treehugger

Every nurse encounters poop. Like, lots of poop. And this, friends, is a poop story.

Pt. was admitted to the Medical ICU for a series of TIA's; he had already suffered multiple strokes before this admission, and resided in an assisted living home. He was not as well tended as he should have been there, and that trend followed him here. I normally work in the CVU, but because our unit was short on patients ("low census," for the uninitiated), I "floated" to MICU and took care of Patient. I took him from Odessa, another CVU nurse, who had received him from Jimmy, my partner in crime. In his entire admission, he had not once been cared for by any of the native nurses. My guess is that the charge nurse, Heidi, didn't think we were up to the usual medical disasters present on the MICU (her words to me: "Well, we don't want to give you anything too hard." Wow, you're right, I'm probably stupid. Fuck you too, lady.) Hence, Patient was being handed to the floats because he wasn't challenging or sexy enough. Whatever. For once, I knew I would get a lunch.

We had a good day, and yes, it was easy to care for him; I felt badly for the regular staff on the unit because they were working unbelievably hard compared to what I was doing. Toward the end of the shift, I received news that Patient was being returned to his facility. I went in to share the news with him that everyone thought he was stable enough to go home. Before I got a single word out, he stared at me dolefully and moaned, "You know, my stomach is just killing me." I immediately stopped and gave his belly a listen, then pushed on it a bit...damn. It was kind of firm, more so than when I had assessed him previously. I asked him if he felt like he needed to poop, and if he had been passing gas lately. He was bed-bound, so I wasn't too surprised that no one knew the last time the poor bastard had gotten the pleasure of unloading.

I took a deep breath. Of course, it was 1800, and I was supposed to be preparing his transfer paperwork. But damn it, a man's gotta move the mail sometimes. Apparently, 1800 with transport en route was that time.

I explained disimpaction to him. He didn't care, he just said "please, just help me."

Gloves. A heavy duty chuck (which is a really absorbent pad...sort of a "pee pee pad" for people). Wipes. Surgilube. A garbage can. It was on.

I asked him to try one more time to push on his own. I may be the Brown Queen, but that doesn't mean I want to wedge my fingers in anyone's ass. He was unsuccessful, grunting and sweating and groaning all the way.

GO TIME!

I started working on the dry matter. Some poop made its way. Then...he started pushing again.

We had busted the dam.

I had never seen anything like it, and I haven't since. It was HUGE. The size of a small baby. I am not exaggerating. I was immediately angry that no one at his home had even noticed that he hadn't notably crapped recently, but relieved I caught it...so to speak. Technically, it had actually landed on the chuck. At least there was no cord to cut.

Another nurse had noticed at this point that I hadn't been out of the room for a while and came to check on me. Her head popped around the privacy curtain. "Are you okay in here?", she asked. "Yeah, I'm fine, but I could use a hand getting my friend here cleaned up." My voice was calm, but I was jerking my head back to urge her to LOOKIT THIS GIANT DOOKER, OMG. She came around the bed to where I was, frowning...and then she saw. Her eyes got big, but in her best nursing voice: "Sure, I'd love to help you. Are you doing all right, sir?"

Honestly, we sound like airline stewardesses in turbulence.
More coffee? SkyMall magazine? A bit of the Finger?
It's just a little turbulence. We only dropped a few dozen feet.
You only shit a cinder block. It's fine now.

God. Patient was so happy. I'd swear his grips even improved on his weaker, affected side. He said "thank you so much" at least four times in the time it took me to clean up and wash my hands.

After we got Patient situated, did I do my paperwork? Did I call report to his home? Nope. I texted Jimmy.

"didn't you have the guy in room X yest?"
"yep, why? is he ok?"
"i just disimpacted him", then
"omfg, it was like a sequoia log"

Patient went home a new man.

uneptitude

The first entry in this blog described what generally happens in a code. What I did not make clear is that there are "good" codes and "bad" codes. The quality of the code has nothing to do with patient outcome; rather, it has to do with the organization, teamwork, and clinical judgment of the team involved. A "good" one is almost boring; everyone present has a role, and they're performing it to the best of their ability. The code concludes when either the patient's cardiac function is restored, or it's determined that death is imminent regardless of efforts.


This was not one of those codes.

I was living pretty fat on this shift. At this particular facility, the techs were relied upon to do a lot of the grunt work (vital signs, feedings, hygiene and so on), so at 1215, I'd finished up a lot of what I had to do for my patients; now I just had to figure out what to write about them on the archaic paper charts. I was doing my best to ignore some of the background noise around me, but I'm terrible at that; I ended up eavesdropping on a couple of nurses discussing a patient that had recurrent seizures and seemed to be having one now. "Don't go look," I reminded myself. "I don't have to be ambitious every day."

Just as I was refocusing on manually writing a narrative (quelle horror), I heard a commotion from across the hall---the seizure patient's room. I threw my chart and pen down and jogged over as someone was yelling to call a code.

A code? How do you get from a seizure to a code? They're almost exactly unalike.

Patient was pale to dusky colored, unresponsive, and trached. His heart rate was in the 40's; bradycardic, but otherwise normal. No clonic, no tonic. There was a nurse on either side of the patient, and an RT standing at the head; I wasn't totally sure what any of the three of them were doing right then.

Me: "Did anyone check his pulse?"
No answer. I pulled his gown up and checked his femoral pulse. There it was, under my fingers, consistent with what I saw on the monitor. Strong, too. I looked toward the RT and nurse closest to Patient's head. "He's got a pulse. Has anyone tried to suction his airway? Are you gonna bag him?" I asked.
"We're having a hard time passing the cath," one answered.
"I think if you can get whatever's plugging it, that'll fix this," I offered.

Patient's nurse decided to start (initially very pathetic) CPR then. "Wait! He's got a good pulse," I repeated. Puny compressions continued. The charge nurse was yelling, "GIVE HIM ATROPINE! GIVE HIM ATROPINE!"

Fuck it. Not my house. I looked behind me to see if there's a crash cart coming; good, there it was. I told the nurse pushing it to pass me the pads in case we needed them. "GET THE BOARD! GET THE BOARD!" bellowed Charge Nurse. (She was referring to the back board normally placed under patients during CPR---which was being done, but badly.) "I think we really need to see if we can clear this guy's airway first, since he has a pulse," I reinforced...to the air and no one else. I grabbed the object out of the torn package offered to me; what should have been AED pads were just...wet, pink rubber thingies. (???) "What the fuck are these, dude?" I snorted. Freeman, another nurse I knew from my old ICU and the one that handed me the...things...started laughing too. "I have no idea." I tossed them aside and turned to the Cart Pusher. "Have you found pads? We should have them." She ripped another package open. Pads! Okay. I got Enthusiastic Bad CPR Giver to stop so we could get the pads stuck on Patient's front and back. I directed the Cart Pusher to plug the pads in to the AED. CPR Nurse resumed compressions.

"GIVE HIM ATROPINE! GIVE HIM ATROPINE! GET THE BOARD! GET THE BOARD!"
Fine. Board too. Might as well. Someone passed me an amp of atropine. I looked up to confirm the order with---(god, who's in charge?)--- and tell the recorder that I'm about to push the amp.
No recorder.
Now I was annoyed. The room had become an abyss of panic.
Me: "Who's in charge of this code, anyway? And is anyone charting anything? Who is recording this?"
A ragged, loud chorus of "yeah, who's in charge?" followed. As my eyes swept the room, there was a physician at the foot of Patient's bed. Just standing there. Saying nothing. He could have been twelve years old. He was even shorter than me, and I'm no giant.
"I'M IN CHARGE! GIVE THE ATROPINE! WHO'S RECORDING?" Charge Nurse bellowed. Al Haig revisited. I guess since the only physician in the room wasn't saying anything, this was constitutionally correct. I pushed the atropine. "Pulse check!" squeaked Mystery Nurse on the other side of the patient. "...hey, he's got a great pulse!" I started to tell her that she was feeling CPR Nurse's now more energetic compressions, but, well, she looked so happy. CPR Nurse, too, was in the zone.

"WHO'S RECORDING?" yelled Charge Nurse. "YOU! FREEMAN! YOU'RE RECORDING!"
Freeman sighed, put aside the drug box that he had taken charge of, and asked me what had happened so far.
"Okay," I asked CPR Nurse, "when did this all start?"
"Uh...1226, I think."
"Good. You called a code at 1226. Freeman, code was initiated at 1226. Pulse was detected. I don't know what his sats were...is his PulseOx even on? Compressions initiated. I pushed one amp of atropine for a heart rate in the 40's at 1229. Pulse check also at 1229."

It didn't look like anyone had cleared Patient's airway yet, but a different RT was trying to re-insert the suction cath to try. I turned to the cart pusher and asked if she got the AED fired up. She hadn't. As she turned to the cart to flip it on, I followed the cord to make sure the pads were at least plugged in. Aaaaannnd...no. No, they weren't. I grabbed the cord and demanded the AED end. As I started trying to fit them, Cart Pusher said, "I couldn't make them fit."

(oh, no)

The AED pads belonged to a totally different system. We would have had more luck with jumper cables and hot glue.

Just as I started to wonder about the ethics of abandoning a goat rope, there was a tremendous sucking sound. "I got it! Plug's out," the new RT called out. And like magic, Patient's heart rate bounced into the 120's and he pinked right up. One of the other nurse managers took the code sheet from Freeman. He and I both offered to sign the sheet, but she waved us away. Freeman looked like he was fleeing the scene of a crime. I felt like he looked.

I walked out of the room and into the hallway. A frail older woman, Patient's wife, sat in a chair just outside; she was crying silently, like someone who had cried a bit too much for a bit too long. Sorry, lady.

But you know, we saved him.
Time to chart.

geneva dreams

I want to make it clear: one, I do not think poorly of floor nurses, though part of this blog entry may indicate that. Rather, I wish to underline the strain they work under, and how goddamn hard their job is. I would make a terrible floor nurse, myself; big ups to the nurses that do it. Two: I have known amazing, brilliant, compassionate physicians; so, physician friends, please don't be offended if it appears that I'm bashing your brethren. I just tend to have bad ones in the stories I tell.

one:

Report from Innocent Floor Nurse, 0740: "Patient, 89, male from Local Area. Admitted for shortness of breath, found to have pneumonia. I've taken care of him on and off for a couple of weeks, and he was living independently prior to admission. He's deteriorated over the last couple of days. His O2 requirements have gone up. He's now on eight liters nasal cannula." (I stifle a snort here. A regular nasal cannula is useless for anything beyond six liters.) "Significant history includes COPD, extensive cardiac issues (I don't know all of it, sorry; it's a lot, though), rheumatoid arthritis, and prostate cancer."
I butt in here: "Is he a former smoker? Is the CA a current concern? Does he still have a prostate?"
A pause, then, "Uh...I don't know. Sorry. Anyway, did I mention his RA? He doesn't complain much of pain, but it's made his PulseOx readings impossible because his hands are in such bad shape. According to that, he was satting in the 70's." (A normal read for someone in decent respiratory status: 92-99%.) "RT thought that was accurate. They got one of their portable readers and got the same readings."
"On his fingers?"
"Yeah. He was struggling to breathe, so we turned up his O's. At that time, he stated that he was 'ready to go', and that all his affairs are in order. He asked for the doctor, so we called in Dr. Golf. We made him a DNR per his wishes."
Me: "Oh? Okay. Two questions, then: one, how is his family coping, and two, why is he coming to the ICU? He's a Do Not Resuscitate. We resuscitate people here."
"Well...okay, I don't know. But DNR doesn't mean 'do not treat'. And he doesn't have a family. Oh---he's been hypotensive, too. I haven't given him any of his blood pressure drugs."
"What are we treating? End-stage Everything? Look, I know you're not driving here, but...why are we doing this? Shouldn't we just give this guy a buttload of pain drugs and a quiet room? If he's with it, he knows what he's asking for, and there's no one around to fight it, this seems like the wrong place for him."
"I know, but...I have seven other patients. Can you take him now? We're not supposed to have patients out here on more than six liters."
"Yeah, sure. Bring him to room X."

And ten minutes later, I meet my pink, warm, dry, in-no-distress patient that's ready to meet his Maker.

two:

Patient turns out to be a really nice guy; neurologically intact, cultured and educated. Very funny for someone whose body was busy betraying him. He makes me promise that I wasn't going to do anything extraordinary to save him from the inevitable. He even went down a list: "No CPR, no artificial breathing, no feeding tube with artificial food...although I do want water...and I don't want any more pain." I told him that my goal was to make him as comfortable as possible. Throughout the morning, I talk a couple of times to Dr. Consulting about Patient.
"I don't get it. What are we doing here? Shouldn't we talk to the Palliative team about him?"
"Probably, but he's not my patient. Besides, just because he's a DNR doesn't mean we don't do anything for him."
"I know that, but that means treatment of symptoms up to what the patient wants for comfort. This here"---I gesture wildly with both arms around the ICU---"isn't what he was asking for."
"Not my patient. Have you talked to his primary?"
"No. He signed the order and went out of town."
"Hmm. Well. I'm starting some Albuterol for him, as well as some Lasix. He needs to be IS'd" (a respiratory exercise) "so his pneumonia resolves."
"Sure. Makes sense."

He falls asleep around 1230. While he naps, his blood pressure varies from the 110's to a low of 76 systolic. When I go to wake him periodically, his mentation is still intact. I decide not to do anything about the pressure. Trista, the charge nurse, is getting kind of antsy watching his vitals fluctuate.
"Are you gonna call his doc?"
"No."
"His pressure's in the low 80's right now."
"Yep."
"You're not worried?"
"No. He's totally with it, he's peeing, he's completely asymptomatic. And he's a DNR. He wants zero interventions, minus pain meds."
"That doesn't mean 'do not treat'."
"What am I gonna do, start Dopamine on him? That's an intervention. Pretty sure he doesn't want it. Besides, he's got one peripheral IV, and that's it." (For the layman: drugs meant to support blood pressure should be administered through a central line. Peripheral IVs are destroyed by this type of drug.)
"There's nothing wrong with that."
I decide it's time to look too busy to talk.

1700: I wake Patient and ask him if he's hungry for his dinner. "What time is it?", he asks, squinting at the clock.
"Five p.m., Wednesday evening."
He gasps. "And...I'm still alive? I didn't expect to wake up!"
What do you say to this?
What I choose to say is: "Yes, you're still alive. Did you not expect to be?"
It turns out, he didn't.

three:

The Palliative Team's nurse arrives as I'm trying to figure out how to tell Patient that naps weren't normally fatal. Gratefully, I ask her to find me after she's done interviewing him. She comes out 15 minutes later, and what she says utterly floors me. "He thought we were going to give him drugs that would kill him. He thought we would assist him with suicide."
"!!!"
"Yeah. That's what's going on, and that's why he's surprised he's still around."
"DUDE. I can't just throw him in the Suicide Machine! This isn't Switzerland."
"I know. I'm going to make a call to his primary, and see if we can get him transferred someplace more comfortable. We'll get him some better drugs so he doesn't hurt." I think about the air hunger this poor guy is going to experience as he drowns in his own body. "Yay for drugs. I like it. Thank you. I've been beating my head against a brick wall all day with this." She smiles and goes to make her phone call.

She returns to my desk a few minutes later looking dismayed. Her voice stays controlled as she relates the bad news. "I just talked to Dr. OnCall, since Dr. Golf is out of town. OnCall says that since he's never met him, he's not comfortable giving those kinds of orders. So Patient's going to stay here unless your unit needs a bed for a critical patient. You can give him one milligram of morphine every three hours."
"One? I sprinkle that on my Corn Flakes every morning so I can cope. That's not gonna touch him."
"That's all I can get for you."

Just because someone's gonna die, it doesn't mean 'do not treat'. Right?

I give a halfhearted report to Kesler; I don't even bother expressing my disgust. Kesler writes and stays silent for most of it, but finally goes nuts at the pathetic morphine dosage, slamming his pen down and making the Manson Lamps at me. "ARE. YOU. KIDDING. ME?"
"I don't make that shit up."
"That's not anything! Oh my God, I am going to call, and call, and call that doc. He's gonna be tired by the time I'm done with him."
"Good luck. Anything else you wanna ask me?"

Like, do I wish this were Switzerland?
It's 7:45 pm. I'm not answering that.

fan mail

"I've been through it all, baby. I'm mother courage."
Elizabeth Taylor

"Full code? Really? Are you fucking kidding me?!?"
Jimmy

Dear Ms. Taylor:

I've been following, with some interest, the news of your recent hospitalization. First and foremost, let me wish you the speediest of recoveries, assuming you survive this admission.

Forgive me for being so blunt---this is my first letter to a celebrity, after all, and I have the social grace of roadkill. However, I think it's time that someone from the unwashed masses shares a fact as sure as tax collection: your CHF is going to kill you. If not now, within the next two years. (That is an optimistic number that I've pulled out of, as you Brits say, my arse.) I hear of your 'second month in hospital', and I picture others of your cohort, struggling to breathe, praying to make it to their granddaughter's wedding in June, or their 53rd anniversary next week, or to Christmas, or to tomorrow.

I think of a BiPAP mask cutting the skin across the bridge of your nose, and your thoughts every moment of ripping it off. I consider the pulmonary congestion, the daily chest x-rays, the barely concealed horror of every nurse that sees your ankles for the first time. I wonder how tired you are of every nurse, every shift, checking your butt for pressure ulcers. I frown at the idea of Cleopatra on a bedside commode with maximum assist back to bed.

I picture your violet eyes crossing when the BiPAP comes off and you get a little hypoxic.

And, since we're being honest here, I'm going to tell you: if you have any personality "quirks", well, it's being shared over report. Repeatedly. Someone who sees you naked daily probably speaks with at least momentary irritation about you and your hatred of oral care/ability to get out restraints/self-extubation/specific odor of your bowel movements/obsession with Pepsi products.

Ms. Taylor---Elizabeth, if I may be so familiar---Elizabeth, let's cut the crap. The ICU is no place to die. My own grandmother is dying of CHF. She was an ICU nurse, she knows she's dying, and yet she still practically told my mother to fuck off when Mom suggested she go to an assisted living facility. Grandma told her that she wanted to die in her home, in front of the TV. Get out of that shiny, decontaminated, tastefully decorated, well-staffed hellhole, Elizabeth. Die surrounded by the things that remind you of your admittedly kick-ass life; your family and friends. Hell, if it's all you have, your cat, sofa and TV. Put on National Velvet, hire some cute boy to rub your feet (tip him well; let's admit, CHF-affected feet are not "dainty"), drunk dial your exes that are still alive, and have a hospice or home health nurse come visit you. He or she will manage your air hunger, your diet, any wounds you might have, and possibly keep you company when you're feeling low. They'll help you make the most of it. Jesus, they don't even let you have a decent drink and cigarette in the ICU. Something about a "fire hazard" and "not good for you".

Go home, Elizabeth. Live in peace, like I wish the rest of my patients would do.

Your adoring admirer,
Kilgore

that book was a hoax anyway

Patient arrived in the mid-afternoon on a stretcher. Not because she couldn't walk, but rather because she was in four-point restraints, and probably would have kicked the still-beating heart out of any staff member in her way if she hadn't been. I looked directly in her eyes, and saw Jodie the Pig Demon from The Amityville Horror.

"YOU FUCKING STUPID-ASSES! WHY THE FUCK AM I FUCKING TIED DOWN, YOU FUCKS??"
Yes, really.
"LET ME THE FUCK GO, I GOT FUCKING FIVE FUCKING KIDS AND YOU HAVE NO FUCKING RIGHT TO DO THIS! FUCKING ASSHOLES!"

And so on. She wasn't even creative about the way she was shrieking at us, but she was persistent. It was old before we ever parked her in her room. She was Mother Superior's patient; I offered to help tuck her in.

Mother Superior is one of the best nurses I know. She is the supervisor for my shift, the leader of our posse. Soft-spoken, thoughtful, reserved and brilliant, she makes The Job look effortless. I have never seen her run, rush, or become flustered. Sometimes, she'll shuffle a little faster, but that's about it. She is the nurse that I endeavor to be. She was the perfect person to take on Satanette. I watched her talk to the patient in that soothing, maternal way that she has, and wondered where someone finds that kind of restraint. I certainly don't have it. That's why I chose to keep my mouth shut that afternoon.

Mother Superior and I worked together to attach Satanette to her EKG leads.
"I'M FUCKING ALLERGIC TO TAPE, FUCKHEADS!"
I asked Mother Superior if she thought she would need any labs.
"YOU BETTER NOT FUCKING TRY, YOU STUPID BITCH! I'LL TAKE THAT FUCKING NEEDLE AND STAB YOU WITH IT, CUNT!"
Mother demurred on the labs.
What about a glucose check?
"LEAVE ME THE FUCK ALONE, THEY ALREADY CHECKED MY GODDAMN SUGAR! DON'T YOU FUCKING PEOPLE TALK TO EACH OTHER?"
She was diabetic as well as apeshit crazy nuts. Mother Superior stuck Satanette's finger for the requisite drop of blood. She was rewarded with a soul-curdling howl and a 352mg/dL.

I pulled back the sheet to assess Satanette and realized, with horror, that the ER staff had left her partially dressed.
That underwear was gonna have to come off.
Both Mother Superior and I sighed.
"Well," Mother said, "I guess we're going to have to just cut them off. I always feel badly about cutting people's clothes off, though. It's all she's got with her."
Satanette's eyes glowed red, but before she could string together a new, ear-wilting string of FUCKs, Mother and I had each whipped out our scissors and sheared up either hip seam.

"YOU STUPID CUUUUUUNTS! IIIIIIIII'M... OOOON... MYYYYY... FUUUUCKING.... PERIOOOOD!"
"I noticed," I muttered, as the offending pad came into view. "See, I'm a nurse. I know stuff. We'll get you a fresh pad."
"FUCKING BITCHES! I CAN'T FUCKING BELIEVE YOU CUT MY FUCKING UNDERWEAR OFF WHILE I'M FUCKING BLEEDING! YOU'RE SO FUCKING STUPID, BITCH!"

Then it happened.
Mother Superior jumped the gun.

She walked up to the head of the bed.
She bent over Satanette.
She took up the edges of the blanket, as if to tuck Satanette in, all snug and comfy. I marveled again at Mother's eternally composed state. I thought of incorruptibles, the scent of lilies.

She wrapped the corner of the blanket around two of her fingers, and started to stuff them in Satanette's mouth.

She whispered. "I...am tired...of your...filthy...mouth."
And kept stuffing.

Satanette was quiet now; not by choice. Her eyes were bulging with fear, and I began to worry. "Uh, Mother? I can't believe I'm saying this, but it might be time to take it down a notch." I gently touched Mother Superior on the arm. No sudden moves here. She was still armed with the blanket.

Mother Superior never broke eye contact with the Pig Demon. She looked over her narrow granny glasses, and slowly withdrew her fingers and the slightly soggy blanket from Satanette's mouth. "You need to be quiet now," she said with deadly calm. Satanette obeyed. The demon had been cast out, for now.

No lillies.

"where there were eyes, there's only space"

Patient was a tough guy and he prided himself on it, to a degree of boneheadedness. He was in a manly profession. He kept his woman in check, and she liked it. He drove the stepdown staff to drink with his tales of great vengeance and furious anger, along with his total inability to follow directions or stay put. In short, he was tiresome. 

He came to the CVU for a CABG, and he'd had a surprisingly rough course. He was intubated for several days (though this was not through a physiologic deficiency. The pulmonologist kept waffling about Patient's ability to breathe, leading me to loosen his restraints so he could "stretch a little"---right up to his own tube. I hope no one billed him for extubation). Once he regained the ability to speak, I found that he wasn't himself just yet.

I walked into Patient's room. He was hunched down in his bed and looking extra bitter. I put on my Customer Service Face and said, "Hey, Patient, I was thinking we'd go for a spin around the unit, but you're looking a bit down. Wanna talk about it?"

He started sobbing.

"Aw, come on"---I fucking hate it when people cry because I don't know what to do---"what's going on? Maybe I can help."

He muttered something unintelligible and continued to sob. What did he say?
He repeated it. "I doh-hnn't ha-a-ave ah fuhmmphmphph." Sniffle.

A frump? A phone? A frog? What the fuck was he saying? I thought for a minute. No one had been to see him but his wife. Friends? A-ha! I grabbed a greeting card signed by all of his co-workers. "No, look. You have all kinds of friends pulling for you. There have to be at least forty names on here. These people all care about you."

"NO! NO! I SAID, I DON'T HAVE A FACE!"

Oh. Oh, dear.

Propofol has a short half-life. It's effective within 30 seconds of initial administration; if only used for short periods of time, it wears off in roughly three minutes. However, if you sedate a pudgy guy for, say, a week, the drug starts collecting in the Pudgy Guy's adipose tissue. Effect: it makes Pudgy Guys koo-koo for Cocoa Puffs.

Patient was a Pudgy Guy that had gotten, oh, a week's worth of propofol.

I tried to convince Patient that his face was still on him. I grabbed a shaving mirror and started to hold it up. "No, dude, no...you still have a face! It's the same one we admitted you with! See?"
He screamed. "DON'T DO THAT!" The sobs were hysterical now.
And unexpectedly, he sat up and clutched me in a a desperate bear hug.

Earlier, after he'd self-extubated but before the Crazy had made its way to the surface, I'd set his bed alarm as a precaution. I didn't trust him to not fall out of bed or walk out of the unit. When he sat up, his bed alarm sounded, loud and proud. Jimmy came running to my room.

There I was, patting Patient on the back while he cried his missing eyes out.

"Uh...are you okay?" Jimmy asked hesitantly.
"Yeah, we're okay. Really. Patient seems to have misplaced his face, but we're gonna find it again, aren't we, Patient? It's probably lost in the sheets, or in your cubby next to your shoes. Could you do me a favor and shut off the bed alarm, Jimmy? It's killing me."
Jimmy's face was scrunched up; he was making his "ew, hugging" face. "Er...sure. Whatever." He flipped up the edge of the bed's console and disarmed the alarm. The only sound left was that of Patient's crying, and it was easing up.

I decided to let Patient take a powder. He'd already yelled, done some deep breathing, and sat up in bed, thereby meeting my goals of pulmonary toilet and exercise. Done, done and done. I got him tucked back in, and turned down the lights so he could try and nap. As I started to slide his door shut, he asked: "You're really nice. If I weren't married...would you marry me?"
I smiled. "You seem like an okay guy, Patient. I'd think about it."
"Even though I don't have a face?"
"Even so."
I shut the door and stepped out into the light of the Unit.

haldol, np: the reason for the season

And finally, a contribution from one of our psychiatric brethren, Haldol NP. I'm especially appreciative of this, because I've been played by some of psych's frequent flyers before. Still a little bitter about that. Thanks, Haldol!

19 year old Patient began her relationship with me by missing her scheduled appointment. She decided to instead drop-in unannounced later in the day to be fit into the schedule. She flopped down at my desk and shoved a piece of paper in front of me.

"Can you sign this?" Patient asked. "This" appeared to be paperwork from the state that proved that she was actively engaged in mental health treatment. I explained to her that I couldn't sign it because this was the first time I'd met her and that treatment had yet to begin. "Whatever," replied the young lady. Emphasis on "lady."

She was actually pretty good at talking and snapping gum loudly, if one considers this a talent.

As the psychiatric evaluation opens, Patient's chief complaint seemed to be anxiety. "I need Valium, I need Klonopin...this is what makes me anxious, talking to you." Patient's cell phone started blaring tacky hip hop; of course, she answered it.
I waited until she was off the phone.
Tacky hip hop again.
I requested that she silence the ringer.
Patient informed me that I was mean.
I insisted I was not mean, but rather straightforward and trying to do my job.
In response, Patient immediately began texting on her cell phone.

She followed up this singular act of respect with knocking on the window of my office to get the attention of a young man in an extemely puffy white coat with dog fur trim. She was trying to guide him to the office. I told her that I consider texting on a phone the same as talking on a phone. The delicate young creature exploded. "I don't understand why you can't just give me Valium. This is why I hate doctors!"

I tried to get across that the point of a psychiatric  evaluation is to collect a history and get to know the patient in order to guide diagnosis and treatment options. I shared with this sweet, sweet girl that I hadn't gotten an opportunity to know anything about her, as she has been otherwise focused.

Patient, the darling turnip blossom that she was, jumped from her chair and stormed out the door. She screamed: "I'LL JUST GO TALK TO MY THERAPIST! AT LEAST SHE HELPS ME, YOU FUCKING BITCH!"
I called back after her: "Happy Holidays."

the virgin mollie: how to get saved!

"I'm a little high on NyQuil and Tramadol as I write, so feel free to edit," the Virgin Mollie starts her submission. We won't hold it against you, Mollie. 

 

You know how we're supposed to have scripted bits we use to talk with patients? I want to know why we haven't received this as a script, because I'm fucking using it. Thanks, VM!

 

This is a story about coming to Jesus.
 

I started my career as a floor nurse. There, on Satan's Li'l Tele Unit, I learned what is probably my most valuable nursing skill: the Come to Jesus Meeting. This is a one-sided conversation, during which I lay out for my patients why we're going to do things my way.  It's a sort of behavioral modification tool, where we---Patient and I---come to an understanding. Usually it is used for those who:

• ride their call lights incessantly with the mistaken idea that their nurse = their bitch
• have unreasonable expectations (only ordering chocolate cake on a diabetic diet, refusing to walk until done watching the Maury Povich rerun marathon)
• have family members who believe, after careful research on Wikipedia, Facebook polls, and Ask.com, that they know MORE about disease/pharmaceuticals/avoiding death than our staff.

Patient was typical of our clientele. He was angry at us for his illness, as if we "gave" him coronary artery disease ("Here's a lollipop for you, and here's coronary artery disease for you"). Since surgery, this patient had been a terror---he'd been on the unit nearly a week. He was the sort of patient that, during global report, was not referred to as "pleasant", "confused", or "cute" (code word for "batshit crazy". Bulldog, the weekend charge nurse, understands "cute" differently than most). I forget the exact terminology Bulldog did use, but it boiled down to "unpleasant".

Usually report and nursing assignments go quickly. "Good" patients are divvied up accordingly and the less intense ones are paired with a sicker patient. There was absolute silence this Saturday morning. No one wanted this guy. Finally, I spoke up: "I'll take him." A collective sigh of relief. 

 

Off I went to get report. I'd been working in the CVU for only three months, so I wasn't trusted with very sick patients at this point. Background on Patient: male, in his late 50s/early 60s; angry; smoker; drinker; had major heart surgery. Secondary complications of renal failure and constipation, and did I mention he was angry? Meanest motherfucker ever, by report. The offgoing RN gave me the rundown. He shared that Patient was a "one-shifter", meaning "after one shift of having him, you will want to kill him and possibly yourself to eliminate every possibility you might end up with him again".

 

Patient hit the call light. Ding, ding, ding, ding, ding. He was also loudly calling out, using a string of obscenities, for his nurse. Night RN finished his report and asked, "Do you want to go look at him (which, in our unit, means 'so I can show you anything abnormal/ interesting/etc' about him)?" He was a recent graduate; he just wanted to go home. 

 

"No, I got this," I said.

 

Patient's call light continued to ding. 

As soon as he saw me, Patient immediately launched into a tirade about his call light going off for more than 30 seconds, which was how soon he expected "the help" (me) to arrive. He then began to curse me at the top of his lungs and tell me everything that was wrong with me. I stepped inside his room, calmly shut the sliding door to his room, and drew the curtain.

 

"I only have to come in here once an hour," I informed him. 

"I am not your maid. I control the pain medications, the nausea medications, the benzodiazepines. Also, the stool softeners. You are at my mercy and I will be directing your care today. I will be polite to you and I expect you to be polite back. You will NOT be hateful to me, or to other nurses."

 

"HOLY SHIT," said his face. And he was saved. Jesus 1, Patient 0.
 

It was mentioned in report for several mornings that someone had done something to him and now he was actually being pleasant. Nah. I'm only an instrument of the Lord.

o-dubs: on the other hand...

I've been really lucky to get such positive feedback from readers, and even luckier to get contributions from some of them. o-dubs wrote this in response to "my empire of dirt". Lightly edited. Thanks, o-dubs!

Patient had already completed round one of chemotherapy, with no discernible progress; she was admitted for respiratory distress. She and her incredibly supportive family were trying to decipher all of the information presented to them by the pulmonary team, the oncology team, the nephrologists, the medical ICU team. She was pleading with me through her tired eyes as I replaced the biPAP mask that she had worn for the last three days; this was the only way for her avoid intubation. I would explain to her again and again why it was necessary for her lungs at this point; she would just politely say, "Do what you need to do, sweetheart. You all know best."

I brought the attending into her room following rounds. He made direct eye contact with each of the expectant faces looking toward him and said this: "Look, here's where we're at. Right now, you are alert, you are aware of what's happening around you, you are able to talk to your family and enjoy the company that they bring. At any moment, all of that may change. Our medical technology will not be able to cure your condition. Yes, we will be able to keep you alive---possibly longer than if we stop aggressive treatment at this point---but your mental status will decline, you will be supported by machines, and some of those machines require sedation that would dull what capacity you have left. If it is more important to maintain the quality that you have right now, to be able to see and speak to your family and enjoy them...get the hell out. Now. Today. Don't stay here one hour longer than you have to. You don't have much time left either way, but right now you have the opportunity to choose to spend that time in a comfortable place, surrounded by these people who love you, not worrying about any more tests, procedures, or results. If that's what you want, now is the time to get out of here. We can help you do that, too."

I don't have any words to describe the relief, the happiness on Patient's face. Her cheeks had color for the first time in the three days I'd taken care of her. She smiled. As her family looked shocked and dismayed at this "failure" of medicine, this woman emanated a peace that was almost palpable. the family discussed this "new development" in the room for quite some time, but the woman's ultimate decision was delivered as a quiet, "Yes, please."

I removed her biPAP mask and traded it for a simple face mask. She was able to speak again. I could finally give her ice chips to moisten her dry, cracked mouth. No more lab draws. No more consults. Later that day, I sent her off to spend the rest of her life in a hospice house surrounded by gardens and art and a family who now had the freedom to focus on enjoying this woman as a mother, a wife, a sister, a grandma. A person.

Not a patient.

my empire of dirt

Patient came to us about a month ago. He suffered from the ICU FunPak of cardiopulmonary diseases----80 pack-years' worth of smoking, emphysema, multivessel disease, and a newly acquired septal defect that took away his heart's "lub-dub" and replaced it with a pathetic "whooooshwhooooshwhoooosh". He was also unable to hear, leaving all of the staff to use his worried family as interpreters. When they weren't available, we wrote short technical manuals for him in Sharpie pen, explaining test results, procedures, and the fact that if he didn't have surgery to correct his defect, he would surely die within weeks. If he did have surgery, he had a great chance of dying on the OR table, but a slim chance of surviving and returning home eventually. The physicians on different (one could say opposing) teams argued with each other, then got passive-aggressive. Send him out to a larger facility? No. Cut him now? No. Recommend palliation and give him a bunch of drugs and an opportunity to live with his family at the end of his life? Oh, hell no.

Precious time passed, and Patient finally went to surgery. After much debate, he decided he was willing to roll the dice on dying because for him, it was worth it to try to survive until his grandchild's first birthday, a short two months from this point.

Patient spent the rest of his life after surgery on an air mattress, stoned to the gills and terminally air hungry. He couldn't be assessed for neural function because he was sedated. He couldn't have sedation lifted because he would fight the vent. He couldn't respond to commands anyway because he couldn't hear us. All he could do was occasionally open his eyes, writhe, and get bolused with more sedative, to keep him manageable.

I use the word "manageable" loosely.

The last time I took care of Patient, I could have sworn I heard more of a whoosh at his apex than I had previously.  I frowned at the find, and chastised myself for not paying more attention during my previous assessments. I couldn't think about that sound being a new development. I talked to his children, his wife; I refused to say "better" or "worse", and just stuck to the facts. I honestly didn't know what to say otherwise. The Surgeon brushed off concerns, and would only say that we needed to give Patient more time. That night, over drinks, I decided to swear Patient off. I couldn't care for him anymore. I was dreaming about him, thinking about what else I might have missed, wondering what I could change, and dreading further arguments with Surgeon. It was time to stop.

A few days later, Patient tanked and died. It was one of those TV Hospital-style deaths, with everyone being heroic, and every measure taken. A horrible, horrible death. He didn't live any longer than he would have without the surgery.

I can't quit thinking. I can't quit thinking.

let me give you the nickel tour.

There have been a few questions about what this blog is.

It is:

• all true, with some story editing for flow and readability. That includes the bit with the "Taco Bell" patient...that one seems popular with you guys.
• complete with all names and some genders changed to protect the employed.
• a way for me to vent, on behalf of all nurses who wish they could share the amazing, dismaying things they see, hear and have to do.
• if you wish, a place for you to vent as well. I don't have the market cornered on the insanity that is nursing. (As a matter of fact, I have a new entry I'm working on editing for "Haldol, NP"---an advanced practice mental health nurse who last year began his work in the private sector).
• A display acknowledging how much we know and give in the course of providing care. I don't care what my mom says, I don't get paid well enough. And neither do you. 
• not intentionally a forum to mock anyone. It just works out that way sometimes. Okay, frequently.
• me trying to wrap my head around why we do what we do; not only within the profession, but within American health care.

sliders

Bulldog:
"I spent years trying to explain to these people that things work a certain way, and I did it until I was blue in the face. But it's not good for my mental well-being, so I stopped. When I'm faced with ridiculous orders and general stupidity, I just smile and make sure all the numbers match, and do whatever I want in between those numbers. The letter of the law, honey...not the spirit."

 

:::::

Resident: That guy that died last weekend? I stayed up the whole night before, keeping him alive. I go home on post-call, he dies.
Kilgore: That'll teach you to go home, ever.
Resident: No, that'll teach me to keep dead people alive.
[pause]
Resident: I never said I was a good doctor or a nice guy.
Kilgore: Touché, sir. Welcome home.

 

:::::

Patient: I got a question. Is Taco Bell bad for you? I eat there a lot.
Jimmy: You're on the CVU. You're almost 500 pounds. Do you think Taco Bell is working for you?
Patient: Jesus. It's just a question.

 :::::

Kilgore: Sir, are you ready to go for a walk?
Patient: Nah. I'm good.
[pause]
Kilgore: I see now how poorly I phrased that. Get up, we're going for a walk.

:::::

Family member: I don't know how you guys work the way you do. How do you do this stuff for 12 hours straight?
Kilgore: I don't know about the others, but I eat like a shrew while I'm here and drink heavily when I get home.

:::::

On a float to the ED:
Kilgore: ...well, sir, since you abraded your scrotum, I need to take a look to make sure it's not extra swollen or already infected.
Patient: What?!?
Kilgore: Yeah, I know. Sorry. If you're uncomfortable with me, I can get a male escort or we can get someone else to look.
Patient: No, it's not that. It's just...you're pretty. I wish this were under better circumstances.

 :::::

During the installation of a rectal tube:
Kilgore: .....aaaannnd...I think I'm past the sphincter...his rectal tone sucks, let's see if we get anything...
[Kilgore watches from the "action side" while Grace and Susie peer over the patient's other side. Diarrhea pours through the tube.]
Kilgore: God, that's a thing of beauty.
Grace: High five!
Kilgore: I guess all I need now is to know when this became normal for us.

:::::

Dr. Obvi: That patient's a dick.

Kilgore: I know. I assessed him.

:::::

The Metatron, overhead: Attention, visitors, it is now time to close the unit for change of shift. The unit will reopen at X o'clock when you may be welcome back onto the unit.

Every nurse, under their breath: Or you may not.

:::::

i'm so glad we've had this time together

RN: Hi. Your nurse is tied up with another patient right now, but since your light is going off, I thought I'd check on you. Is there something I can help you with?

Pt.: I'm in pain. I'm in so much pain I feel like crying. And I feel like I'm lying in bed funny. I need to be fixed. And this alarm over here [jerks thumb over shoulder] won't stop.

R: Okay, let me get you some pain medication, and then I'll get you repositioned, okay? [Stops alarm.]

P: Don't I look funny here? Like I'm really laying in bed wrong? How did this happen?

R: Well, your bed is tilted upright so you can see the tv, but you have to lie flat because of the procedure you had. We'll get you fixed up. I'll be right back. [backs away, silently curses not faking deafness, comes back two minutes later]

R: Okay, I've got your pain medication.

P: What is it?

R: Fentanyl. It's a narcotic.

P: Pssht. That shit never works. How long will it take it to work? Why can't I have more pills?

R: If it never works, how come...[decides, "fuck it" and doesn't ask anything] You can't have more pills because you already took some about 15 minutes ago, remember?

P: Oh. So how long will it take this to work?

R: Since it's IV, about five to 10 minutes. [pushes it, prays it makes P shut up]

P: OW. Jesus. That stings.

R: [tries to care]

P: [tries to sit up, lies back down immediately] OW, shit! That hurt! I'm not supposed to sit up, am I? What is that thing?

R: In your leg? [takes a peek under the sheets] It's an arterial sheath. It's a tube that goes through your femoral artery. There's medicine going through it that keeps you from clotting, so if you antagonize it by sitting up, you could bleed to death. That's why you have to lie flat. I'm sure someone has explained this to you, since you've been here a couple of days now.

P: Whatever. Can you move me? I'm sliding down, I can just feel it. Does this look right to you? I wouldn't slide if you'd let me sit up.


R: Someone is on her way to help me move you.


[RN2 enters.]


R: Thanks for coming, R2. We're just going to scoot this lady up. On 3. Okay, 1, 2, 3.


[RNs scoot Pt. up to top of bed.]

P: God, you could have warned me. I told you I was laying here wrong. Now can I sit up?

R: No.


R2: [rolls eyes, stifles giggle]

P: I could probably move myself if I weren't all tied down. [Waves hands around in the air for emphasis.] Hey, I need cream.


R2: [flees the scene]

R: I'll let your regular nurse help you with that. [Starts to leave]

P: This really itches. [Lifts up gown, right tit; starts scratching vigorously.]


R: I'll tell your nurse.

P: It's a fungus. I really need a cream, it itches so bad. Worst damn rash I've ever had. Jesus, my leg really hurts. Can I have more pain medication?

R: I'll tell your nurse.

P: Tell my nurse. I really need that cream. And my catheter really hurts. I hate that thing. Tell my doctor, too.


R: I'll tell your nurse. Goodbye. [Flees.]

~FIN~

this blog is supposed to have a clear cover.

Attention, staffers:

1. Unless the needle on your patient's Well-O-Meter is closer to "going home" than "needs a morgue pack", do not tell his family that he's doing much better.

2. There are multiple bake sales and events on our campus today. You will not be able to go because your staff is overburdened and only two out of eight of you will be able to sit during your designated lunch periods, as the other six of you opted to walk 20 of your 30 minutes to and from the cafeteria; however, it was felt that staff morale might improve, knowing how diverse life without you is.

3. Overtime will always be approved, even if you don't think you want it. Please speak directly with your manager; otherwise, Staffing will be happy to contact you for opportunities as they arise---frequently.

4. Our administration has decided to abort beta testing of any new technology we plan to implement over the next five years. Customer satisfaction is a must; after careful consideration, it has been decided that regardless of how poorly new systems initially work, that  our clients deserve to have bleeding-edge technology at their nurses' fingertips. "Bugs" can be corrected as the staff integrates barely functional software into their workflow, thereby making it more effective in real time. We will be working closely with our IT department; they will be as prepared as we are, since they are receiving notice of this change upon the release of this memo.

Happy Holidays! Thanks for all that you do, even though you're going to have to do even more next year.

Best,
Administration

chip shot, charlie!

News item found on Philly.com:

"Shortly after Kent Schaible died of bacterial pneumonia at his family's Northeast Philadelphia home in January 2009, a city social worker and a nurse visited to check on the well-being of his five siblings.

During that visit, Kenneth Dixon, of the Department of Human Services, asked Herbert Schaible if he had sought medical treatment for his 2-year-old son, Dixon said.

'He said that him and his wife were faithful to their religion and they believed in God to make their son healthy,' Dixon testified for the prosecution yesterday, the second day of the manslaughter trial of Schaible, 42, and his wife, Catherine, 41.

...The Schaibles are members of the First Century Gospel Church, in Juniata Park, which shuns medicine and doctors in favor of prayer to heal the sick."

I'm sorry for the loss of this child. Also, I've made it a point to not mock religious beliefs that differ from mine, no matter how ridiculous they seem. Lastly, it's not my business to tell anyone how to raise their family or choose their actions. I feel, however, that it's time to point something out.

1. You believe God is the Creator, and responsible for everything.
2. Following this line of thought, he also created bacteria and viruses.
3. But the good news is, Man is what He created in his image, and, if I've got this right, Man is also supposed to be a steward for God's other creations.

4. Maybe hospitals and health care are part of that stewardship.

5. Parenting is definitely part of that stewardship.

6. Unless God was specifically paying attention to your situation and actively rooting for the flora causing your kid's pneumonia, you blew it. God asked you to do one thing, and you actively fucked it up.