The Worst

There are lots of stinky, drippy, oozy, things in my day. Most of them I barely register before moving on. Some register more than others, though. I used to think the worst thing I'd ever felt was the sensation of being buried elbows deep in the abdominal fat tissue of a patient. Tucking Kerlix (total: 6) into the far recesses of the subcutaneous tissues while the skin and fat lapped over my gloves onto my forearm was horrifying. I learned very quickly to wear the blue, plastic isolation gowns and sterile gloves, since they're longer than the nitrile for dressing changes.

But I was recently reacquainted with the feeling of an unstable chest. Long ago and far away, I had my first code blue. I'd been a part of a good many before this one, but this one was mine. Since it was my patient I felt, all in one moment, ashamed that I'd missed the warning signs, the shot of adrenaline that comes with the ohshit moment, and eager to prove my worthiness as a nurse. So I bounded into the room, cape flying, and purposed to give the best possible compressions that had ever been given in the history of CPR. On all 80lbs of my patient. The first crunches that accompanied my first compression are marked indelibly in my memory. The room spun and my vision narrowed momentarily. But I yanked on my bootstraps and kept compressing, tears running down my face. That patient didn't make it and I forever swore off compressions. I didn't know then that effective compressions, about 1.5 or so inches in depth, will often break ribs. I didn't know how to modify the force of my compressions to suit the individual. I certainly didn't know that at a future point I would be throwing my entire body weight into compressions, actually lifting my feet off the stepstool, and barely making a dent in the body habitus I was endeavoring to "save." I just knew when I got home after that shift, I spent a long time crying.

I was the recipient of someone post CPR the other day. The code was prolonged and bystander CPR was ineffective (it usually is). There was a high probability of irreversible damage to the brain and so all medications that might sedate were held for a period of time to see what, if any, neurological function was preserved. Eyelid opening did nothing, neither did nailbed pressure. I casually went to sternal rub my patient and immediate flashback. Unstable chest. Fractured ribs from compressions. Once again horrified, ashamed, de-caped as it were. I couldn't bring myself to inflict any more pain on someone who'd been through so much.

As bad as being inside that belly was, being outside those chest walls was the worst.

Dear Mom

I've seen a lot of you lately. Weeping mutely next to your son or daughter. Lovingly wiping his or her face with a damp cloth. I've seen you despondent and hopeless behind the bed so he or she can't see. I've seen you put off battling your own life-threatening illnesses to be at your son or daughter's bedside 24/7. I've seen the bags form under your eyes as the days go by without sleeping in a bed, showering in a friend's shower, eating whatever those who love you bring to the bedside. I've seen the weight you've lost, the grays form in your hair, the tightening of your mouth with the doctor's entrance. I've held you while you've cried and held you while you've celebrated. I've eaten the chocolate and homemade truffles you've sent. I've privately agonized with you while professionally ministering to you as best I can. And, to my eternal shame, I've sat next to you and held your hand while I advised you to withdraw care on your daughter.

I'm amazed and awed by you. What would render me completely incapacitated puts steel in your spine. What would have me curled up on the floor in tears strengthens your resolve. I promise you that it's your tender, everpresent, palpable love that heals your child. I provide the framework and some fancy drugs. But you do the healing.

How do you go from kissing a skinned knee to seeing your baby helpless in a bed, hooked up to monitoring equipment and life support? How do you look your child in the face after I let him or her wake up and ask them why they would take all that medication without crumbling? How do you restrain your anger and censor your accusations and just let your love pour out?

Mom, you are fabulous. You are lioness and mama bear. You are iron wrapped in cashmere. Your family derives its strength and cohesion from you. You are healing and sustenance.

And I couldn't do what I do in that room without you.

Burnout

Sometimes we get stuck in a physical location that just seems to breed discontent and mirror our internal processes. Case in point:

Beginning of the workweek:

Room 1: Jabba the Hutt with hoverfamily, all feeding into Prince Syndrome. I initially started with an empty bed in Room 2. I eyed it unhappily, expecting the typical ALOC/PNA/sepsis/UTI/anyother SNF bound, fully accessorized admit. I coveted the nurse receiving the balloon pump patient down the hall. But, not today. I jinxed myself. Admitted a woman, hx IVDA and EtOH, Hep B and C positive, end stage liver and kidney disease. So far uncompliant with BP, NH3, and other meds. Complaining initially of belly pain then became somnolent with periods of combativeness and generalized freakout requiring her family to call 911. Came to me after Vitamin A(tivan) in the ED, one 22g PIV, no foley, no NGT, nada. Breathing about 80bazillion labored breaths per minute, complete with preggerbelly indicative of a fuckton of ascites. The admitting doc was on the unit and I called him in to look at the breathing, oh and the BP of damnnearzero/notquitezero. He said the breathing was fine, baseline, but if I was going to be all up in a snit about it, I could get an ABG. Far from the respiratory derangement I was expecting, she was in metabolic alkalosis with a pH of a whopping 7.58. Still, the MD was not impressed. I did get an order for, oh, fluids, blood products, and more fluids. I worked on that most of the shift and got a BP of marginal/shitty. Long about an hour before shift change, the doc rolls around, spies the exact same breathing pattern that I had called attention to 10 hours earlier and decides that it's time to hit the ohshit button. In short order we're intubating and thanks to the sedation, the BP is back to nil/nyet. Now she's received 3L of crystalloids, 3L of colloids, 5 units of PRBCs (for an H/H 6/19... why she's labored, right? Diminished oxygen carrying capacity? My ass), 6 units of FFP and 2 units platelets for the pancytopenia she's got brewing. She should be able to maintain a decent MAP if nothing else. No go. So I finally get the Levo I'd been gunning for and we're shooting it through the one PIV we've got. Turn off the sedation, hook up the Levo at 10... no 30... no 75mcg/min! Through a 22g! And still marginal BP. I get her turned on her head, thusly distending neck veins enough for the doc to get a central line in and now we're playing for keeps! I move the levo to the central line and no, I didn't change the tubing yet, and get an order for vasopressin and neo drips. Start the neo at the max, 200mcg/min and tap my foot nervously for the vasopressin to arrive from pharmacy. Meanwhile, I'm getting pure blood out of the OGT I'm finally allowed to drop and 0ml of urine out of the foley I placed on arrival. I've got 3 more liters of NS running wide open and albumin on the pump at max infusion rates, switching out 500ml bottles every half hour. By the time an hour after shift change rolls around, I've got a decent pressure, I'm running PRBCs in about as fast as she's losing them, and I can sign off. I don't believe I've seen Jabba since 4ish; I'm thankful for the other nurses who've swung in and done my meds, coddling, etc. I come back in in the a.m. to find an endoscopy in progress and what it finds is not heartening; varices have burst all through the GI tract. Too hard to cauterize/clip/etc all of them. The family is called in, the decision is made to withdraw. She dies a slow, lingering, destructive death.

Two days later I'm back, same room assignments, similar story in Room 1. Another Jabba, still in excess of 300lbs and just shy of 5'1"; all pannus and no periphery. Same empty bed in Room 2. This time it's a floor transfer. I get a bullshit report of "I think he came in with pneumonia, but his bowel sounds are great. His BP is 50/48... do you think we should turn the Dopamine up?" God, I wish we had some semblance of a rapid response thing going on here. Yes, I think you should turn up the dopamine and just get him down here. Nevermind that I believe 50/48 is impossible and you've failed to recycle the cuff. I can hear him yelling in the background. You can't cerebrate if you can't circulate, but whatever. And then I see it: three RTs and 2 RNs hauling ass around the corner, bagging en route. I don't funk around this time: I yell for the charge and charge relief to bring the slide board, the intubation tray and a central line setup. Miracle of miracles, they do. And it's the same doc. This time he says maybe BiPap will fix dood. Um, nuh uh. I bought your line earlier in the week. I ain't buying today. I stare at him as our monitor gets hooked up and sure as shootin', sats are... subpar. We gown up, mask up, bonnet up and away we go. But he's got this jacked up rhythm, too, and I can't feel anything. I can't hear anything. The doctor magically does, so I've got one hand on his carotid pulse (nothin' there), my stethoscope in my ears with the diaphragm on his chest trying vainly to even hear breath sounds (since the intubation happened even before we transferred beds), and the other arm hitching up his not insubstantial pannus while the doc tries to get another line in. I hear a strained "get me an art line setup" and we lock eyes over the umbilicus. Seriously?? Well, shit, we haven't been able to get anything other than 40/doppler since he hit the unit, so an art line sounds great, even if it's unintended. I spent a sum total of 4 hours in the room, soaking my scrubs through and yanking every joint out of place maneuvering to look, listen and feel for anything that would indicate cardiac activity, giving epi, running pressors wide open, running fluids, again with the gastric sanguine fountain only this time I was treated with a top-down exodus. Something deep and important had opened up in his gut, something an endo wasn't going to fix. Again, Jabba II was forgotten except by the grace of other nurses. And I still had 4 other nurses in my Room 2, all performing critical, vital functions. Eventually we got him stabilized. Another family conference, another decision to withdraw. But tomorrow, if we could. More family is arriving from points unknown. And so we acquiesce, warning that no promises can be made. Yes, he's still a full code, to give the other family their best chance to say goodbye. And he makes it through until I come back the next morning. And everyone comes in, tearful and muted, and I shut off the pressors while my RT extubates. He never took a breath. And his blood, my sweat, and the family's tears all for naught.

I wonder why neither of these two were DNRs. They both had end stage disease that we in the unit didn't know about until we'd flogged them away from the last inch of their lives, but both families were well aware that that inch was only an inch away. Nobody informed us early enough to make their deaths peaceable and dignified. Don't get me wrong, I'm an adrenaline junkie. I'm in my element pushing fluids and tubes and lines and calling out orders. And I'm grateful for the opportunity to practice high stakes medicine instead of the fluffnpuffing I'm normally doing. The withdrawal orders were appropriate, but comfort care at the outset would have been the humane thing to do. I'm so tired of futile care. I'm so frustrated with doctors that spend their evenings pulling the splinters out of their asses from riding the fence all day long. I'm short on patience and not able to suffer any lapses in judgment gracefully. From anyone. I'm grumpy and sad and have reached critical mass. What am I doing? Who am I saving? I went through over 20 units of packed red blood cells on dead bodies. Those units could have gone to someone that had a reasonable shot at using them through the lives of the red cells in them. I don't necessarily believe in battlefield triage in the ICU, but damn. What did I do that lasted any longer than a wad of chewing gum in a dike?