Mrs Leakey, Jelena, and Wen Li

So, uh, I’ve been on hiatus.

I’ve been working on a few chapters for a book proposal, and trying to get things pretty enough to be useful for publication, but I really REALLY prefer blogging to book writing (at least in this format) and I’d like to get back to this. So I plan to keep working on the blog, not necessarily shift-by-shift but following specific batches of pts, and work on the book between posts.

The upside to this is: I have a lot to tell you guys about. I expect to update once a week from here on out, and I actually have a backlog of posts ready to go, so there shouldn’t be any major hiccups for a while.

You have been wonderful and supportive, all of you, and I promise that if any of you is ever unfortunate enough to end up under my care, I will wipe your asses with the warm wet wipes.

(I also told a trio of trusted coworkers about my blog, so they could peek over it and make sure it’s both factual and HIPPA-compliant. All three of them immediately identified Crowbarrens. Life is good.)

Anyway. Let me tell you about Mrs. Leakey.

A new post!

Late post! God, I hate working a huge raft of shifts in a row. Out of the last ten days I’ve worked eight, and tomorrow I go back for two more. You know what’s great? Having more than one day off in a row.

I came back the next morning and discovered that the supply-room coffee was even worse than usual, with a bitter, rancid edge that made it damn near undrinkable even with a carton of milk stirred into it, a petty-theft latte for the desperate. I coughed down a few gulps and rinsed my mouth in the sink, promising myself Starbucks as soon as I could get break coverage.

I don’t usually blow cash on Starbucks. I live a block from an independent coffeeshop that makes lattes to wake the dead, the kind of perfect espresso miracle that makes you sigh with relief every time you take a sip. It’s hard to get excited about the over-roasted stuff you get at the white-people-with-yoga-mats chain. God, I’m such a fucking snotty hipster these days I piss myself off.

(A week or two ago my husband and I dug an old, perfectly functional turntable out of the trash, bought a cheap pre-amp from an audiophile wizard of our acquaintance, and rifled a local yard sale for a few albums—ELO’s ‘Out of the Blue’, Tubular Bells, Neil Young’s ‘Heart of Gold’, and some Fleetwood Mac or other. We have been offending the neighbors ever since. This is probably a huge improvement over our usual evening soundtrack of Star Trek reruns, Bill & Ted’s Excellent Adventure, and Conan the Barbarian. The point is, we are now the worst kind of dad-flavored hipsters and should be euthanized for the good of society.)

But I can be as hipster as I want on my own time. When I’m working, I am 100% down for peppermint disks from the crystal dish in the conference room, PB&J in a paper cup with saltines, and the hospital cafeteria’s Clam Chowder Fridays. I have dumpster tastes and raccoon appetites and I belong out back of the Waffle House instead of in a high-tech facility for healing. Starbucks is outright classy compared to my workin’ self.

So it was quite a blow to realize that I was getting a pt who’d just landed fifteen minutes ago after having been airlifted from a smaller, rural hospital. Landing a critically ill pt—too sick to be managed by the local teams—meant I would be glued to the bedside, monitoring and giving meds and managing drips and performing all the little tasks that are so hard to adequately describe because they’re so boring. No time to go get Starbucks.

But if you can’t get coffee, adrenaline will do. I nabbed my stethoscope from my locker and headed down the hall with my pulse already picking up, seeing the cluster of transport techs and docs and nurses and other beasts swarming around my pt’s room.

Adjusting my plans!

Okay, so, that week off was desperately needed. I hadn't realized, but I was writing a ridiculous amount of verbiage, and it turns out that writing that much was a recipe for burnout.

Plus, I feel like you guys are starting to get the feel for ICU patterns: a little heart failure here, a little COPD there. Unusual things happen sometimes, between the cardiac caths and respiratory failures, but there are only so many times I can explain pressure imbalances or tell you that titrating vasoactive drips is both boring and strenuous.

So here's my new plan: I will post one shift report per week, based on the most interesting shift I worked, with extra coverage for any interesting short bits that happen on the other days. This will give me time to write another post every week-- a story, a piece of patho, or even an extra shift report.

I'll post the shift reports on Tuesdays, and the second posts on Fridays (Thursdays would make more sense except that my work schedule has me wrapping up a major week of work on Thursday nights, and I am usually dead by that point).

And yes, I will write up that one awful story. The first time I wrote it up, I wasn't satisfied with how it turned out-- clean-edged, internetty, and all about the shock value. I would like to rewrite it, and see how a year or two has aged it in my head.

See you all tomorrow night!

I meant to post Friday, but I was so tired after that last shift that I fell asleep on the sofa and didn't wake up until 1030. Today is my one day off, and I got about half a shift written, so I will try to finish it up tomorrow after work and post it then.

Boy I tell you what, working more than four shifts a week is a profoundly bad idea for my sanity. Definitely gonna have to find a better balance so I can make the writing work.

Week 9 Shift 1

I showed up late for work by about five minutes, having lost track of time while I was standing in the shower performing my usual morning devotional of cursing, groaning, and ordering myself grimly to wake up, come on, you can do it.

Any time I’m late to work I sort of creep in from the staff elevators and try to sidle up behind the group report cluster without being seen. No luck this time—a bright-faced unfamiliar nurse called out: “You must be Elise!”

Turns out I was precepting today. Okay. Surprise?

Maycee has moved on to another preceptor—each new nurse gets two days with each preceptor, to make sure they get a good variety of teaching methods. I like precepting and am pretty good at it, but everyone learns differently, and I have precepted more than one person who wasn’t really meshing with my style and needed someone a little more methodical and hands-on. Today I would be precepting Anne, who loves airplanes and hiking and pictures of gross wounds, and who was very patient while I poured half a carton of milk into a cup of ditchwater coffee from the supply room dispenser, then thousand-yard-stared my way through the first half of it before my brain came back online.

Our pt was a tall, strikingly pretty older woman who had been very active and independent before she fell last night, smacked her head on something, and developed a huge head bleed—a subdural hematoma. There are several different types of common head bleed, and this is not usually the deadliest, but an SDH can really wreck your shit.

A night off

It's been one hell of a week-- I've actually worked five shifts in a row this week and am too tired to think straight, and as a result I've almost run out of my backlog of shifts. So I won't be posting anything tonight... back to normal schedule on Wednesday.

Man, who would have thought that writing three to four thousand words three days a week would turn out to be a pretty intense job?

Week 8 Shift 4 (I picked up an extra shift)

I didn’t sleep well after that last shift, and coming back in the next morning was an act of sheer will. This summer has been broiling hot, and I moved out of Texas for a reason, namely that for humans to live in Texas is an act of defiance against the great god Ra, and that if the away team of the Enterprise were to visit Texas in the summer they would refer to this entire world as a “desert planet” and four redshirts would die of fatal solar radiation. I did not move across the continent to a cooler climate so I could sweat like a wrung dishrag all day and all night.

One of my pts was exactly to my tastes: somnolent and needing very little intervention. She lives in an assisted living facility, where she’s mostly independent and hooks herself up to his peritoneal dialysis every night before bed. For the past few nights, though, she’s been “sick,” and hasn’t been running her PD, which has only made her sicker.

Hemodialysis involves sucking your blood out, running it through a machine the size of a Volkswagen that scrubs and washes and concentrates it, and pumping it back in to pick up more trash and water from your overloaded tissues. Peritoneal dialysis is a much less common form of dialysis, and one that doesn’t work for everyone, but which can be much less troublesome if it works right. A PD catheter is inserted through the wall of the pt’s abdomen, and dialysate fluid is pumped in and out, washing toxins from their body and blood through the permeable membranes of their gut. The fluid typically contains sugar, so pts have higher blood sugars on PD, but if it works for the pt… well.

After HD, a pt is typically sick as shit, often confused and shaky, usually weak and exhausted, and frequently nauseated. Regularly dialyzed HD pts tend to go in for a scrub three times a week, and with each round of HD the pt can count on being completely wiped out and useless for the rest of the day. This tends to really interfere in little things like “having a job” and “functioning for a majority of the week,” and that’s before travel time and expenses, interacting with health care staff (I will be the first to admit that we are terrible company), and having to rub elbows with other gross people from your medical community while hoping that they aren’t crawling with MRSA. So if you have the option of doing dialysis in the privacy of your own home, while you’re sleeping, and waking up the next morning ready to go about your day… PD is a total godsend.

The learning curve is a little high though. The pt needs to be thoroughly educated on how to maintain sterility, how to use and troubleshoot the machine, and how to recognize when something has gone wrong. A pt who skips days, who doesn’t follow up on appointments, who cuts corners—that pt is likely to have some really nasty outcomes. A PD catheter is a fast way to fill your belly with all sorts of microorganisms if you aren’t safe and clean with the thing.

Anyway, she had a UTI, which explains both the “sick” part and the reason she, a normally very sharp and independent older lady, made the very bad decision to stop doing dialysis rather than going to the doctor. Those of you with vaginas have likely experienced the burning agony of the UTI, with its bloody boiling lava piss and its ability to leave you feeling like you slept in a dumpster and were picked up by the trash truck before dawn. Sad fact: that shit is a blessing, because you think to yourself: gosh, I have a UTI, I should go get antibiotics. Older women are less likely to have the burning pee sensation, and sometimes their earliest clue to the presence of e.coli in their bladder is the fact that they lose their ever-loving goddamn minds.

That’s right: old ladies with bladder infections go fucking crazy. I’ve seen sweet grandmothers cursing and biting at their descendents, calm-faced knitters who turned into screaming paranoid kung-fu masters, and even a deacon’s wife railing about shit-eating demons crawling into her body and jacking off into her belly button from behind. Forgetting to plug in your advanced medical equipment is kind of tame in comparison.

But hey, no matter how well you handle a pelvis full of creepy crawlies, a few days without dialysis will absolutely make you loopier than a tatted doily, and sicker than shit to boot. This poor lady had no idea where she was or what was going on, except that she was nauseated and unhappy. I came into the room, scrubbing my hands with Purell and offering a chipper greeting, and she groaned and leaned over and barfed corn chowder down her shoulder and off the side of the bed.

There’s this thing, right, where you see or hear someone puking and you feel like puking too, right? I guess the evolutionary advantage is that, if your fellow cave-dwellers start horking up last week’s mammoth, you can get a head start on the mammoth evacuation process before the salmonella poisoning really gets a grip on your duodenum. Being a nurse for more than a few months will completely destroy that impulse. My immediate instinct when someone starts throwing up is to grab the nearest wad of laundry and jam it into the flood to keep it from spreading.

The last time my husband ate bad sushi, I nearly ruined our feather duvet.

God, the best thing about working in a hospital is that so much of the really gross shit gets done where I don’t have to see it. Laundry absolutely saturated with a grainy flood of shit? Put it in the big white bag and throw it down the chute and forget it! Pt took a whiz over the bedrail and threw his dinner into the results? Mop up what you can, and call the long-suffering housekeepers to do a bleach mop. I swear to god, I am not anywhere near this obsessively clean in my daily life, and I am 100% sure it’s because I can’t just page someone for backup whenever shit gets literal. I hope to sweet sainted fuck that the laundry is done by soulless aluminum launder-bots. I have this awful hunch, though, that it’s not, so I’m that picky nurse loser who separates all the plastic padding from the cheap muslin to minimize the necessary sorting before the blankets go in the wash.

But lord almighty, it is so good to be able to get rid of the stench immediately and start forgetting I ever smelled it.

A dose of Zofran and a housekeeping call later, the corn chowder was a distant memory and my pt was sleeping like your dad in church. On her left side, of course. The right lung is set at an angle that makes it easier for inhaled food and puke to slide down the right mainstem bronchus before you can cough it up, which means you want the right side elevated if your pt is at any risk of throwing up and drowning in it. Left side fetal position is often called the “recovery position,” because if you’ve had CPR or had a seizure or been very close to death, you’re likely to throw up at some point in the immediate future and you might not be awake enough to make sure it leaves your mouth and goes all over your nurse’s arm like it’s supposed to. (There are some other benefits to this position too, but my god, how much do you guys really want me to talk about hemodynamics right now?)

My other pt was a gentleman in for placement of an AICD, an automatic implanted cardioverter/defibrillator, which functions much like a pacemaker except that instead of reminding your heart to beat (although some of them do this too), it listens for your heart to have a dysrhythmic freakout and shocks the shit out of its unruly ventricular ass like a neighbor banging on the wall during a party. Pts who frequently go into dangerous dysrhythmias (also called arrhythmias), like ventricular tachycardia, or whose heart damage from MIs and heart failure puts them at high risk of deadly arrhythmias, get AICDs put in so they don’t suddenly die. If parts of your heart are especially irritable or not getting good communication with the rest of the heart, they panic and assume that they’re going to have to run the whole heartbeat show, and start yelling disorganized orders over the actual heartbeat signal. This can cause the whole heart to spasm and lose track of what it’s supposed to be doing, preventing it from actually moving any blood—this is called cardiac arrest. A good jolt of electricity stuns the panicked parts, giving the normal heartbeat a chance to pick itself back up.

That freakout is called fibrillation. The shock is called defibrillation. It’s one of the best tools we have for fixing deadly arrhythmias.

If the AICD shocks you, you know it. We get a lot of pts in because they were having Thursday night dinner when their AICD went off and kicked them facefirst into the meatloaf. Very uncomfortable and sticky.

So this guy had suffered a major heart attack that left part of his heart withered and necrotic—a part that, unfortunately, carried a lot of electrical impulse. As a result, one little area of his ventricles is now deaf to the electrical marching orders of the rest of his heart, and occasionally it gets the idea that it should be doing something and starts barking its own confused orders at its neighbors. He’s gone into ventricular fibrillation several times already, and had multiple rounds of CPR. Fortunately, since he’s been on the ICU hooked up to a heart monitor, we’ve been able to shock him immediately each time; the sticky electric-shock pads that we use to defibrillate him are just staying on his chest at all times now, until the AICD goes in. Because the defibrillation is happening very quickly and he’s only had to rely on CPR for circulation for a few minutes total, his organs haven’t really taken a lot of damage and he’s had good outcomes each time.

Despite three code blues this week with accompanying chest-crushing CPR, this guy is in good enough shape to be sitting in a chair, grumbling because he can’t have breakfast this morning. (No breakfast before surgery—anything in your stomach when you get anesthesia is going to be ejected at some point, and you definitely can’t spit your barf out while you’re unconscious, so breakfast before surgery leads directly to aspiration pneumonia and ARDS.)

When I walked into the room, he greeted me with one of my absolute least favorite quotes: “Hellooooooo nurse!”

Now, I get that it’s meant to be a compliment in some backward way. I understand that if you’re white and male and sixty-five you probably think the highest praise you can give a woman is aesthetic; you might even, if you’ve been reading a lot of noiresque literature, assume that complimenting a woman on her looks is a way of acknowledging her power and independence. But man, I got two problems with pts expressing attraction to me:

--I am pretty obviously not here to look hot. I am wearing pajamas, no makeup, an expression of exhausted patience, and about a pound of someone else’s bile. If you tell me I have lovely eyes with an earnest tone, I will probably accept that gracefully, because while I may check you extra-thoroughly for delirium I can at least appreciate that maybe you have strange tastes. If you react to my entrance like you’ve just been offered a hayjay by Jessica Rabbit, I’m gonna assume that your compliment is the disingenuous flattery of someone who thinks they’re gonna win my favor by introducing a sexual element to our professional relationship, and who intends to milk it for morphine.

--I am far from the most experienced nurse on the unit; I have about five years of ICU under my belt and I showed up for work in critical care two days after my NCLEX with dewy eyes and a trembling chin. But I worked obscenely hard to get where I am, both in my personal and in my professional life, and I am a formidable member of an elite team of life-saving medical staff, and to have that hard-earned accomplishment reduced to a catcall is absolutely intolerable. It reeks of disrespect and inappropriate sexual aggression.

This guy has had several rounds of CPR this week, though, so I gave him the benefit of a quick boundary: “That’s pretty inappropriate, would you like to try a different greeting?”

“Come on over here, little girl, and I’ll give you a different greeting.” Ugh. Uuuuuugh. At moments like this I just remember that I get paid not according to how many lives I save but according to how Disneyland-pampered my pts feel. I picture the dollar signs and bar graphs and ratings, and I grit my teeth and remind my pt that I’m here to provide him with medical care and that I’ll come back in a bit when he’s able to get his behavior under better control.

I’ve learned to be very comfortable with varying degrees of confrontation. I was raised, like many women, to think that the scale goes from “everyone is acting like nothing is wrong” directly to “EVERYTHING IS TERRIBLE” the moment a hint of conflict is introduced. Nursing has taught me that a little conflict in a conversation, like a little pepper on your scrambled eggs, is not only an acceptable thing but even a delicious thing—a thing to be savored, a thing that makes relationships and interactions exciting instead of bland.

I still have the instinct to flee, to placate, to absorb the unpleasantness and smile right through it. And I do keep my smile, and behave politely; but I also have learned to say, That’s super awkward of you, aren’t you embarrassed, and to tilt my head and smile with my eyes and watch that asshole twist.

This was a theme throughout the day. It got very tedious.  

My PD lady continued to vomit, and the doc ordered her an MRI with contrast, which meant I had to take her down to MRI for a full forty-five-minute scan without letting her drown in her vomit. I loaded her with Phenergan, popped a scopolamine patch behind her ear, and borrowed a subglottal suction catheter so I could keep her mouth empty if she vomited while I couldn’t reach her.

Then we moved her down to the MRI chamber and loaded her into the tube. The suction system in the MRI chamber was doing something really weird—like most hospitals, ours has been forced to prioritize its expenses, so some non-critical systems are a bit primitive—so I hooked a big syringe up to the subglottal catheter and stood by her feet as she went into the tube, watching and listening for any signs of vomiting so I could hand-suction her mouth.

The MRI is so loud. I was wearing earplugs and the sound went through me like a bore hole to the terrestrial mantle. If you’ve never heard this sound, I urge you to hit up youtube and have a listen, because no words can do it justice: clanging and crashing, and an all-consuming power-chord thrum of metallic force: DAH DAH DAH DAH DAH. DUM DUM DUM DUM DUM. DRRRR DRRRRR DRRRRRRR.

 It jarred my teeth. My feet ached with the force of the noise. There is an arcane quality to it, a rhythmic intent of pure alien purpose that wants nothing of your sanity and only stops to breathe when it’s finished its task.

While I was in the MRI, my annoying pt was shuffled off to have his AICD placed, and as I returned to the unit the charge nurse told me he would go to the special care unit after the procedure.

So by the time my PD pt was settled, I was ready to take another pt: a craniotomy who had fallen in her home and developed a subdural hematoma. After surgical evacuation of the blood blister inside her skull, they brought her up to me intubated and sedated with a C-collar to keep her spine immobilized. We hoped that the pressure damage to her brain wouldn’t be fatal, but there’s really no way to tell yet, so we’ll wait and see how the swelling goes, and support her medically until then.

She has fake breasts. They are extremely rigid and strangely shaped. The CNA and I noted this and carried on; we see many pts with breast implants and other surgical reconstructions, and I have long since learned that as soon as you start judging a pt for some seemingly voluntary aspect of their looks, you’ll discover that they had reconstructive surgery for cancer or some other thing that makes you feel like shit, and deserve to.

So we made sure that everything on the bed was arranged in such a way that visitors couldn’t see either her nipples poking through the gown, or the unnatural rigidity and wide placement of the breasts themselves. I’m certain that this woman spent a great deal of effort in making her breasts look natural, and it would be cruel and spiteful to let the secret out if she hadn’t already told any of her guests.

It feels very strange to carefully pad a pt’s breasts, let me tell you. I felt a little gross and intrusive. But even if she got them for purely cosmetic reasons, it’s her body, and I wouldn’t leave an embarrassing tattoo out for the neighbors to gawk at either.

The MRI showed no signs of anything wrong in the PD lady’s belly. Thank goodness, she just needs lots of dialysis and antibiotics; we can have her fixed up and home by the weekend. The dialysis nurse dropped by just before shift report and started her on her nightly PD, and I hope that by morning she’s closer to her normal self.

During report, my pt from the last two shifts, the sepsis pt with liver failure, died. An estranged sister had got in contact with us and given us the okay to allow him a natural death according to his wishes, and they turned off the drips, loaded him with painkillers and benzos, and pulled the breathing tube. He breathed on his own for ten minutes, then slipped away gently and comfortably at last.

I am glad for him. He earned his rest.

And after this shift, I’ve earned mine too.