Week 8 Shift 2

The new crop of ICU nurses is coming on this month. We’ve recruited our usual blend of experienced RNs from other facilities across the country, pre-trained travel RNs who’ve been seduced onto full-time jobs after finishing their contracts (I was one of these), and PCU/PACU/telemetry RNs who are excited to move to the ICU and learn the ropes. The latter group requires a hell of a lot of attention before they’re ready to be turned loose on patients.

When I entered the world of the ICU, I was a new grad, fresh off the NCLEX. I knew I wanted to work ICU, and I had done a lot of high-focus work in school to get there, but I was in absolutely no way prepared to actually provide critical care. I don’t know why they hired me—I probably smelled like amniotic fluid and fresh hay, sitting across the desk from the manager with my incisors clamped together and my lips peeled back.

As it turned out, they were desperate. A mass exodus of nurses from their MICU had made conditions very tight there, and I suppose everyone figured it would be easier to foist off the low-acuity pts on a clueless tottering foal of a nurse who probably wouldn’t kill them than it would be to suffer through another month of catastrophic short-staffing. And, I mean, I’m pretty good at making competent faces.

Fortunately, I had excellent preceptors. I sat through two weeks of class, then another week of computer training, then started two weeks of precepting—following an experienced nurse through the care of a single pt, slowly learning the ropes and getting used to all the drips and rhythms and schedules and reports. At this facility, new nurses are precepted for up to three months; at my initial facility, I had two weeks on days, one week on nights, and then a full pt load. I don’t know how I managed not to kill anybody.

I probably did kill some people. Not immediately, but by providing less-than-competent care that didn’t give them the foundation they needed to heal. I over-sedated my pts—to be fair, we all did this—and I often ended my shifts completely confused and with so many chores left to do that I was the terror of the day nurses who had to follow me. I was Not A Good Nurse.

So precepting is really important to me, and I came to work early because I knew I would be teaching someone how to ICU today.

Her name is Maycee*; she is tiny and energetic and has the cute kind of freckles that speckle the bridge of her nose (unlike my all-over sepia dapple that looks like an old-fashioned Instagram filter of a nasty crime scene under blacklight). She has only ever worked telemetry until now. She’s quite smart and used to hard work (tele/progressive care nurses are some of the hardest workers in the hospital), and so I didn’t feel too overwhelmed when they told me we’d be caring for two pts instead of the traditional precepting one.

This is actually an intense load. You can’t just do anything—you’re explaining all of it, the principles behind it, the rationales for your actions, the processes you used to arrive at your decisions, the whole time. You have to ask leading questions and see if your preceptee can follow those routes on their own, which means setting up a decision situation, prompting the preceptee with a question, and taking the time to gently prod and guide them until they answer the question on their own. It basically doubles the time anything takes, which means that taking two pts is an absolutely mind-blasting time-management gauntlet.

One pt was a desperately ill pt with liver failure and sepsis who had, before being intubated, said that he didn’t want to be intubated for more than four days, and who was now on his fifth day with no family members to follow up on his wishes. The other had chronic worsening respiratory issues and hadn’t wanted to be intubated at all, but had been found down by a neighbor who didn’t know his end-of-life wishes, so he’d been tubed and brought in by the EMTs and was now in full-code hell waiting for some family members to get back to us and let us put him on comfort-only care.

This has been somewhat of a theme on our ICU lately. It’s discouraging. I hate to imagine being chronically ill, having no chance of recovery, and being forced to stick around and suffer because nobody can speak for me.

By the way, DNR tattoos don’t count. DNR papers, signed by a physician, are good for something if they’re posted where the EMTs can see them before they get the tube in and start CPR… but they aren’t allowed to pull the tube out or, in many cases, stop the CPR once it’s started. If you really don’t want to get beat up before you die, it’s a good idea to get the signed papers and put them just inside the front door, and maybe to get a med-alert bracelet instructing any rescuers to look at your papers and/or call your POA (power of attorney) person.

Our pt was on levophed, which meant his pressure was okay, but his arms and legs were enormously swollen. He was up by nineteen liters of fluid from his admit weight. We diuresed him as much as possible, using albumin between rounds of lasix to suck the fluid back into his bloodstream from his tissues. An hour into the shift, we started a lasix drip. We also had to keep him on a continuous potassium drip, as lasix works by dumping potassium to force the kidneys to dump water as well (in simplified terms, anyway).

At max rate, the lasix got his kidneys up to a break-even point where he was peeing about as much as we gave him every hour, except hours where we gave him antibiotics or literally any other fluid above and beyond his continual IV drips.

Meanwhile, the guy next door required frequent bolus doses of sedatives to keep him comfortable, and was shitting more or less continuously. He weighed a fucking ton, so we were relieved to discover that his room was one of the two-thirds on our unit that has an overhead lift by which we could turn and haul and move him. It didn’t really help a lot with cleanups, since it lifts pts by hoisting the corner-straps of a mesh hammock the pt is lying on… so if you need to clean the pt’s butt, you have to move the hammock out of the way. But it made turns a thousand times easier.

Our liver failure/sepsis guy was really not doing well. His PEEP had to be cranked up; he was so fluid-overloaded his lungs were flooding, and the high doses of levophed provided even more systemic resistance that backed up into the left side of his heart. I’m not actually sure if this is true, as I haven’t fully researched it, but I’ve heard that levophed and phenylephrine in particular contribute to pulmonary hypertension by squeezing the lung capillaries, which causes the same swelling in the lungs that happens in the hands and feet with those drugs.

Either way, I can tell you that a pt on a high dose of levophed isn’t going to be breathing on their own for long.

(The hand and foot swelling comes from the way levophed closes up your peripheral blood vessels, resisting blood flow to those areas so that the blood is redirected to critical organ circulation… but also impeding the return flow of fluid that actually makes it out that far.)

So we had him on a whalloping fourteen of PEEP. I can’t remember if I’ve explained PEEP before, but I am the kind of person who precepts well because I can’t stop myself from ranting, so buckle the hell in.

PEEP stands for Post-End Expiratory Pressure. If you just breathe all the way out at the end of each breath, the little air sacs in your lungs—the alveoli—can collapse at the end of expiration. And because the inside of each alveolus has to be wet and gooey with lung-mucus to allow oxygen to diffuse across the membranes, the walls of those little sacs stick together when they close—especially if there’s lots and lots of goop, ie lung boogers or edematous flooding.. It takes a shit-ton of work to force those stuck-shut alveoli open again, and until they pop open again, they aren’t exchanging any air. It’s better to keep them open in the first place… but how?

As a bonus, if your alveoli are swollen up with too much water, they might stop working properly—in which case you gotta bring that swelling down. Diuretics might work if it’s a systemic overload problem, but if your lungs are just irritated and inflamed, you need to find another way to squeeze the fluid out. If you’ve ever had a sports injury, you know that compression helps a lot… but how are you going to squeeze your lung tissue?

The answer to both of these questions is PEEP. At the end of each breath, a sharp puff of air forced into the lung keeps the interior pressure of the lung juuuuuust high enough to prop open the alveoli, and maybe even force a few closed ones to reopen. And by maintaining pressure on the alveolar tissue, PEEP compresses the swelling, forcing fluid back into the bloodstream so your heart can pump it and your kidneys can dump it.

There’s a problem with PEEP though. And we ran into it almost immediately, as our pt suddenly bombed his pressures and had to be given albumin, then cranked up on his levophed even further. Why was this happening, I asked Maycee?

She pondered this for a while. It’s not an easy concept to grasp, and I was asking her to piece it together on her own. I hinted that it had to do with pressures and pressure imbalances in the thorax, and she worked on that until I could see her brain sweating. At last she ventured: is his heart not making enough pressure?

Yeah, I said. There are three reasons why the ratio of pressure involving the heart might be off. The heart itself might be having trouble generating pressure; the pressure beyond the heart (either in the body or in the lungs, the two areas the heart empties into) might have spiked, making the heart’s normal pressure insufficient compared to the new resistance; or the heart might not be getting enough pressure supplying blood to it. Or a blend of these things—it’s rarely just one.

Had we recently changed any pressures in his body?

Any post-end expiratory pressures?

At that point she got it, and it was amazing to watch the string of lights behind her eyes igniting a trail from one concept to the other. “More pressure in his lungs from PEEP,” she said. “More pressure for his his heart to push against; more pressure to resist the flow of blood back to his heart from his body. We changed the pressure! So can we fix that?”

The answer is complicated. More fluid in his bloodstream would increase the return pressure to his heart, but stood a good chance of never making it back to his veins after the pressure in his arteries petered out, and he was already desperately fluid-overloaded. He had run out of places to put extra fluid; his arms and legs were weeping and taut, his scrotum had inflated to the size of a basketball, and his belly was a distended, thumpable tank of fluid that had oozed from his liver into his abdominal cavity.

And honestly, you can only give someone so much levophed.

So we called the charge nurse and asked if we could hand off the other guy at 1500—the answer was yes—and then called the pulmonologist/intensivist, our brilliant and beloved Dr. Padma, and asked if she felt like tapping this guy’s abdomen.

She agreed with us: we needed to get some fluid off this guy, and a quick bedside ultrasound showed that he had too much fluid in his belly to measure easily just by looking at it. She said she would go finish her rounds, then come back after shift change.

I sent Maycee on an extended lunch break. It’s hard to absorb all the things you’ll see in an afternoon on the ICU if you’re not used to it, and I firmly believe that part of the learning process involves time spent staring at the wall, trying to piece all the memories and ideas together. By the time she got back, it was ten minutes after shift change, and I had the room more or less prepared for the paracentesis.

Dr. Padma set up a paracentesis kit at the bedside, and we watched as she used the ultrasound machine to guide a needle into a fluid-filled pocket of his abdomen, thread a hollow plastic catheter over it, then withdraw the needle and leave the catheter to drain.

The bag that came with the kit filled to its total—a liter—almost immediately. We emptied it, then drained some more, then realized that this was going to continue for some time. So we hooked the catheter up to a wall suction canister, turned it to low suck, and changed the canister every time it filled up.

The fluid was thick and gooey and wheat-colored with a pink tinge. It also foamed as it poured into the canister, forming a thick layer of bubbles at the top that forced us to empty the one-liter canisters whenever they hit 800mL. I explained to Maycee that the foaming came from protein dissolved in the fluid, a common finding in ascites runoff. Albumin—yes, the same protein that we give intravenously to thicken up the blood and draw in fluid from the third space—is essentially the same thing that you get in egg whites, albumen, which means it foams up nicely when agitated.

I pointed this out to Maycee, and added that you could probably make a decent meringue out of the stuff. She tripped over a gratifying dry-heave and then spat in the sink. “That’s fucking gross,” she said, the first time I’d heard any real language out of her, but her tone of voice was not one of censure.

I mean, you probably couldn’t make meringue out of it. Any decent cook can tell you that any kind of lipid or protein impurity in the albumen can keep the foam from locking; additionally, the acid-base balance of ascitic fluid is more likely to be alkaline than acidic, which means you’d need a lot of cream of tartar to make the foam stable.

Either way, the gates of gross stories had now been unlocked. As we removed liter after liter of fluid from his abdomen—we totaled at nine and a half liters—she told me about a pt she’d had once with severe osteomyelitis in a leg-bone exposed by rotten diabetic flesh, who refused amputation until the doctor reached into the wound and squished the bone audibly, pointing out that it felt like soggy Triscuits.

I told her that one story about the guy and his mother and all the cats, and she called bullshit, which is an appropriate reaction to a story that grim (I will probably never have another story to rival it), but I texted my coworker from that night: “Hey, remember that one guy and his mom?”

Thirty minutes later she responded: “FUCK YOU WHYD YOU BRING THAT SHIT UP AGAIN”

“But you remember it, right?”

“Uh I’m carrying that smell to my grave. How’s your week going, stinky oatmeal?”

The weird thing is that we actually do talk about this almost every time we hang out. We get a bloody mary each and order a thing of garlic cheese fries and sit there picking at the gooey stuff, talking about that guy intermittently between gossiping about coworkers and bitching about administration. I don’t know what we hope to unearth about it, or what draws us back, but in some ways our friendship is about that guy. We’re still working on it.

We finished the paracentesis and Dr. Padma retrieved the catheter. In its wake the insertion site continued to ooze copiously. His blood pressure gained by twenty points within thirty minutes, and we started titrating the levophed down. We administered intravenous albumin again, and shortly after that deep wrinkles appeared in his feet as the swelling started to recede.

A short-term fix. We’d just reclaimed his abdomen as a reservoir for extra fluid; he was still weeping internally. But it felt nice, and it gave Maycee some visible indicator of the pt’s improvement.

The charge nurse appeared in the hallway and beckoned to Maycee. “We’re putting in a trach and PEG down the hall,” she said. “You should come see this.” I waved her off and wrapped up the shift while she and the other preceptees crowded around my abd guy’s bed, watching the doctors attempt to open a hole in his neck and one in his belly for breathing and feeding on a long-term ventilator in a care facility.

He’s actually getting… not well, exactly, but better. His hemorrhagic necrotizing pancreatitis seems to have turned around, and while I’m sure he’ll never have full pancreatic function—or, at this point, full neurological function, as he barely responds to questions and commands—he doesn’t look like he’s going to die of this anymore.

At this point, it’ll probably be pneumonia that gets him. That’s what usually gets people on long-term vents.

They did not have much luck with the trach, although the PEG went in easily enough. He just has weird anatomy. It will need to be done surgically.

I barely recognized him when I poked my head in. His hair has grown a lot, and he’s grown a full beard and then had it shaved. The distribution of weight in his face is really different. You can tell, now that the swelling is down, that he’s not a tall man. As they cleaned him up after the trach attempt and let him come back around, his eyes opened and he looked around the room: a human expression of bewilderment, a hint of comprehension, a glimpse… I regret, now, that I hoped he would die. He didn’t seem to be in much pain, despite someone having just literally slit his throat. He looked uncomfortable, but who knows what discomfort and pain mean to him now?

I wonder what his life is going to be like from this point on. I wonder if he’ll ever really wake up. I wonder how much brain damage he sustained during his intense illness, and whether the dialysis and the tube feeding and the tracheostomy will give him some quality of life. It’s entirely possible. It’s also possible that I’ll never know.

When the night nurse came on, he flipped his shit because we had forgotten to change the propofol tubing at 1600. Because propofol is suspended in a lipid solution, we change the tubing every twelve hours to keep it from getting goopy; I had completely forgotten. I didn’t feel like the flipout was completely appropriate, though. He browbeat Maycee when I left the room and told her it was unacceptable to forget to change the tubing, which is a bit much considering that she didn’t know the rules on propofol tubing—it was entirely my fault—and that we were now three hours late on a non-critical task with a pt we’d spent all day struggling to keep alive. Then he cornered her into performing a full bed bath on the pt with him before she left.

Well, part of a bed bath. He’s notorious for this: you give report to him, and he’ll try to keep you until 2030 as his own private CNA, bitching at you the whole time. I hooked Maycee by the elbow, gave the night nurse a frosty look, and dragged my preceptee off to the break room to clock out.

She looked exhausted, excited, ready for a few hours of sleep and another shift tomorrow. She doesn’t even seem upset at the prospect of spending another day in my tutelage.

I think she’ll do well.

Week 8 Shift 1

By the time I got back, my DKA/wannabe escapee guy had not escaped, but had made everyone on the unit so angry they wished he would. His nonstop bitching and creepy remarks, combined with his gross treatment of his girlfriend and his frequent not-jokes about how we should just let him shoot up because he was going to anyway, had really not endeared him to any of the staff.

When I arrived, he smirked at me, then informed me that he would be leaving at 0930 whether I wanted him to or not, and if I had any shit left to do for him I better get it done in a hurry. And that he would have a long list of breakfast foods from the cafeteria, but didn’t want to stay on the line and wait to order, so he would just tell me and I would have to call down and order for him. When I told him he could either order his breakfast or go hungry, he shrugged. “Fine,” he said. “I have my own insulin, I’ll give myself a dose and go into hypoglycemia, and you’ll get fired.”

I have honestly never had a pt so openly threaten to harm himself to manipulate me. “I’ll give you IV dextrose,” I said, “and your insulin will mysteriously go missing while you’re unconscious, and you’ll wake up just fine except you’ll be hungry. Here’s your phone, you decide if you want breakfast or not.” Then I went and reported all this to the charge nurse and documented it.

His girlfriend met me in the hallway a little later. I won’t tire you with the entire conversation—it was very long and wandering and difficult to listen to—but the gist of it seemed to be that she wanted to stay in the methadone program and get clean. If she stayed with him, she said, he would never let her get clean; but if she left him, who would take care of him?

“I think you’re right,” I said. “He’s gotta find his own rock bottom, and hope that it isn’t a grave. If you want to get better, you’re definitely going to have to get away from him, and you’re going to need some professional support while you’re remodeling your life.”

“But what if he dies?”

“Then he dies, chickadee. Maybe you won’t die too. When you’re drowning, you gotta kick off your shoes.”

I know there’s not much hope for her. But I really hope, if she dies of this, she’ll at least die without that asshole being rude to her the whole time.

At any rate, I got that dude’s discharge paperwork done in record time. I am already a lightning discharge nurse, which usually helps out my pts who really really want to get home in time for the game, but I had him ready to go by 9:15. I cornered the hospitalist that was seeing him and told her she could either give him discharge orders or sign his AMA*, that I had everything ready to go for him to leave, and that the only medical reason I could see to keep him was that he’d threatened to inject himself with insulin so I’d have to order his breakfast. We could have stretched that into a suicide threat, but honestly, it wasn’t. And there wasn’t much else we could do to help him.

(*AMA, in this case, has nothing to do with reddit—it just means Against Medical Advice.)

If I seem callous about this, know that I have zero interest in whether a person is addicted to a substance—it’s a disease we understand very little about, and one that destroys lives as ruthlessly as any sepsis or stroke. The mental health issues that so often accompany addiction, those I have even more sympathy for: my family is not without its comorbidities, and I have seen firsthand over many years the impact of addiction, bipolar disorder, major depression, personality disorders, and post-abuse trauma, all untreated and all devastating. I see this shit every day on the ICU, and it’s a parade of tragedies that never fails to make me sick with frustration that I can’t save them.

But there are, among the tragedies, people who victimize others in their tragedy. Just as it’s hard to feel fully sympathetic for a person who survived horrific childhood abuse and goes on to abuse their own children, it’s very difficult to feel that sympathy for a person whose lifestyle is so self-destructive and so poisonous that they won’t let their loved ones escape the same trap, and whose attitude toward the people they’re hurting and the people who care for them is one of loathing and snide gloating.

And there are people who are offered the help and support they need, and laugh at the people who offer and how disappointed they are when those gifts are refused.

Not a lot of sympathy, no. I was glad to see him go. He asked if he could keep his IV “for convenience.” I gave him an incredulous look and then “accidentally” pulled his IV out with one sharp yank.

“Oops,” I said. “Usually I leave those in until right before discharge. Oh well, you’re leaving soon anyway.”

He and his girlfriend sat in the room, rolling cigarettes from the tupperware of tobacco, until I escorted them to the door. On the way out he joked that maybe he’d offer me a ride in his truck sometime. I couldn’t even feign a farewell smile.

Meanwhile, next door, a coworker of mine landed a pt with Evans Syndrome, a rare autoimmune disease that causes your body to eat all its blood. The pt was acutely psychotic for some unknown reason and lay in bed screaming as if being burned with hot irons. Pain medication did nothing; anxiety medication helped. He couldn’t tolerate anything touching his body and ripped off his ECG leads and clothing constantly. We didn’t bother putting in a foley, but any time he needed to urinate, he would start screaming extra loud and rolling back and forth, cursing and wailing, until he finally let it all loose and soaked the bed/floor/wall/everything in the room.

The second time this happened, I was helping hold his legs down while he struggled to kick and bite the nurse, and the dam broke just as he started bucking. The ensuing arc of piss undulated across the room like one of those floppy-hose kids’ toys that squirts water at shrieking babies in the back yard. He got himself in the face pretty good, and it shut him up for a minute, his whole face contorting in puzzlement as he smacked his lips and snorted. Then he saw that he’d peed comprehensively all over the other nurse—he only got my arm a little—and started laughing hysterically until he passed out from more Ativan.

Meanwhile I had a second pt to take care of: a woman whose uterus had been removed earlier this year for cervical cancer, whose extensive internal scarring had formed massive adhesions and twisted her small intestines until pieces of them died. She’d undergone immediate surgery to resect the dead bowel, and been in pretty good shape afterward. Yesterday morning, however, she had become confused, then gone into respiratory distress. Early in her confused state, she’d pulled out her feeding tube, vomited, and possibly aspirated before finally being intubated and sedated. My job, today, was to support her through what could either be the return of bowel ischemia, or the beginning of ARDS.

She required lots of fluid support and plentiful pressors. She could hardly tolerate turns, and her urine output was minimal at first, though it picked up as we started Lasix to get rid of her sixteen liters of extra fluid. She was in Tiberius’s room, which felt very strange, because her family was also delightful and friendly and religious.

By midafternoon it was pretty obvious that she had ARDS. What’s more, her intestines started to pick up slack and give me some really gross noises, which is fantastic to hear in a pt whose guts are still stunned from massive injury and surgery. But man, that ARDS was not treating her well, and we kept cranking her fiO2 and PEEP up to keep her ventilated… and, eventually, oxygenated. It takes a lot for your lung tissues to stop exchanging oxygen well. We finally found a nice plateau at a whalloping PEEP of fourteen. (Five is the average. Ten is what you get when you’re ARDSy. Twelve is considered a bit much.)

The rest of the day was a matter of balancing her pressures with her body’s ability to tolerate pressors. Levophed made her arms and legs mottle deeply and turn icy cold, and didn’t have as much impact as I would have hoped on her blood pressure. The PEEP was making it hard for her heart to fill and squeeze effectively, which dumped her BP, which in turn made it difficult for her body to get rid of the excess fluid that had accumulated in her body.

There are three spaces in your body where fluid can hang out. Well, I mean, there are lots of places where fluid hangs out, but there are really only three we care about when we’re thinking about fluid overload and blood pressure.

One space is inside your cells. They’re just little water balloons, right? Some DNA and RNA and a mitochondria or two floating around in there, maybe some enzymes doing heavy lifting, some proteins grabbing shit and gluing it together… and, you know, water. This part is pretty boring to me unless a) my pt has been exposed to cyanide or b) my pt is going to need some kind of insulin fuckery to move sugar or potassium into their cells.

Another space, which I am HIGHLY obsessed with, is the vascular space—your actual bloodstream. Water, albumin to thicken the water and keep it osmotically the same as everything else, blood cells, dissolved gasses and sugars and shit… but mainly, blood pressure. Blood volume. If you’re bleeding out, the first thing I’ll give you won’t be blood, it’ll be saline; it’s the same salt concentration as your blood, and it will expand your blood volume so that the blood cells you have left can actually get around and your heart has something to pump.

Remember: if you ain’t got pressure, you ain’t got shit.

But there’s a third space: the areas between the cells, the structural nooks and crannies of the flesh. And when you’re massively inflamed, that space fills up. When your finger gets stung by a bee and swells up, you don’t suddenly get twice as many finger cells—rather, your inflamed cells call out for help, and your body responds by flooding the areas between them with water so that your white blood cells and antibodies can move around more easily and clean up the toxins. Your finger swells up.

When your whole body undergoes systemic inflammation, as with sepsis, that is a whoooooole lot of swelling. And all that water has to come from somewhere—namely, your vascular space. Pretty soon, there’s not enough water volume in your blood for your heart to circulate effectively, and your bloodstream is drying up, and your organs are dying for lack of blood flow while your body happily carries on dumping all its water into your puffy fingers like it’s gonna do any good there.

That’s the basic dynamic of sepsis. And this lady, with her aspiration pneumonia and her fucked-up guts, was septic as all hell. We had boosted her blood volume over and over with fluid boluses, and done our damnedest to pull the fluid back from her third space into her vascular space, but in the end all you can really do is try to interrupt the septic/inflammatory processes with antibiotics and other drugs, support their blood pressure with volume and pressors, and wait for them to pull out of it so you can dry them out again.

Thus, we gave her Lasix. Albumin first, to draw the fluid into her vascular space; then, after thirty minutes, Lasix to diurese her, to pee off the fluid so it didn't overload her struggling heart and increase the pressure and fluid drainage inside her lungs.

It was a long, exhausting afternoon, full of minutiae and sweating into my eyes. Her mottled flesh continued to spread, and her edema increased visibly from the beginning to the end of my time with her. I don't have a good feeling about her outcomes. I suspect she will never be stable again until she's dead.

Meanwhile, another crazy substance-abuse pt was admitted down the hall. I could hear him screaming and cursing even while I was turning my lady, and one of the other nurses poked her head in to ask if I still had the key to the velcro restraint box (I did not).

Things seem to come in waves on the ICU. We’ll get a bunch of STEMIs in a row, then a bunch of GIBs, then a bunch of ARDS. In reality, it’s probably just a normal distribution of all the shit that can go wrong in a decent-sized city; to the endlessly superstitious nurses on the ICU, it means that once you get two pts with similar symptoms, you are destined to get at least two more in the next week or so. This happens often enough to turn our confirmation bias into rock-solid religious conviction. Not looking forward to the next round of crazy.

But who knows? I could just be destined for admit after admit with stuck gut and sepsis. Or I could be too tired to think straight. I suspect the latter is more accurate. Time to pass out.

Week 7 Shift 3

This shift did not start well. I gave report the night before to a nurse who has, best I can tell, the most brutal ball-shriveling resting bitchface I have ever seen in my life. Alex* is extraordinarily pretty, always immaculately groomed, incredibly capable and conscientious, and has the amazing power to make me feel like a feeble, wriggling brine shrimp during report.

“What have his sugars been running?” No eye contact.

“Oh, uh…” /checks the lab sheet “Not too high. Uhhh… One-sixties. See.”

Her lips thin out. “Mmmm-hmm. Did you cover him?”

“I gave him… uh… one unit at noon. And uh…. I didn’t cover his last blood sugar.”

Flat stare. “You didn’t.”

“No, it was… his blood sugar was like… one point above the cut-off. I didn’t want to crash him.”

“Mmmm-hmmm. So I’ll cover that, then, and recheck in four hours. When I’m supposed to. Did you get all the tubing changed?” Her expression is somewhere between of course you didn’t and I can’t fucking believe this.

“Yeeeeeah.” Then I wither in my seat and stare at my report sheet for a while. She never says anything hurtful or really judgmental, she just has a tone. Also did I mention she’s beautiful? That makes it a thousand million times worse. I always tell myself after report with her that I didn’t fuck anything up, that I did a good job this shift, that the things I didn’t get done were things I had good reasons not to do.

So, having given report on the crazy lady to her, I came back in a little terrified in case I had missed anything.

Instead, she informed me that she’d got a sitter for the pt again once her daughters had left for the evening—our night CNA who always stays over, Rose*—and that she’d really gone nuts last night. Great. Alex also said that she’d had two seizures last night, both of them beginning with the characteristic left-eye jerk that she usually pulled, and ending with tonic-clonic seizing.

She’d also had something that Alex described as “really weird,” an apparent syncopal episode. She’d recovered afterward, although her mental status was not so great for the rest of the night, but she’d gone apneic (unbreathing) and unresponsive for almost a full minute, and her heart had raced. Her post-ictal period had been extremely short.

“I don’t think it was a seizure,” said Alex. “She didn’t jerk her eyes around. But I don’t know what else it could be. Honestly? I was about to start coding her when she came to. The doc said that if she’s not back to normal by eight this morning, we’re going to start a bunch of lab panels and get a CT scan. Which won’t be fun, because she literally will not be still.”

Sure enough, she was fidgeting in the bed, occasionally mumbling to herself, pushing at the blankets with her hands and then pulling them back up. God, putting her in a CT scanner was gonna be hell. But hey, 0715, she had forty-five minutes to get some sunlight and snap out of it. My other pt was my little GI bleed fella again, so I got a ten-second “nothing new, discharge today” from the nurse and came back to see about getting my fidgeter out of sundown land.

Rose was a huge help. “We can just get her up to the commode,” she said, “and then maybe if she does well we can put her in the chair for breakfast, have her look outside. That should bring her around.”

So we hoisted her up to the commode, and she immediately dumped a gallon of dilute urine and let out a huge sigh of relief.

I fixed her gown. “Better?”

She nodded, then looked up at me with a puzzled expression on her face. “My name is Martha*,” she said, as if just remembering this fact.

“Yeah,” I said. “You ready to sit in the chair, Martha? We have some toast and scrambled eggs for you.”

A big emphatic nod. She looked really confused, kind of blindsided, and I didn’t blame her—if she was snapping out of sundowners, she would just now be entering the period where she starts genuinely waking up, the way I often stagger to the toilet in the morning without being quite sure whether it’s day or night. Rose helped me stand her up in the waltz position—her hands on my shoulders, my hands gripping her gait belt, my knees braced against hers in case hers buckle—and we started the process of pivoting to sit in the chair.

About halfway there, she made a strange expression. “My name is Martha,” she said again, and her pupils spilled wide, and her body went completely slack.

Rose and I barely kept her from hitting the floor, mostly by hauling on her gait belt and thighmastering her lower body with our knees up into the waiting recliner. She was completely limp, taking little hiccup-breaths, going gray in the face. Her eyes stared into the middle distance. “She’s having a seizure,” said Rose. On the monitor, her heart raced, then fell into a high bradycardia, rate of 55. Her bladder emptied. She wasn’t really breathing, and even the hiccup-breaths were diminishing into nothing.

We kicked the chair into full recline and I grabbed the ambu breath bag. “Check her pulse,” I said. On the monitor, her heart rate cruised down into the forties. “Check her pulse! Does she have a pulse!”

“It’s a seizure,” said Rose, but she fumbled for a pulse—wrist, throat, groin. “It’s just a seizure!” Meanwhile she kicked the bed into flat mode, max inflate, pulled the CPR board off the head, and slapped her walkie-talkie to call for a respiratory therapist and the flex nurse. We all do this: we say what we really hope is true, and the whole time we prepare for what we really hope isn’t true. Rose moves very quickly; the flex nurse, Franklin*, ducked into the room within seconds.

“You guys need help getting her back to the chair?” He looked at Rose prepping the bed, me bagging air into the pt’s lungs while still trying to find the flicker of pulse I’d felt before, and raised his eyebrows.

“Code,” I said. “Press the button!” Rose smacked the alarm and the whole unit dissolved into organized chaos.

“Jesus,” said Franklin. “You don’t fuckin do half of report, do you?” He dove over the bedside commode, nearly slipped in the lake of urine from my technically-dead pt, and helped me cradle-lift her in one adrenaline-filled swoop back into the bed, where we laid her flat and started compressions. On the monitor, her heart rate alarmed in the twenties with a wide complex—slow movement of electricity throughout the heart, a very bad sign—until we took up the lead-hammering pace of CPR.

Good pulses with compressions. The RT took over bagging. The intensivist—one I forgot to introduce before, a mild-mannered fellow with a soothing presence and a way with difficult families—pushed into the room just behind the code cart, which the charge nurse was plugging into the wall while Franklin stuck defibrillation pads to the pt’s chest. “What happened,” he shouted—codes are incredibly loud—and I told him the very short, very confusing story: she was on the commode, she stood up, she died.

We coded the ever-loving shit out of her. Pulseless Electrical Activity was all we got—not even a shockable rhythm, just that useless, flaccid bradycardia on the monitor with no physical pulse at all. PEA arrests tend to have incredibly bad outcomes; the heart is too fucked for the electrical system to even realize the muscle is dead.

In the middle of all this I walkie-talkied the unit secretary to ask her not to let any visitors past the desk for this pt. I mean, god for-fucking-bid that her daughters walk into this shit: their mother blank and staring in a bed, her few unbroken ribs mashing into pieces under my hands, blood foaming up in the breathing tube we’d just crammed down her throat, naked violent death at its least lovely.

Nothing worked. Nothing even started to work. Rose and I were both in a pretty bad emotional state—this was not the pt we’d have expected to code. For fuck’s sake, she had broken ribs and a UTI! And, okay, it looked like she’d thrown a clot and had a pulmonary embolism—the blood clotted in the tube as the lab tech drew it from her arm—and there wasn’t much we could have done about that, but I thought about last night’s syncopal episode and about the expression on her face as she died in my arms and felt absolutely, bottomlessly sick.

We called it after thirty-five minutes, a lifetime to code a woman in her eighties. The intensivist went in the hallway to call her family, and managed to get through to the two most anxious daughters, both of whom went completely to pieces over the phone. The other daughter wasn’t picking up her phone.

I arranged her as best I could, then took over the phone after the intensivist, calling the organ donation group (a legal requirement, typically to rule a pt out for donation) and the medical examiner’s office (another legal requirement, in case someone dies under suspicious circumstances or there’s a chance of hospital wrongdoing), trying to get the okay quickly to take the breathing tube and IVs out. You can’t take anything off or out of the pt until you get the ME’s okay.

While I was on the phone with the ME, the daughter whose phone had been off rounded the corner, ignored my attempt to flag her down, and pushed into the room. “Mom,” she started, then screamed: “Mom! MOM! Somebody help!”

God almighty, the unit sec hadn’t stopped her at the desk. Her sisters hadn’t got through to her either. She hadn’t answered because she’d been on the road, coming here, to visit with her mother over breakfast.

I’m just glad it was the more level-headed one. Of course she was devastated, absolutely wrecked—but she’s more familiar with death, and she was able to integrate it and understand it much sooner than her sisters would have. By the time her sisters arrived, I had taken out all the tubes and wires, brushed her hair, tucked her in, and had her looking halfway like herself again, except for a smear of blood beside her pillow that I covered with a washcloth.

I called the chaplain. Turns out the chaplain was off that day. The family hovered in the waiting room, terrified to go see their mother’s body, wailing and crying, at least one daughter nearly fainting twice. I called the weekend chaplain, who often covers on her days off, and asked if she’d be willing to come in and sit with the family while I finished up their paperwork and helped them get to a settling point.

She came in. I owe her big. Unfortunately, after she talked the family into going home and awaiting a call from the funeral home to go see her recovered body there, she hung around and tried to be emotionally supportive to me, at a time when I had a shit-ton of paperwork to manage and really wasn’t feeling terribly in need of a shoulder to cry on.

Mostly I was pissed as fuck, and frustrated, and I wanted to punch something. Every last fucking thing that could have gone wrong seemed to have gone wrong. I couldn’t believe she was dead; I could not believe that we had failed to keep her daughter from being surprised with her death. I was very polite with the chaplain, but finally I hid in the bathroom until she left.

Then I went into my GIB guy’s room for the first fucking time that whole shift. It was now 0830.

I gave him his breakfast, which was mostly cold by now, and took his blood sugar so he could eat it. I smiled graciously the entire time and apologized for taking so long. “I guess you heard everyone in the unit running around like crazy,” I said. “We were trying to save another pt who had taken a bad turn.”

He dug into his toast and asked: “Were they okay?”

“Not as okay as I hoped.” I don’t want to lie to people, but I can’t always tell them the truth, and either way it’s bad form to bomb somebody’s day with a spiel about how their neighbor just died.

As I emerged into the hallway, Alex appeared, expression of stern disapproval firmly in place. “That went badly,” she said, and I braced myself to defend my actions. “Here, I got you this.”

It was a Starbucks latte. A real, honest to god Starbucks latte. I am a little ashamed, but not much, to tell you that I got a little misty. “Thank you so much,” I said.

“You did really well,” she said. “I can’t believe she just coded like that. And her family… You handled that really well.” Then she left for home, while I sipped my latte and rejoiced in the knowledge that her chronic bitchface doesn’t reflect her actual opinion of me.

Ten minutes later, the guy showed up to carry Martha’s body away, and I finally gave the GIB guy’s morning meds and helped him to the bedside commode. I don’t mind telling you I was sweating like a horse the whole time. Waltz position and pivot, knees locked to knees, the whole time I’m chanting in my head: Please don’t code, please don’t code.

He didn’t code. He did shit an absolute lake of filth. I bet he felt better after that.

After this I took a nap. My blessed coworker and patron saint Mavi covered me for what we euphemistically called an “extended break,” and I spent forty-five minutes facedown on the break room sofa, dreaming about a bubble bath full of little adorable swimming mammals that would pop up through the bubbles and squeak, then dive like otters.

I awakened to the charge nurse shaking me gently. “Can you take the guy in twelve*? He has a sitter.”

Okay. Whatever. “What’s going on in twelve?”

“His nurse is getting a fresh VATS and he’s just… a little heavy.”

“Oh good. Sure. Whatever.”

He wasn’t just a little heavy. I mean, physically, he weighed maybe 200lb, but he was in four-point locking Velcro restraints with a bedside sitter and an ass full of Haldol injections. The dude is in his late twenties, a Type 1 diabetic, with a serious drug problem.

I don’t mean that he’s addicted to something, although I’m sure he is. I don’t even mean that he’s taking something nasty on the regular, although I’m sure he is. I mean that this guy will, apparently, do literally anything to avoid sobriety, up to and including begging Robitussin from a pt family member in the waiting room. I don’t think he even got enough Robitussin to get high.

And at any rate this was two days ago, when he was on the med-surg floor, before he went completely apeshit, ripped the whiteboard off the wall, threw a chair at his nurse, and ran down the stairwell to escape from the hospital. He was in for DKA and pancreatitis, and definitely didn’t seem to be in control of his faculties, so we hunted him down; he was in his truck in the parking garage, screaming and banging on the window because he couldn’t figure out how to get the door open.

He had taken a whole bunch of god-knows-what—tested positive for amphetamines, cocaine, opioids, and benzos, although the latter two he’d had in-hospital with his pancreatitis pain and his alcohol withdrawal. Oh yeah, his blood alcohol level was elevated too.

We weren’t able to figure this out until he had been thoroughly restrained, jabbed with an obscene amount of Haldol, shot up with about 4mg of IV Ativan, and strapped down while he drifted off into a mumbling daze. His blood pressure was out the roof—not uncommon for cocaine, especially crack, which we suspected because a) he’s homeless and poor as shit and b) he had a bunch of copper brillo pads in his passenger seat. He was also difficult to sedate, which we expect with meth usage… and he was insanely violent and psychotic, which we expect with the kind of bullshit gas-station drugs that get sold as ‘potpourri’.

I mean, he successfully tricked us into keeping him from being sober for another 12 hours. But he did not endear himself to us, what with all the punching and broken furniture.

By the time I got him, he was starting to calm down, and I was able to ease him off the restraints, although the sitter remained. His girlfriend came in, tearful, also obviously accustomed to sleeping in cars and shooting up, and I got her a sandwich and a warm blanket and told her to go ahead and sleep in the recliner for a while. When she woke up, her boyfriend was still semiconscious and mumbling, so she and I had a little contract chat: she goes to the methadone clinic, so I promised her that while her boyfriend was in the hospital, she could stay here and sleep in the chair and have three meals a day—as long as she attends her methadone clinic meeting times and doesn’t bring in any drugs or alcohol, which are absolutely forbidden on campus.

An hour later I caught her rolling a cigarette (no, not even a joint, a cigarette—loose tobacco leaves in a greasy recycled lunch-meat Tupperware), and explained that if she lit it up in here, the ceiling sprinklers would come on and drench everything. “It’ll ruin your phone,” I noted, and the pt spoke up from his groggy muttering to shout: “Put my phone in the drawer!”

I started to suspect that he wasn’t as gorked out as he seemed.

An hour after that I took his blood sugar and it resulted at 422. “What did you eat,” I asked him.

“Nothing! I haven’t eaten in, like, days.”

A cursory bed-shake revealed four full-sized Butterfinger wrappers and an unmistakable pile of Oreo crumbs. Like really, dude. We had a talk: “I know you want to get out of here as fast as possible, but you realize if you drive your blood sugar up, you’re just gonna end up back here, right? And if you have to have an insulin drip started again, you won’t be able to leave easily?”

He shrugged. “I’m leaving here tonight, even if I have to escape.” Big smile. “Hey, you wanna come with me? There’s always room in my truck.”

His girlfriend started complaining, then called me a whore. I left the room “to let you guys get control of yourselves,” and heard her berating him as I left.

“Why do you say shit like that? It’s not even funny!”

“It’s just my sense of humor, babe. Roll me a cig?”

God. Gaaaaaawd. By this point he was 100% conscious and aware, just being a total asshole. Every time I went in the room, he gave me a steady stream of “humor” about how he was leaving in an hour even if he had to hit someone, how the doctor had dropped by and said he could have dilaudid, how he would “sign whatever you guys say” to get out this evening because “I gotta meet a guy for some drugs. Just kidding!”

His expression didn’t say ‘joking’. His expression said that he thought I was stupid enough to believe he was joking.

A lot of people tell inappropriate jokes in the ICU. It’s a stress-coping mechanism, usually, if not a flattering one. A lot of people who feel out of control of their lives and bodies try to make the staff uncomfortable to re-establish their own feeling of autonomy. Typically I’ll handle this by setting strict boundaries, leaving the room with an admonition for the pt to get themselves under control, and looking for other places to give the pt some perception of autonomy. You can tell that it’s a stress response—they laugh with brittle force, they make lame uncreative jokes and remarks, they show their teeth and the whites of their eyes. There’s a little panic in their voices, a little aggression in their eyes.

Some people harass staff because they’re depressed, detached, feeling hopeless. They’re terminal, or their condition may never improve. They feel out of control, but they also feel like the world around them is hostile and unsafe. They self-deprecate as much as they attack; they have a bleak laugh, monotone voice, the kind of jokes that cut deeper than they should. They kinda joke like Robin Williams: all mania and grief.

(I could never watch Robin Williams comedy. He just looked so sad all the time. He looked like he was joking so he wouldn’t cry, or like he was trying to make someone laugh to keep them from swinging at him.)

These people need to feel control, but they also need to feel safe. They need palliative care, to help them find ways to live meaningfully at the end of their lives. They need a wry sense of humor to deflect their jabs, and to help their grim outlook become an enemy they can despise instead of surrendering to.

This guy… well. Some pts have zero intent of changing their lives, and resent being in the hospital at all. Some pts think they’ve tricked you, because here you are taking care of them when they hate you and would gladly hurt you if they could get away with it. Some pts think you’re a sucker, their bitch, their waitress; they make remarks and take potshots because they can, and they want to remind you that in their minds, they’ve already won.

I can’t stand pts like that. I hate seeing the expressions on their faces: the smirking challenge, the gloating, the certainty that they can get away with anything they try to pull. It turns my job from a joy and a labor of love into a gross afternoon of feeling wasted and exploited.

About an hour before end of shift, I got to give up my GIB guy and take on a new admit from the OR, a tiny old woman with Alzheimer’s who fell in her assisted living facility and now has a broken clavicle, broken facial bones, and a brand-new left hip repair. I barely had time to get her settled before shift change.

As I was waiting to give report, the afternoon charge came up to check on me. This is the same charge from yesterday afternoon, the one who knew my pt. “Oh,” she said, “did you transfer Martha to the floor?”

Explaining that was not fun.

After I gave report and was headed to clock out, I passed my tiny old lady from the other day, the one with the Diet Dr. Pepper and the razor-edged, if slightly unhinged, wit. “Hey,” she called, “can you come get these men out of my bed?”

“Which men,” I asked, poking my head into the room. She was alone, lying in a bundle of blankets.

“These men behind me,” she said, gesturing to the pillows shoved under her left side. “I’m all wore out! I’ve had enough. Tell ‘em to go home.”

I took the pillows out and told her the gentlemen wouldn’t be bothering her any longer. Then I made it halfway to the garage before I started wondering what, exactly, she’d thought those “men” were up to in her bed, wearing her out.

I hope I grow up to be an old lady just like her.

With an hour to go til report, I took a walkie-talkie call from the charge. “I need you to give report to Franklin on your GIB guy,” she said. “There’s a fresh hip coming up from the OR who went into a-fib on the table, and I need you to recover her until the nocs get here.”

“Shit, why can’t Franklin land her?”

“Franklin has the heart. So you’ll need to keep an eye on the GIB guy for him, and give your 1800 meds, because he won’t be able to get into the room easily.”

Sigh. “How about I just keep GIB for an hour and give report to the night nurse, and not waste time reporting to Franklin before the hip gets here?”

“Oh, could you do that? Thanks!” Click.

Yeah, whatever. GIB guy was happily chowing down on dinner, and I brought him his 1800 phosphorus-binding med (oh yeah, he was on dialysis too, and required medications to prevent his phos from climbing too high between trips to the fridge).

(The fridge here refers to the huge chunky dialysis machines that our dialysis nurses push up and down the hallways and use to scrub our pts’ blood. We call them “fridge nurses” and exchange good-natured jabs about the relative superiority of our respective nursing careers. Most of the hospitals in this area either keep their own dialysis fleet or employ the major dialysis-nurse agency in the city, which means that I’ve known most of them for years even though I changed facilities last year.)

The fresh hip was a little old lady with Alzheimers who had taken a dive while going to the bathroom and ended up with a broken clavicle, hip, and left hand. The stress of surgery had irritated the shit out of her heart, which went into a-fib, raising her risk of clotting. When the top chamber of your heart is just wiggling around ineffectively, it forms the perfect environment for clots to form—a warm, open compartment with walls that massage the blood rather than pushing it. And since she’d just had surgery, anticoagulating her was not an option.

So we started her on a diltiazem drip to slow her heart rate—she was quite fast—and laid her flat to recover. And then it was time to give report.

After which I went the fuck home and made dinner, checked with my sister to make sure she was doing okay at the GED tutoring sessions and to ask if she has an internship lined up yet, and then went out for an hour with my writing buddy to work on something besides a shift report: a highly simplified D&D campaign I’ve been running for some friends who wanted to learn tabletop RPGs but were intimidated by all the numbers and charts. It’s a small dumb thing that’s more story and flimflam than hard game-crunching, but I’ve been enjoying it, and it’s adapted well enough to a beginning group that it’s keeping ten simultaneous players occupied nicely. Plus my writing buddy is a game designer type so I can pick his brain for help when shit gets real, and he plays NPCs when I need them.

This is my first time DMing since I was in college. I am not good at it, I don’t think. But we have fun. 

Week 7 Shift ACTUAL 1

I posted my reports out of order. Friday's was actually supposed to be today's, and vice versa. Mea maxima culpa, and also whatever dude.

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Started out this morning with a couple of sweet pts—my first day back since Tiberius died. I was kind of hoping for a pair of raucous assholes I could joke around with and care for without working too hard; instead I got two cute tiny old folks, both with Parkinson’s, both with lung cancer.

One had undergone a right mid-and-lower lobectomy, leaving him with nothing of his right lung but the upper lobe. The other had undergone chemo, had a really rough time of it, and then come back for her checkup to find that the cancer had spread quickly, after which she developed a UTI and sepsis.  The former will be going home in a few days—the surgery was successful. The latter will also be going home in a few days—antibiotics will have her comfortable enough to enjoy her remaining months at home.

The lobectomy pt had a little extra challenge to face. He’s orthostatic at home: when he sits or stands up quickly, his body can’t keep his blood pressure steady, and he faints. He fell a month ago and broke a small bone in his foot, requiring him to wear an immobilizer boot whenever he gets up to walk. Not that he was walking far; the previous shift had tried to take him for a walk down the hall, and he had made it as far as the med cabinet before his eyes rolled back in his head and he dropped like a rock. His chest tube made it even trickier to mobilize him, since it drained into a big square box called an atrium that had to be carried along everywhere he went.

And he really wanted to walk around. His pain was well-controlled with an epidural in his back, which numbed him from nipples to liver, preventing him from feeling the full impact of the huge surgery. Pain control is crucial in major thoracotomies like this one—I think Tiberius had an epidural too, immediately after his pneumonectomy and before things went south—because, as with cardiac surgery pts, this pt population is at huge risk of death if they lie still for too long. They need the pulmonary hygiene of coughing, which is almost impossible to manage if you’re in agony every time you breathe in; they need the blood-pumping action of muscles massaging their legs’ veins to return the blood to their hearts; they need to be able to breathe deeply, so their lungs don’t collapse, and the volume of air you breathe in declines sharply when you’re in bed all day.

None of these things are particularly compatible with a fresh open chest. If you’ve ever cracked a rib, you know what I’m talking about: fighting the urge to cough, breathing in sips and whispers, cursing your significant other like the Nosferatu because he strolled through the room and made a stupid pun and you laughed unexpectedly.

I cracked a rib about a year ago because I was at the pub for Drink & Draw with a bunch of my artist friends, and was invited by one of them—a massive Hawaiian man whose job is an even split between “draw monsters for video games” and “travel around the world giving workshops on how to draw monsters for video games,” both of which are hard-drinkin’ jobs—to help him finish off some shots that a group of art students had bought for him. I am an inveterate lightweight who gets a little woozy after a couple glasses of wine, so it was deeply stupid of me to take him up on his offer. At some point I asked him if people tried to fight him in bars, and joked that I (one hundred twenty-five pounds of hair and freckles) should totally fight him sometime. He responded by picking me up in a bear hug, which cracked my rib. He was very sorry and expressed disbelief that anybody could break that easily; I was very sorry and expressed a lot of vomit and groaning.

Anyway. This dude had to walk if at all possible. With fear and trembling we propped him up on the edge of the bed, and let him sit there for a while, reminding him over and over that he needed to wait to stand up until his body caught up with its new position. A few false starts later, and we propped him up on the cardiac walker—its big elbow cushions make it easy to walk with, and staff are known to rest their forearms on it and dangle their feet to help relax their spines during a hard shift. Heck, I like to lean on it and sail down the hallway, propelling myself with gentle taps of the toes, scaring the piss out of the CNAs and smacking into the medicine cabinets as I go. (This only happens in the late afternoon, when things have calmed down a bit.)

On the walker, he made it out into the hallway and down the hall before he turned white, slumped sideways, and said: “Leave me alone, I feel fine.” His eyes stayed open, but his head sagged and his knees wobbled. The charge nurse came running up, pushing a rolling recliner she’d snagged from a nearby room. “I ain’t sittin down,” said the gentleman as he slowly toppled, trailing his chest tube behind him.

“Sir, you’re passing out,” I said, trying to maneuver his swerving backside into the recliner while bending around the walker and juggling the chest tube atrium. “Please, sit down.”

“I feel fine,” he repeated. He was definitely staying awake, but his body was absolutely done with this standing-up bullshit.

“You look like a package of used hot dogs,” I said. “Sit the hell down.”

He started laughing, which I guess was too much for him, because he lost consciousness and slumped back (mostly) into the recliner like a sack of wet bricks. Thirty seconds later, as his body caught up with the change, he came back to… still laughing. “Hot dogs,” he said. “Hot dawgs. This girl’s a pistol, bang bang.”

I’ve had worse compliments. Once a pt told me: “I’d marry you, honey, but you’re a bitch from hell.” Still a little heartbroken over that one. But I have to agree with him.

His chest tube had kinked off when he flopped over on it, and the pressure differential had him feeling a little stuffy by the time we got him back in his room. I straightened the tube and hooked the atrium up to wall suction, and he gave a little start as a huge bubble slurped from the tube through the water seal. “Whatna hell was that,” he barked.

“Well, sir… your chest farted.”

More laughter. “Does your mama know bout your mouth?”

I assured him that my mother was a good, upstanding Baptist woman who would rather not know about my mouth, locked the chair brakes, and went to the break room to open palm slam a cup of coffee and two ibuprofen for my unhappy back.

I try to take care of my back. Lots of nurses get hurt and end up on disability. Back injuries build up over time and then suddenly seem to happen all at once, and I don’t want to end up slipping a disk mid-turn. I use the equipment at hand, follow strict body mechanics protocols, and am shameless about demanding help from other staff. Still, nursing is a high-contact sport, and sometimes you just throw yourself between someone else and the floor.

I’m not always funny, either. Sometimes I hit a charming, exhausted zone where my filters are down and the words fly fast, but shortly after that I turn into a blathering mule who can’t get three words out in a row. Panic increases my chances of witticism; exhaustion makes me sound clever. People are often surprised that I can tell a quippy story with a solid punch line and then be asleep before everyone is done laughing.

So I tell people about black holes. They come from supermassive stars, I tell them: huge flaming whirling nightmares so massive that hydrogen is crushed into iron at their cores. At last each one collapses under its own weight, crushing itself into nothing, waves and particles of radiation squirting out of its terrible fist at every crack and seam. And just as the star reaches the point of no return, ripping through space-time itself, swirling into the inescapable singularity, an enormous gout of brilliant blue light pours out, scouring everything in its path with searing, perfect illumination: Cherenkov blue.

That’s me, right before I collapse. I get tired, groggy, lazy; then, for a few moments, I am brilliant and clever and unstoppable and incisive; then I am lying on the break room sofa in a puddle of my own drool.

Anyway. I digress, boringly.

My other pt, the one who will go home on comfort care, is loopy as a rabbit in the grass. She is also deaf as a loaf of bread. She has hearing aids, which she hates wearing, and I don’t blame her because they scream constantly from the feedback hell of being turned up to max and shoved into her wax-plastered brain-holes. She grimaces and nods and looks completely confused while you try to talk to her, and the whole time there’s this distant metallic squeal like robots fucking. She is, however, so cute I can hardly stand it.

She keeps saying these things that sound like complete wacko non sequiturs, that make sense a few minutes later in context. She was cold, so I brought her a blanket from the warmer, one with blue stripes on it. She declined it: “Not with the red! I’m not a traitor!” Okaaaaaay. She did have a big red allergy bracelet on. I got her another blanket, one with no stripes, which she accepted.

A little later her family arrived, and as I relayed this story to them, they nodded sagely. “Of course,” they said, “those are XXXX University colors, and she cheers for XXXX State.”

I mean, I like football. I hated it when I lived in Texas, where football is a religion and the weather during football season is the best evidence we’ll ever have of God’s wrath, but since I moved to Seattle I’ve learned to enjoy it. (Something about how obnoxious and balls-out gleeful the fans are, and also about how Richard Sherman was fucking hot even before he opened his gorgeous mouth and a whole higher education drifted out of it like a fleet of sexy butterflies. Pardon me, I’m going to have a drink of water now.) I am the worst possible kind of football fan, and I still don’t think I could maintain that level of team spirit while slowly dying in a hospital bed.

We got her up to the chair for a while—yes, we ICU beasts have a total obsession with mobilizing our pts—and then had trouble getting her back into bed a few hours later, during shift change as I passed her off to the next nurse. Fortunately the oncoming guy was strong and good-spirited, and we wrestled her back into bed without dropping her somehow, even when she wobbled and her knees went completely limp. “The black-eyed ones always did that to me,” she quavered as we tucked her in. “Weak in the knees.” I was halfway home before I realized she was talking about the night nurse, who is a genuinely attractive young man with lots of muscles who quite literally swept her off her feet.

My lobectomy pt transferred up to telemetry immediately after that, keeping me late to give report to the upstairs nurse. I stressed the importance of taking things VERY SLOWLY with him, and told the whole grisly story of his afternoon walk. “Are you sure he’s tele status,” protested the nurse, and I don’t blame her, because nobody wants a pt who can turn into a floppy lump at a moment’s notice.

“Yeah,” I said. “Bye!”

I am a dick. Sorry, folks, that you have to know that about me.

(Generally speaking, orthostatic hypotension isn’t a reason to keep a pt on the ICU, especially if they’re orthostatic at baseline and need exercise to get moving again, which the tele floors are better at administering since ICU is focused on early mobility. It would have been very bad form, and dangerous to the pt, for me to pass him off without explaining how serious his orthostatic hypotension could be, but I honestly didn’t have time to coax the upstairs nurse into recognizing all this.)

As I left, they were already moving a new pt in, a tiny little lady who screamed and thrashed and hit everyone within reach. Her daughter stood in the hallway, dancing from foot to foot in that telltale hand-to-breastbone posture of a family member who is going to be ridiculously anxious the whole time. I will bet you one US dollar that I get that pt in the morning, and that she hits me.

Maybe I can jinx her into being a perfect doll.