a start—she’d been the caretaker for a pt I cared for at my last facility, and she’d been an absolute nightmare. A few delicate questions confirmed my suspicion, and she recognized me too.

She had been enormously controlling, extremely anxious, convinced that we were neglecting her ward even though her nurse could never even get out of the room. She would regularly decide that the pt needed something—a breathing treatment, a new medication, a very specific positioning, an aggressive round of nasotracheal suctioning—and she would insist on it until the doc either gave in or had a stern, invariably ugly talk with her about appropriate care. She was absolutely unable to manage her stress, and this led to her ward being absolutely punished with unnecessary and uncomfortable turns every time she got comfortable.

But this just meant I’d had time to establish a rapport and a set of boundaries with her, and thank living fuck, I was able to get those back into place pretty quickly. I promised to genuinely consider any request she made, but told her I wouldn’t sugarcoat anything or perform any kind of care that I felt endangered her mother, and that if she got stressed out I would stay in the room for fifteen minutes at a time while she went to the waiting room to collect herself.

It worked pretty well.

Then she fired the sitter. The new guy who’d come in for the morning shift is this super sweet CNA I’ve worked with several times, a tall black guy with a genuine smile and dimples to boot, who spent thirty minutes with me last time he floated to our floor while we scrubbed a massive Code Brown off the walls even though he could by rights have ducked out halfway through. He is a wonderful, compassionate human being whose bedside manner is gentle as a lamb and soothing as a fifth of whiskey, and within thirty minutes of his assuming sitter duty, the daughter fired him for being ‘intimidating’.

“My mom is kind of old-school,” she said, clutching her elbows and speaking in low tones, trying her damnedest not to sound racist as hell. “She gets really scared if there’s anyone… intimidating around.” Inside the room, my pt was holding the CNA’s hand and smiling at him while he asked her about her grandchildren.

I told her I would see what I could do, and dove into the chart. Turns out, this cute little old lady with the crazy thrashing etc had not received any pain medication during her stay besides her scheduled toradol, which seemed unrealistic to me considering that she had six broken ribs and regularly freaked out like somebody had filled her bed with bees. She had PRN dilaudid IV available, and I drew it up and headed into the room.

“Are you having pain,” I asked her.

“No,” she said. “I want to go home.”

“Are you hurting?” Sometimes it helps to ask again a different way. “Maybe just a little bit?”

“Yeeeeeah. But I want to go home. So I’m not hurting.”

“We’re gonna get you home as fast as I can,” I said, and pushed the dilaudid. Pts with dementia often have trouble recognizing and expressing pain, and sometimes they think that if they tell you they’re not hurting, they can go home faster. Sure enough, five minutes later she was sleeping like a baby, had peed another liter without freaking out, and had gone from shallow rapid breathing to deeper, regular breathing.

So I sent the CNA off to the charge nurse to be reassigned, and gave her round-the-clock dilaudid coverage. She woke up nicely between doses, no thrashing, coughed on command, and gradually improved to the point that she could get up to the bedside commode.

Pain control is a big deal. And it amazes me that, with all her WebMD recommendations for care, her daughter hadn’t seemed to pick up on her pain. She didn’t need a sitter for the rest of the day.

Her two other daughters dropped by that afternoon. One was even more anxious than the first, terrified of the hospital, terrified of her mother’s condition, not wanting to talk about any of it. The other was fairly laid-back, having worked for a nursing home for a long time, and was mostly stressed out because her sisters were stressed out.

The pt did have a seizure. It started with her eyes jerking to the left, which apparently is her characteristic onset symptom; her daughter called me in, and I gave her Ativan to break the seizure as it kicked in, so she ended up having a few seconds of genuine tonic-clonic seizing before lapsing into post-ictal grogginess.

About 1300, just after my hastily-shoveled lunch of microwave burrito and cottage cheese, the charge nurse cornered me. “I hate to do this,” she said, “but we have a new pt coming in and nobody to admit them. Can you give your tele lady to this other nurse, and admit?”

Charge just seems like a position where you have to constantly deliver bad news and ask people for huge favors. I will definitely want to train for charge someday, but I also dread the thought of having to tell someone that I’m screwing them over because their assignment is too easy and I need somebody to land a clusterfuck and you’re it.

So I gave report and handed off my cute little lady, who was chugging her fifth Diet Dr. Pepper, and took report from the emergency room on a frequent flier.

This poor guy has been in the hospital five times already this year, and god knows how many times last year. He has some kind of GI bleed, probably in his small intestine, which recurs regularly for no reason anybody can pin down—no history of alcohol, no NSAID use, no fucking idea. Last year he had what our GI docs call the “million-dollar workup,” a cascade of diagnostic tests culminating in a literal swallowed camera capsule that films your entire gut as it passes through. No results.

This time his hematocrit was really, really low. I gave him several blood products and wiped his ass a few times while he shit out the last of the blood, and his GI bleed was over—just a couple days of blood transfusion and crit checks, and he’d be back home with his mystery bleed, happy as you please. He’s been here so often that the docs ordered him a full meal plan as soon as his crit stabilized, recognizing his telltale signs of recovery. Usually GI bleeders have to wait a while to eat… we just know that this poor guy is done bleeding once he starts getting hungry, and there’s no use in keeping him ravenous all the way up to discharge.

We did an EGD though, because we kind of have to, because it would be shitty to miss a bleeding ulcer just because he’s never had one before, and have him perf his stomach and die. It was a five-minute affair and he was damn near awake for the whole thing—he said he was used to it by now. That is not a thing I can imagine getting used to. He had a beautiful pink happy stomach lining though. His breakfast of scrambled eggs was still intact and recognizable and made me extremely hungry. I really need to start bringing multiple freezer burritos per shift.

I got hiccups toward the end of shift. I used to get them all the time on nights, usually between three and four in the morning, big whooping hiccups that sounded like some kind of lost stork wandering the darkened hallways calling for its young. My coworkers used to make relentless fun of me. Well, guess what, these coworkers also make fun of me when I start yelling HOOP uncontrollably in the middle of shift.

I could close my mouth and kind of muffle them, but that hurts. So fuck you, I’m gonna contribute to noise pollution, and you can all suck it and/or wear earplugs.

I hope this doesn’t become a regular thing.

At 1500 shift change, the new charge nurse dropped by and poked her head into the room. The pt’s daughter gasped. “Oh my god, I didn’t know you worked here now!” Turns out, this particular charge nurse once directed the adult family care center where my pt’s mother spent her declining years, had known my pt since she was a teenager, and had held all three anxious daughters while they were all still in diapers.  There was a distinct change in the dynamic after that—they seemed to trust us more, now that their old friend was in charge, and I didn’t have to enforce boundaries quite so stringently.

It’s a small fucking world, my friends. I never met this charge nurse before I started working here, and now here I am, taking care of a pt she practically raised, whose daughter I knew from another facility as a pt caregiver. This isn’t a huge city/region (technically the two facilities are in different cities, part of the sprawl of the central metro), but I am always amazed at how often I run into nurses I know from other places, pts I took care of years ago, and people I have to pretend not to recognize lest I violate HIPAA or make shit awkward.

Been checking up on my abd guy. Yeah, he’s still alive. Why, how, I’m not sure. His hemorrhagic necrotizing pancreatitis and total kidney failure have reduced his quality of life to “constant torture when he’s not in a coma.” Lots of legal pushing later, and they’ve assigned him a guardian ad litem… who now has to jump through a million legal hoops and decide whether or not to let him just die.

It’s not an easy choice. He’s very far removed from anyone who could speak for him. His roommate, who only realized he was hospitalized because nobody was using the toilet paper for three days, says he has a daughter somewhere…. But he’s never said her name, just called her ‘my daughter’. He left no living will, no advance directive, nobody with a durable power of attorney.

His coworkers keep coming by to check on him. They’ve all shelled out to get a rental storage unit for his belongings; they show up in their work uniforms, still sweaty and obviously exhausted from their shifts, to stand by his bedside for a few moments and tell him what’s going on at work. We can’t tell if he understands any of it. He opens his eyes sometimes to painful stimuli.

They obviously care about him a lot, and to me this means something. Most people who suffer from major addictions don’t have a lot of people who care about them; they sever their ties, drive away their families, and are slowly devoured by whatever chemical owns them, alone. Even recovering addicts usually spend a little while with their only friends being fellow recovering addicts, if they’ve been addicted for some time. At least that’s what it feels like.

But it’s telling that this guy, despite being a profound alcoholic, separated from family and friends, struggling with addiction, is still someone that his coworkers care about. They’ve worked with him for a long time. Some of them know that he had big issues with alcohol, and have delicately made the awkward effort to inform his nurses so we can “make sure that gets taken care of too.” They really miss him, and that means something to me—even feeling isolated, even in the throes of addiction, even sweating on his deathbed… he (like many other addicts) is still loved. And they are so glad to see him get help that they’re holding out hope he’ll recover, even though he’s long past the point where his death can be more than delayed.

It breaks my heart. I wish he’d got help sooner. He would have been surrounded with love.

In the meantime, all I can really hope for him is that he dies soon, and quickly. Maybe somebody will show up for him that has some legal authority.

Fucking depressing, man. On a bright note, today one of the consulting MDs accidentally locked himself into the staff bathroom, jamming the doorknob somehow. While the environmental services guys scrambled to try and get him out, he kept up a steady litany of exhortations and pleas: “You guys have to hurry, I gotta get out of here. I took a power dump in here. You gotta get me out, guys. Take off the hinges…”

I’d laugh harder if I didn’t occasionally get locked in a room with a pt who’s shitting uncontrollably. The aftermath of a three-pounder is nothing you wanna breathe in a closed space.

A brief note

Starting Friday, I will be posting new material-- Monday, Wednesday and Friday of each week. Having a little bit of backlog is really nice, but I'm excited to get back to the fresh stuff.

Week 6, Vacation

I called the unit in the morning, during the drive to our camping site. "He went down to the OR at 0800," said the charge nurse. "Victor* is his nurse today. Want me to have him call you when Tiberius gets back?"

"Yeah," I said. My phone had two bars of service, and I knew by the time we reached our campsite, my phone would be an expensive paperweight.

I called again two hours later, as we reached the area of no service. I could barely understand Victor. "He's still in surgery," he said. "They got the full open-heart scrub team. They expect it to run four to six hours."

It was, by the way, totally illegal for him to tell me even this much over the phone. I am grateful that Victor is a bit of a cowboy, because I was so stressed out over Tiberius I was having heartburn.

The lake, when we reached it, was beautiful. It's a deep glacier gouge between old mountains, blue and green with dissolved calcium, clear down to the bottom, with milky mists rolling over it in the morning and evening. Ducklings paddled at our shoreline campsite. Smoke from the campfire drifted through the old-growth trees; I sat in a hammock, holding a book, breathing the scents of peaty moss in the sun and mineral water lapping against the trees, listening to a two-year-old chatter about rocks over the soft unlikely moan of wind in the highest branches of the forest.

"I'm going to drive back to Port Angeles," I said suddenly. "I'm gonna get more firewood, and some ice, and a salmon to roast over the fire."

"I thought we were having chopped vegetables and sausage," said my husband, who was burning his fifth marshmallow already, because he likes his smores carcinogenic and only camps so he can stick food in a fire without getting weird loos.

"I changed my mind," I said, and put on my shoes and hiked back to the car.

In Port Angeles I picked up the aforementioned goods (and a bottle of wine and some extra baby wipes and a bag of chips), but before I even reached the town I was checking my phone every five minutes to see if service had returned. At last I got my two bars back, and called the ICU.

"He's still in OR," said Victor. It had been seven hours. "I'll text you when I get elevator call, okay?"

I ate the chips in the car, parked outside the grocery store, waiting. Thirty-five minutes later I jerked awake to the buzz of my phone.

Four texts in quick succession, apparently sent at different times, just now squeezing through the terrible cell coverage:

He's closed

Elevator call

Landed- BP good + sats 95

Looks like shit but stable + bronch fixed + thorx closed

I responded: Thanks man, keep em alive. Then I drove back to the campsite through the growing dusk and crawled back into my hammock, where I lay ignoring my book and staring at the lake until my brain finally remembered to be somewhere else than work.


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It was a good camping trip. I forgot to worry for a while.


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On the way home, passing through Port Angeles, I called the unit again. It was Monday morning, eightish, and I was ashamed of myself for not remembering until after I'd had breakfast. "Can I talk to Tiberius's nurse," I asked the secretary, and she made a sound of regret.

"I'm sorry," she replied. "He had another STEMI last night. They withdrew this morning. He died about an hour ago."

"Oh," I said. "Okay. Thank you."

It was a long drive home.

Week 6 Shift 2

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

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

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

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

“So… should I go home?”

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

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

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

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

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

And I started working really hard on his bowels.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But man, Tiberius wore me out.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Week 6 Shift 1

I called in on my day off to make sure Tiberius was doing all right. Pretty good, said his nurse for the day, still slowly tuning him up for a thoracotomy revision. He had another episode this morning, but he’s recovering all right.

Episode, I replied. What episodes? Did something happen?

Turns out, his left chest tube—the one draining his empty pleural space—clogged itself up the night before, and within about twenty minutes he was building up air in the space, which rushed in and had no way to escape. Slowly the pleural space was inflating itself like a balloon, crushing his heart and his other lung and pushing even his larynx off-center: another tension pneumothorax, one of the deadliest complications possible in his current state. The prickly doc made a quick desperate decision and stripped the tube, sucking the clot out into the drainage chamber and restoring the escape route for all that air.

In the short term, of course, she saved his life. There wasn’t any other option. In the long run, she gave the cardiothoracic surgeons a complete mental breakdown, because the suction created by the tube-stripping ripped his stump just a little more.

Which tells us a really awful thing about his prognosis. That bronchial stump is not doing well. It bleeds frequently; it leaks air occasionally; and with the slightest tug of pressure, it tears and leaks even more. For the flesh to be that friable, that ready to fall apart… it sounds an awful lot like lingering cancer.

The CT surgeons had already noted that they couldn’t get a clean margin on the tumor. His prognosis isn’t great even if he makes it through this immediate crisis. I should not be getting attached.

The afternoon of my day off, the pulm doc gathered together a team and exchanged his breathing tube for a longer one with two lumens (tubes). One lumen’s inflatable cuff put it right in the carina, the bronchial split; the other was placed by careful bronchoscopy in the right mainstem bronchus itself, isolating that lung from the stump so that they could finally, finally crank up his PEEP.

When I came in, however, his morning chest x-ray looked great from the nipple down and horrible on top. His right upper lobe had, apparently, collapsed. The pulm was called in again to retract the breathing tube from where the balloon cuff had slipped a little and completely occluded his right upper lobe. Then we cranked his PEEP way up for a while to pop it back open, and by the time this was done I finally crawled out for lunch and scarfed a freezer burrito before taking a short nap on the sofa.

My charge nurses and coworkers are a little weirded out by how easily I fall asleep on my breaks, and how soundly I snooze until my phone’s alarm clock goes off. I dunno, man. I think it’s understandable.

Back in the room, I found his wife alone for once, the rest of the family having gone for lunch. Despite the usual brightness in her voice, she looked exhausted and sad, and her expression as she held his swollen hand (puffy from the pressors, bound up with tape and tubing) was not one of hope. “It’s hard,” she said, “him not being here.”

And he wasn’t. Since we’d started sedating him deeply, he’d been gone: absent in presence, the center of the room and still conspicuously missing. For the first day or so, it had been a relief, to see him sleeping instead of grimacing in pain. Now, though, it started to sink in—Tiberius was somewhere else, leaving his wife to make decisions for him, leaving me to tend his body until he returns to it.

If he ever returns to it.

The shift stretched on: fine-tuning, occasionally stripping the chest tube in fear and trembling, turning him very carefully to avoid putting pressure on his remaining lung. I noticed that lying flat caused him to drop his pressures sometimes, and of course his vomiting continued—a mouthful of liquid green every time we turned him, often pouring out of his nose as well.

A little chart necromancy later, I realized he hadn’t had a bowel movement in… oh god, like a week. More than a week, despite all the bowel meds. He must be backed up to the collarbones. Which would explain the positional blood pressure—between the stuffed gut and the hiatal hernia, his heart was probably starting to feel the pressure. I talked to the doctor, gave him an enema, and started doubling down on his bowel meds.

At 1800 the charge nurse came up and asked me who I would choose to follow me on nights. The list was not confidence-inspiring. We have a lot of good nurses, and all of the nurses available were quite good, but few of them specialized in blindingly seat-of-the-pants critical pts like Tiberius and the few who did were earmarked for cardiac pts and an intra-aortic balloon pump. “Nobody else?” I asked, and the charge nurse winced.

“We’re incredibly short-staffed,” she said. “We’re just going to pair him with another pt and hope for the best.”

No fucking way. “I’m staying until 2300,” I said.

Sixteen-hour shifts are not fun. They aren’t a thing I like to do at all these days, and I won’t do more than one every couple of months. It’s too easy to fuck up your body—I’m 29 and I have gray hairs that all popped up at once after a six-month sprint of heavy shift work with multiple sixteeners per month. But they’re worthwhile in some circumstances, and this is one.

Still no bowel movement. I got an order for magnesium citrate, and carefully dripped it down his feeding tube, trying to avoid causing him to vomit.

The extra four hours passed much the same as the rest, but without any family members—they all went home to sleep. The room turned dark, and the unit started to really feel like night shift, my old stomping grounds (I went days in December). In the quiet, I nattered around the room, cleaning up and labeling lines and doing all the things that don’t fit during the hectic days, and which are a burden to the proper night shifters who come in after 2300 to a hospital with minimal support staff and pressure to keep all their work quiet.

I realized at some point that I was singing. I am not a singer—I actually have half a college degree in vocal music because I was a dumb kid at a bible college once, but I hate the sound of my voice and I only sing in the shower, or when I’m alone.

Alone, where nobody can hear me. Or where the only person who can hear me is too far gone to care. I was singing Rainbow Connection: have you been half asleep, and have you heard voices? I wasn’t doing a good job. Tiberius breathed softly under the coercion of the ventilator, not flickering an eyelash at my terrible singing, drifting on an opioid sea. I wonder what dreams he’s chasing, out there in the dark.

Week 5 Shift 3

Day three with Tiberius. I showed up at work a little early, caught up with the night nurse, then headed to the charge nurse station and insisted that he MUST be made 1:1. They asked if I could take a telemetry overflow admit on the side, and I gently but firmly reminded them that I regularly balance absolutely unreal workloads and am very good at handling high-acuity spreads, and that the last time I insisted on a 1:1 the guy ended up with an open abdomen that afternoon. I got Tiberius 1:1.

Which is a good thing. His sedation was cranked way the hell up, which was appropriate-- even his breathing impulse was completely knocked out on 250mcg of fentanyl per hour + precedex at an obscenely high dosage (got an MD order to double the hourly dosage if necessary, rounded out about 150% of the normal max). And yet he was still waking up from time to time, glaring rings of white around his irises, the expression of puzzled horror that comes with sudden sharp agony. I've had my share of dental work done-- consequences of growing up without owning a toothbrush-- and I recognize the expression well enough, although I'm sure nothing that's happened to my mouth even comes close to the torture of two chest tubes, a partially-closed thoracotomy, a pneumonectomy, and multiple bronchoscopies per day. I dosed him with fentanyl until his blood pressure bombed, and his pressure was still labile for the rest of the morning, dumping whenever he dozed off and soaring whenever he awakened to stabbing pain.

The intensivists had switched out; Dr Sunny was covering him today, and I pitched my case for a new sedative. Given that he was still periodically vomiting, even though we weren't giving him anything by mouth/feeding tube except for a few ground-up pills every day, I was slinging antiemetics at him left and right, and the night nurse had reported a significant prolongation of the QT interval-- the time it takes for the heart to recover from each beat. (The risk being that his heart would try to start the next beat before his ventricles were fully recovered, which could cause his ventricles to freak out and fibrillate, a deadly arrhythmia.) I did some crazy ECG analysis and research and determined that his T wave-- the marker of repolarization, or post-beat recovery-- wasn't prolonged, but he did have a U wave, which is not uncommon for a pt on amiodarone (an antiarrhythmic we were giving him to control atrial fibrillation). The U wave is an extra little bump after the big T bump (after the jagged QRS complex), and apparently it represents the post-beat recovery of the papillary muscles, the little muscle-fingers that anchor and pull your heartstrings to stabilize and open your heart valves. The night nurse had measured from the beginning of the QRS to the end of the U, which made for an incredibly prolonged QT interval, but after a little fishing around on the internet (hey, we google stuff all the time on the ICU!) I found that most cardiologists recommend a slightly different approach.

You measure from the beginning of Q to the end of U only if the U wave is conjoined to the T wave, obscuring the end of the T. If the line returns to its baseline before the U starts, you only measure to the end of the T. Measured this way, he had a perfectly normal QT interval, and I was able to hand Dr Sunny a spittle-flecked piece of paper covered in deranged scribbling and caliper scratch marks and walk away five minutes later with an order for propofol.

It worked beautifully. Thirty mcg/hr of propofol later and Tiberius was sleeping like a baby. 

His wife, Amanda*, was finally joined by a bunch of family from around the country. They have a pretty large family, with various health issues and other things delaying their travels, but the trickling-in of relatives became a steady influx. They are a delightful family, some of them members of a very conservative religion, but free with their affection and bright in their humor and generous with their love. I am not a religious person-- I have some deep and intense spiritual drives that are still bleeding where they were severed, and I still dream of something more satisfyingly divine than the mannequin-god behind the curtain of my milk-faith, but I also have some major bones to pick with organized religion-- but if I had to live in a church faith, I would want one that let me laugh and gossip and cry with my husband's sister and her wife, one that made his grandmother's travel-induced diarrhea an affectionate family joke instead of an unclean shame, one that gave me stories and hope and peace with either life or death, whatever pain or loss followed in its wake.

Good people. Dear people. I wish I could give them the miracle they're hoping for.

While all this was happening, there was a code blue in the ER, followed by a rapid transfer of the pt to the room two doors down, where the horrible family had been before. (They were moved last night because the workstation-computer-cart caught on fire, shortly after which the grandfather had another hypoglycemic episode because the family paused his tube feeds again while they were trying to turn him WHILE THE STAFF WERE TRYING TO EVACUATE THEM FROM THE ROOM. Security was called and the family was limited to one member in the room at a time, with a warning that whichever of them was present next time he had an episode would be banned from hospital grounds.)

This new pt was an older man with a medical-condition necklace on: heart failure, diabetes, etc. It didn't matter much to me, since I didn't get report on him and didn't have any part in his actual care. Except that, ten minutes after arrival, he coded again, and because I was close by I jumped in to help. There wasn't much to do, as everyone else had their hands on the code stations: med nurse, push nurse, chart nurse, resp therapist, and shock nurse. However, from the door I could see that the two-man rotation on chest compressions was having a hard time, mostly because the pt had nothing hard under his back and had to be compressed deeply into the bed to get enough smash to move his ventricles. So I dove in, spiderwebbed through the lines and tubes to the head of the bed, ripped off the CPR board, and shoved it under him at the next compression switch, put the bed on max inflate for a harder surface, and jumped in at the next round to be the third man in the compression chain. Three is a good number; otherwise your arms get really tired.

I am relatively new at this facility, and we are pretty good at preventing codes, which means that I haven't been in a full-bore code in a major role yet. I've carried flushes and even pushed meds, but codes are fast and wild and require strong communication, which means that I'm still at the stage where chest compressions are an appropriate role for me to fill-- a role I share with CNAs and even housekeeping staff in a pinch. I don't mind-- compressions are a workout, and good compressions can make all the difference.

However, this dude was completely fucked. Flash pulmonary edema filled his breathing tube with bubbling red at every compression. His heart wobbled through ventricular fibrillation with the kind of half-assed exhaustion that doesn't respond to shocks. Med after med failed to get a response; shocks and compressions were like rocks thrown down a well. In the hall, his family wailed and collapsed against the wall, and shouted for us to save him. A nurse from down the hall gently guarded the door to keep the more frantic family members from seeing the bloody wreck of a corpse that we were preparing to stop beating.

We called it after twenty minutes. His chest was the texture of new banana pudding, before the cookies have a chance to get soggy-- bone fragments scraping the sternum, muscle and fiber pounded to a pulp. 

CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest.

The family burst into the room, still screaming, still demanding that we bring him back. "Keep going," they said, "he's strong, he'll be fine."

The RT popped the ambu bag off his breathing tube, and blood flecked my left elbow where I stood, wringing the numbness from my fingers over his demolished chest. Someone had thrown a pillowcase over his genitals. His skin was the mottled color and temperature of cheap cotto salami. "Wake him up," his son shouted at me from the door.

Instead I leaned over him and closed his eyes. "I'm so sorry," I said. I don't think his son heard me over the post-code chatter in the room, but he fell silent and white. There's a finality to that gesture that speaks more to our sense of gone, lost, dead than any words or blood or broken bones. They retreated into the hallway and sobbed there until the chaplain ushered them away to a private room. I scrubbed my bloody elbow in the sink and slipped out among the other staff, back to Tiberius, back to smile and offer support to Amanda while she and her family told stories about his childhood.

That disconnect is like a ringing in the ears. Death is touch and go: it touches you, and you go. If you're the lucky asshole in scrubs, you go into a different room, and think about it later. If you're the unlucky asshole in the gown, you go where we all go, eventually.

Anyway, after that I insulted the living hell of out an RT by accident, calling her a "respiratory technician" instead of a "respiratory therapist." I actually am shit at terminology like that sometimes and I felt terrible, but I think she understood my ignorance. Any RTs reading this probably just bared their teeth at me a little. Sorry, dudes, I couldn't do a quarter of my job without you. My apologies for fucking with your fiO2.

After that, I spent the evening fine-tuning Tiberius. He needs another surgery, a repeat thoracotomy to finish closing the stump and properly close his back, which looks like fucking hell. Before we can do that, we need every possible advantage to keep him alive, which means crazy tuning up and blood pressure management and cardiac output optimization. I can't describe to you how boring this process is, or how riveting. It's a game; manipulating numbers, one up one down, tightening your margins and leaving wiggle room; it's also a slog, poking this button and that button and making puckered mouths at the monitor while you try to decide whether this is a fluke or a trend. Overall, though, he trended upward. 

By the time night shift arrived, I was beyond exhausted, and worried sick because I knew I would have a day off tomorrow. I wrote up an extensive report sheet on him to be handed off to night shift, complete with goals, responses to titration on each drip, and precipitating events associated with each previous destabilization. I think the night nurse was a little insulted when I handed it to her, until she started looking over it and asking questions. By the time I left she was making a few addenda of her own to the list, and running off copies. I wished her good luck and godspeed, said goodbye to Amanda, and staggered to the breakroom to clock out and take a fifteen-minute nap before trying to drive home.

I called in the next day and asked how he was doing. Fine, they said. Stable and gaining. Still in ARDS, still on pressors, still requiring extensive sedation, but still alive.

Week 5 Shift 2

Day two of the pneumonectomy pt’s care. Day two, also, of the crazy Farsi family and their merciless caregiving.

I’m afraid the crazy family didn’t get as much attention as they probably could have used today. Specifically, I didn’t have time to do all the boundary-setting and therapeutic communication I would normally expend on a family that challenging. And their level of challenging increased throughout the day.

Early in the day they remembered that some nurse had told them once that their grandfather’s tube feeding should be paused whenever he’s being repositioned, to keep him from throwing up tube feeds. Research doesn’t support this, by the way; a lot of old-school nurses still prefer to pause while repositioning, but the fact is, the 10mL of fluid your pt will get while lying down and turning will have almost no impact compared to the residual that’s already sitting in his belly. And, in fact, I don’t ever pause tube feeds when I have a pt on both tube feeds and an insulin drip, as he was.

This is because an insulin drip carries on dosing the pt whether your tube feeds are running or not, and pausing the insulin drip while the tube feeds are on hold does not guarantee a proportional sugar/insulin level when you resume. And it’s very easy to hold the tube feeds and forget they’re turned off, unless you use the two-minute pause, in which case every two minutes it shrieks in your ear like a demon tunneling into your cerebellum… which, in turn, means you slap at the TF pump with your shit-smeared glove fingers until it stops beeping, and you stand a decent chance of turning it off entirely, which prevents it from reminding you if you leave it off for thirty minutes.

And if you turn off your TFs for thirty minutes while your pt gets 15 units of insulin intravenously, you will come back to a pt with a blood glucose of 12 and intractable hypoglycemic seizures. Fortunately, the first and second and third times the family stopped his tube feeds so they could reposition his legs twenty millimeters to the left and then forgot they were turned off, I checked on him before his glucose could drop too far.

This was bad enough, and I had to threaten to remove them from his room entirely for his safety. But midafternoon I returned to the room to find all his IV pumps turned off, including his amiodarone (an antiarrhythmic we were using to control his rapid atrial fibrillation), and blood backed up his central line halfway to the IV pump because there was no positive pressure to keep it from leaking.

I lost my shit. I threatened to have them removed by the police for attempted murder. I told them that if they touched his IV drips again and he died, they would all go to jail. I told them that if they stopped his tube feeds and he went into seizures and a coma, I would make them all stay in the room while he seized and likely died, and they could all know it was their fault.

I don’t often go off that way. But every one of them was an adult, every one of them had been warned numerous times, and every damn one of them has been caught red-handed fucking with something in the pt’s room in a way that could seriously hurt him.

I went out to the nurse’s station and fired them. I agreed to keep them for the rest of the day, which is saying something given the insane acuity of the pneumonectomy guy, but I made it clear that I would not accept another assignment with that family. They genuinely got my goat. I am a little bit ashamed.

When I returned to the room, forcing a neutral expression and a positive attitude, I found that they had pulled the sterile dressing off his central line and were scrubbing the site with a washcloth they had, presumably, rinsed in the sink. I felt something go phut inside my brain and I said through gritted teeth: “I need you all to leave the room for a bit while I take care of a sterile dressing change.”

And after replacing his sterile dressing, I just called the flex nurse to perform all his care. There were only three hours left in the shift, I was busy, and if I had to listen to them argue about who loved granddaddy the most while simultaneously trying to kill him, I was going to spontaneously combust.

It wasn’t like I had nothing else to do. Pneumonectomy guy, hereafter referred to as Tiberius, started out the morning looking tentative and just went south from there. By 0830 he was having increased respiratory distress, along with bronchospastic wheezes in his lung and, to my horror, hollow rushing breath sounds in the empty space where his left lung was removed. A chest xray revealed a huge air pocket in the left pleural space—his left mainstem bronchus was leaking. I explained this to him and his wife, carefully, and he made a gesture with his left hand: poof, fingers splayed. Then he grimaced and lolled out his tongue and exaggeratedly rolled up his eyes.

“Well, it’s not good,” I replied. “But we can’t tell yet whether it’s blown or just leaky. So you might not die just yet.”

He acknowledged this with a wry twist of his mouth. This is not the first time he’s been handed a really nasty diagnosis. (It wasn’t non-Hodgkins, by the way; there was no effective treatment for that in the 80s. It was Hodgkins—thus the splenectomy and sternal radiation.) 

Today was his birthday.

The cardiothoracic surgeon who had done the original pneumonectomy was on vacation. The Trekker cardiothoracic surgeon who did that heart I took the other day was covering for him. He and his PA, a tall thoughtful-looking stepladder of a man I will call Pilgrim (because, if I’m gonna be writing this for a while, I will need nicknames for some doctors), made eyebrows at the xray film while I hunted up the pulmonologist. 

We have a pretty broad spectrum of pulmonologist and intensivist personalities on this unit: a new mother who goes by a disarming nickname, Sunny*, and will show up when you page her but very strongly suggests that you not waste her time; a prickly but brilliant woman who dislikes me (largely because I couldn’t figure out the paging system for the first month I worked there and paged her 2034832098432 times by accident); a worldly and fun-loving hedonist who gets very focused on one pt at a time and doesn’t like to be interrupted, but handles the highest acuity pts with TV-ready aplomb; a crusty, snappish fellow with eternal under-eye bruises who gets the job done in record time and has razor-sharp skills but occasionally has to be sauced back into respectful discourse; a slightly scattered gentleman whose hands-on skills are often tenuous but who can spot a trend or a rare disorder with incredible accuracy and whose hunches are always bang-on; a tall genuine fellow with immaculate button-down shirts who is gracious under pressure and never sweats; a terrifyingly competent and unstoppable woman who I could pick up and throw at least five feet except that I think she’s a black belt; and the thin, energetic head of the department, who manages to make everyone feel personally listened to and privileged to be held to his high standards. 

And then there’s this guy. This pulm is tall, grave, soft-spoken, relatively new, a recovering Catholic, and… well. As he examined the film, nodding and creasing his brow, the CT guys awaited his advice with bated breath.

“I’m gonna need an old priest and a young priest,” he said at last, and swooped away to examine the pt before we realized we were gonna have to laugh at that one.

That’s his deal. He delivers sterling one-liners and then leaves. I have never seen a single joke of his fall flat and I have never seen him stick around for the payoff of any of them. He is basically my comic hero.

He spent all of thirty seconds bronching the pt, which was a relief since Tiberius’s poor sedation meant he was desperately uncomfortable the entire time and squeezed my hand until the knuckles cracked, then announced that his left mainstem stump had definitely developed a fistula and they would need to perform a thoracotomy immediately.

“Maybe we should manage it medically until he’s more stable,” suggested Pilgrim, and the pulm shook his head.

“You have two choices,” he said. “You can take him to the OR, or you can take him out behind the woodshed.” Then he swooped away. Fuck that guy. I felt awful for laughing at that as hard as I did.

So they packed him up and took him down. His trachea was already beginning to push over to the side, as his empty lung pocket collected air that couldn’t escape and crushed his remaining lung (this is called a tension pneumothorax and is Bad). I made his wife give him a kiss before he left: for luck, I said, but I wasn’t sure if he’d make it back alive, and if my husband were maybe going to die I would want to have kissed him first. Thirty minutes later, just long enough for induction, I heard the overhead pager: the prickly pulm was being summoned to the OR. The OR where Tiberius was currently anesthetized upon the table like the evening in the poem.

This boded ill. This pulm is noted for her steady-handed bedside code work and management of nightmarish near-death situations. For them to page her instead of Dr Swooper... I sat at my workstation, charting furiously, knowing I was unlikely to get another chance for the rest of the day, and performed the first intervention on the crazy family’s TFs. 

Tiberius returned to me looking like death warmed over: ice pale, pupils wide open, with a shitty hematocrit (blood level) and a blood pressure in the seventies. He had two new chest tubes, a new arterial line in his left wrist, his feeding tube pulled out, and a huge fucking incision across his left side and back that made him look like the loser in a machete fight. The incision bulged and sucked in with each breath; Dr Trekker had not had time to close it properly, and had just stapled the skin together.

What happened was this: they put him on the table, right side down, and cut him open. As Dr Trekker opened his chest, a huge clot rolled out of his left mainstem bronchus stump and fell into his right mainstem bronchus, where it completely obscured all airflow to his one remaining lung. The prickly pulm spent thirty minutes bronching it out, during which his blood oxygen levels dropped to around 30% for two minutes, then 50% for ten minutes, before recovering to the 80%s. 

The bronchopleural fistula in the left stump was not repaired. Closure and placement of chest tubes had been emergent, leaving him with whatever chest tubes they had lying around—a pair of narrow, easily kinked tubes rather than the big hard tough ones we would normally use.

The family was glad to see him back alive. His wife cried and kissed him again. He just lay there, blank-faced, a waxy parody of the guy who had managed to write “WHO FARTED” on a clipboard from under full sedation the day before. The staff in the room met each others’ eyes, not the family’s. We have all seen hypoxic brain injuries.

“It could just be leftover anesthesia,” I said to the respiratory technician in the hallway. “He wasn’t down for long. He’ll probably come up soon.”

But he still struggled. Two units of blood later, we started levophed to maintain his blood pressure, and his hands and feet started to swell as the blood vessels in them became too tight to carry fluid back out of them. His blood pressure hovered somewhere between ‘tanked’ and ‘crumped’, which are the words that all ICU nurses seem to have spontaneously and simultaneously accepted as gifts from the ether to describe a pt that is diving into the homeostatic abyss.

And not a single response to anything we did. He stared blankly at the ceiling. I wanted to throw up.

Finally we all agreed: he just wasn’t improving. Air bubbles poured through his left chest tube in a continuous stream. His right lung had diminished breath sounds, and what air was moving sloshed through his semi-collapsed air sacs like shoes in a washing machine. It was time for yet another bronch.

Dr Swooper performed this one, attempting to advance the endotracheal tube into his right mainstem bronchus so that we could apply greater PEEP without totally blowing the stump. As he suited up, I ushered family out of the room and laid the pt flat so the doc could get to his breathing tube easily.

“Tiberius,” I said, more out of habit than anything—you don’t do anything to a pt without telling them first. “We’re gonna do another bronchoscopy, like the one we did yesterday, and see if we can get your breathing tube down a little farther.”

His eyes shifted and he looked at me. Unfocused, but he looked at me.

“It won’t take long,” I added, squeezing his hand, delighted to see his response. 

He locked eyes with me, a proper focused gaze, and then rolled his eyes at me in a big sloppy expression: yeah, sure, won’t take long at all. Tiberius was back.

The bronch wasn’t super successful, but we did manage to get it angled partially into the right mainstem. No PEEP, but protection from rolling clots. After that the GI doc returned and put another feeding tube down, and I held his hand during that and dosed him with huge boluses of pain medication until he was completely gorked again.

At this point I didn’t care to keep him awake. Anybody who can muster a sense of humor like that is gonna be just fine.

I passed off report and then dropped in to check on abd guy. He is not having a good time—his pancreatitis has progressed from necrotizing to hemorrhaging, and he’s taking a lot of blood, not really responding to much. They’re considering moving to CRRT instead of dialysis. His guts are all inside, but not making any noise, and the GI surgeon took him down and washed him out and couldn’t find any obvious problems besides ‘damn, this guy looks raw in there’. Still keeping an ear out for him.

I accidentally called Crowbarrens “Crowbarrens” to my manager instead of using his real name. I got the most confused look, and had to explain that I uhhhhhh made up a name to call him so I could complain to my husband about him without violating HIPAA. I am not out to my bosses about writing shift reports. I don’t think I’m doing anything illegal or unethical—I really am changing significant details—but bosses tend to be a little paranoid about things like that.

Tomorrow I’m going to insist on having him 1:1. He’s sick enough. He’s not appropriate to pair. I want to give him a lot more attention than I can drag away from another pt, and it wouldn’t be fair to the other pt anyway.

I know he’s not likely to live. I should really not be getting this invested.