Love's Labour Lost

So there's days where I love/hate my work.

Yesterday would be one of them.

Mostly, I hated work yesterday.

Loathed it.

It was one of those kind of days where you're getting report on one of your patients and you're thinking, "Lawsa, honey, why the fuck isn't this person in the unit?!" And then you remember, "Oh yeah, she's a DNR/DNI."

The DNR/DNI is a good cop/bad cop scenario. On the one hand (good cop) when they are close to crumping, we all kind of sit around and say, as if to reassure ourselves as healthcare providers that we aren't, in fact, cruel horrid thoughtless bastards, "Oh, well, s/he's a DNR/DNI."

I forget what the "bad cop" scenario would be. Any way.

Okay, so that does make us sound like cruel horrid thoughtless bastards. Let me explain the logic behind the statement, so you can understand what truly cruel horrid thoughtless bastards we are. So what we're really thinking is a) the litigation in factor should the person die will be close to nil, well, maybe not, but b) thank God we don't have intubate and start compressions on a person who will then need life support for the remainder of their waning, miserable hours/days on this planet.

This is like, so not t.v. ER, where you pump on a patients chest five times, shock them while they're in asystole with someone still bagging the patient and then twenty seconds later, they're back in normal sinus, sitting up and having a Healing Hands, Healing Hearts moment with their estranged wives and children. (Because apparently in ER's ACLS protocol--which I believe [community hospital] may have adopted--it's first choice to shock patients with no electrical activity whatsoever and the person bagging the patient is Data from Star Trek, and magically 40th century electrocution-proof, or something. Also, I think [community hospital] has adopted the showboating "As seen on t.v." policy which contributes directly to farcical situations like the one I had yesterday.

So any way, we also happened to be working short, and whoever made the assignment decided it would be a good idea to give El Crumpo to a nurse with eight months of experience, plus the total-care, full feed Alzheimer's guy with a PICC line, central dressing change on ATC IV antibiotics, plus two other patients (one of which was the roommate of Dying Patient; she incidentally happened to be the "good" part of the day, in that her cocaine-abusing/alcoholic fried mind was better able to comprehend and anticipate her own medical needs better than that of her useless attending.)

Any way, so Dying Patient, I'm told, is 'cyanotic as a baseline.' This, I have since learned, is code for "Your patient is going to go into respiratory arrest in six hours, just thought we'd all fake like everything is 'okay' because that's what the house officers have been doing all night, long."
Her labs were a fucking mess, she wasn't putting out any urine in her foley, and yet, the house officer on nights was okay with "just watching her," which is code for "I sense this person has very little life left. Hopefully s/he will die tomorrow, when I will be at home asleep, dreaming of fast cars, beautiful women, and the piles of money at my disposal return l for my part in largely ignoring emergent patient needs."

So at eight a.m., I address all this with the new PA, who is very nice, very proactive, but also very new, and unwilling to make waves with attendings he's going to have to 'work with' for the next few years of his career. I mention the fact that her K is 6.4, her dig level from yesterday is 3.6, her INR is 6.2, she's hypotensive, nauseous, not putting out urine and has been consistently desating over night despite being on 4L of nasal cannula oxygen... hey, what do you think about some Kayexalate for the potassium level, some more Vitamin K for the crap INR, and maybe, I don't know, something for the nausea, and maybe a pulmonary consult, the latter of which the nurse who took care of her on day shift yesterday specifically came up and suggested I root for, because she was roundly ignored when she suggested it yesterday? This advice came from a veteran nurse who I deeply respect, so off I go to ask, innocuously, "So, what thinks you of a pulmonary consult?"

The PA decides to talk to the attending, who apparently thinks our suggestions are all silly, crazy girl talk, for he says to him, "Yeah well, we're not going to do anything about the INR because I've seen higher, and no pulmonary consult." Stunned, and imagining my license once again spontaneously imploding, I managed, "Uh? Are you sure he doesn't want Vitamin K for that INR? She could bleed out! What the hell's his rationale? And uh, she's a chronic COPD'er and has a pulmonologist... why no pulmonary consult?"

These kind of rational questions I find, happen to be the very ones that neophyte nurses like myself should steer clear of asking, for clearly I am treading on sacred ground of Holy Mysteries of [community hospital] Clinical Decision Making Policy Or Lack Thereof that I dare not deign to reckon. For ye, I have learned that there isn't, apparently, standard evidence based algoritihms for patient care that we follow, or if there is, we pretend they don't exist, because how the fuck would scientifically researched care models be useful in insuring quality patient outcomes and reducing mortality and morbidity?! Come on, stop with the crazy talk already! We can all just make up stuff as we go along! It's cost effective (not), much like our ONE ancient bladder scanner that looks like a Soviet bloc reject bought in 1975 and no nurse with her salt is convinced actually doesn't just spout random numbers, as opposed to an accurate reading.

I feel like writing a "Pat the Bunny" type spoof, except my version would be "Kill the Patient," and have passages like, "Feel Daddy's beard! My how rough! Daddy needs to shave! Let's help Daddy shave, shall we?! Oops! Due to the massively high doses of prednisone Daddy is taking for his COPD, that hospital razor just managed to slice through his paperthin neck, nicking his jugular, and since his INR was 6.2 left untreated because "the attending has seen higher," let's now see Daddy lying in a pool of his own blood, bleeding, bleeding, bleeding. My that blood is dark red! Can you point to the color red? Can you dial 1-800-GET-A-LAWYER? Good nurse!"

Any way, so swirling-the-drain patient isn't getting 1:1 care, which she needs, because I'm stuck in Contact Precaution Intermittent Lethargy of the Aged Room, trying to get Mr. Confused to wake up and fucking swallow his pills, do a fucking sterile dressing change, flush his fucking PICC line five thousand times for the 5 or 6 fucking IVs I had to hang, and let's not forget Mr. Chest Pain Guy That Needs His Discharge Typed Up and Ms. Denies Cocaine Abuse, Tox Screen Positive Slack Jawed Yokel roommate of Death Patient, who, believe it or not, was the amusing, funny, possibly-smarter-than-her-attending-with-a-medical-degree-as-advertised-on-t.v.

So at some point, we put Desating Hypotensive Woman on a nonrebreather, her sats go back up to something passable, even though we're all kidding ourselves because she's a COPDer and the numbers merely give us a false sense of security while she's literally losing her ability to exchange gases at all. I'm still thinking she's a DNR/DNI, and thanking my lucky stars (fate is a fickle bastard!) so I go get her Kayexalate, bring it into the room, explain to the husband she'll need to drink this for her potassium level (pointless teaching, in retrospect) and run back out to hang yet another antibiotic on Mr. Confused Lethargic Guy (who I chart as "sleepy" to avoid the question of why his baseline seems a little off this a.m., too, because hey, his vital signs are rock solid, and a little if you can't treat the patient, treating the chart goes a long way when you need it).

Five minutes later I go back into respiratory distress room of doom, and the woman is slumped over, unresponsive. I tell someone to go get the PA now and start working on arousing the woman. Meanwhile, the cute little old husband is standing there, looking unconcerned and saying breezily, "Oh don't worry. She does that. She'll snap out of it in a few seconds."

HUH?! She's been passing out at home and no one knows about this?! HUH?!!

So here's the part where two PAs come into the room, one of whom doesn't know the code status. This is the part where Jamie learns, neither does she, apparently. He asks what her code status is, I say the magic words, "DNR/DNI." and he nods and says in a relieved, well-then-we-can-all-relax-now-can't-we way, which is kind of what I'm feeling despite the shock of having just heard the responsible, loving adult partner of the patient tell me his wife has been syncoping at home regularly as if he was telling me some cute little quirk, like she prefers mayonnaise, not ketchup, with her fries.

Then the other PA goes, "Actually, she's not. I just made her full code a couple hours ago."

C'EST FUCKING QUOI?!

So now I'm starting to go numb, because fuck, now we actually have to code this woman, and worse, no one bothered to mention this little change-of-code-status issue two hours ago.

Somehow, I notice that STAT ABGs are being drawn, which are crappy beyond belief, someone else is trying to get a pressure, and meanwhile, I'm emoting the calm, radiant presence of Gallagher hacking at a watermelon. In retrospect, I must've looked like a hamster running randomly around its cage, scrabbling at the walls trying to get out, which looks productive from afar, but actually is wasted, futile energy.

All I could think of is something one of the nurses had told me just last week, "You know, when it's someone else's patient crapping out, I'm all good. When it's mine, suddenly, I lose it and I'm like, "I'll go get the ambu-bag, 'kay?" This is a nurse I respect, with loads of floor experience, total nursing smarts, who I wish I could emmulate, because I think she is a bad ass, but I know I am unworthy, so I don't even try. But still, if she feels like an ass during codes, then I felt slightly better about being new and feeling like an ass.

And there I was, thinking, "God I hope they give me simple to do, like bag the patient."

I fake a calm air while escorting the poor little husband out of the room, pastoral care gets called, I beg the roommate to leave because "things might get a little busy in the room" (I love, incidentally, how we euphemize dire situations and basically lie our asses off to the patients) start clearing excess furniture out of the room, push the code cart closer to the door, get the bedside monitor hooked up.

So, okay.

If you've ever been in a code or near-code, within five seconds there's literally twenty people in the room--docs, PAs, respiratory therapy, anaesthesia, IV team, six or seven nurses taking over for the primary, who's sitting there numbly registering the fact that her goddamn patient is dying/dead. You, the primary nurse, are stuck in some kind of drug-like trance, replete with strobing effect slow motion. Or least I was. To further the I'm-on-hallucinogens-effect, I was also saying the stupidest fucking things in response to medical questions about my patient like, "The patient likes to play poker on Wednesdays!" Well, not really, but I wasn't exactly spouting brilliant nursing assessments, either.

In fact, I believe I gave the distinct impression of a lethal-gene-expressing dwarf hamster, twirling about madly in place, then in ever larger ellipses, relying on reflexes I didn't have due to inexperience and this being my very first near cardiac code/respiratory arrest.

I was incredibly adept at being extremely unhelpful, and as far as my PTSD related amnesia allows me to recall, I was able to perform the following negligible tasks: handing over saline flushes, passing IV tubing out, tearing at an opsite and failing to put the damn thing on an IV site properly because I just couldn't figure out how this stupid backing peels off! Generally I just kind of ran around frantically and pointlessly like rodent caught in a one-exit burrow, twitching frankly and looking like, "Oh fuck! Oh fuck! Oh fuck!" And not in a good way, either.

At one point, mercifully, the RT needed to set up the vent, and I offered to bag the patient. And I was thinking, "That nurse is right! Bagging a patient is exactly the nice, calming, thing to do as primary nurse! Maybe I can just bag her manually and we just forget about the vent, or alternately, I can just melt into the walls and fade into nothingness and never show my face on the floor again?"

We almost had to call a code (and while we were intubating the patient, someone beat us to the punch and another code was called over in an ICU) as we watched her brady from 110's down to the 80s, then the 60's, 50's and then the 40s, and as we're all sitting there mesmerized by the dipping numbers on the screen, someone snapped to, remembered protocol and suggested atropine. Oh yeah, that drug-of-choice. Good save, everybody! Good save!

To say a code is well-controlled chaos is to be quite generous about the whole thing. In reality, it's a freaking carnvial show overrun by Visigoth barbarians. Visigoth barbarians who are a little slow on the uptake, at times.

What we do not need, in my editorial opinion, is students, standing there, cluttering up room, taking up space, and being totally useless. Hey, being useless is my fucking job, I thought privately, Quit hogging my spotlight, for Christsakes!!

You see, all of a sudden, even though we're fifteen, twenty minutes into the situation, I become vaguely aware that suddenly there are all these extraneous people, including a bunch of students from some other department brought along for the show (which incidentally, upset me, because I truly feel that someone dying is not a goddamn spectator sport, I don't give a shit if this is a teaching hospital, get the fuck out of my patient's room and let her die with some kind of dignity.)

As a sidebar, you're always told in nursing school, "If there's a code, get in the room! Watch!" As if you paid your goddamn admission, you should get to see the show, right? Now that I'm a nurse, and it's my patient who's crumping, I adamantly oppose students being in the room. One, they are generally useless and extraneous bodies getting in the way. Two, I don't think people ask themselves how the hell they would feel if that was their relative or themselves on that bed, unclothed, unconscious, dead, essentially, with all these strangers swirling around doing stuff that under the best, controlled situation is traumatizing, painful and dehumanizing.

If it was ever my loved one in that situation, I'd ask that extraneous gawkers not be in the room, because fuck you, if I don't get to watch my parent or spouse die, neither do you, a complete stranger, for a fucking "learning experience." I wanted to say to those students, "Trust me, you will get more "learning experiences" about the harrowing, heartbreaking suckiness of a hospital death in the first six months out on the job. You don't need my patient to use as bragging rights tonight when you go home and tell six of your friends this "cool code you saw today." She's my patient, she's someone's sister and someone's wife. She is not "a pretty cool thing we got to see in clinical today," so fuck off and get out of her room, STAT. I never realized I was so damn protective of my patients before today.)

And I love students, and having a student work with me, so it's not some snotty prejudice against their learning/being students/being new. I'm all for them learning. I, however, also think we should respect the dignity of our patients, and their privacy, and their need for some kind of protection and shielding in their darkest hours from idle bystanders, but that's just me, and seriously, I have no room to fault any one, because who sat around and moved goddamn furniture out of the room prior to the code, and that was like, her most useful contribution to the whole goddamn process?

Okay, so not only did we yet again send the Titantic out to sink all over again with this patient, then, after the intubation, the little husband wants to come in to see his wife.

And that's were it really got sad.

I was in the room, trying to write a transfer summary to get the patient to an ICU, which as usual, was turning into a unit-based fifty way patient swap, even though the manager of the ICU units was being very cool and helpful. I'm in post-crisis mama-drama-baby-trauma mode, which I would liken to a post-ictyl state, or maybe conscious sedation, when the little old husband totters in to see his wife, who two hours ago was sitting up talking to him and is now lying unconscious with an ugly tube shoved down her throat attatched to a machine that's inflating and deflating her lungs.

It was horrible.

He starts crying, and holding her hand, and saying how he loves her. Then he had to leave the room, all sniffling and blowing his nose into a Kleenex, and he says, "Don't worry, honey, I'll be back in just a minute, I just have to go outside, but I'll be back."

It was one of the most pathetic sights I've ever seen in my life.

Then the sister, who's wheelchair and oxygen dependent, and all the rest of the family comes up, and she's crying too, because the husband has obviously told her the scoop. My patient is being whisked off to the ICU, so I took them downstairs, hearing myself say things like, "When you see your sister, she's going to look different. We gave her medicine to make her feel comfortable, and she's going to have a tube attatched to a machine that is helping her breathe. I want you to be prepared, she will look very different, and she is sedated, but you can talk to her, and she can hear you." The sister said, hopefully, "Really? Oh, that's good! I never knew that." (In reality, I have no idea whether or not patients can hear the loved ones, but at that point, it's easier to believe they can, and it's better for the family to hear that they can, because there's things they need and want to say, and they should be able to at least have that sense of closure).

I walked them into the waiting room, told them I'd be back once I made sure the patient was settled, and then came back and sat with them.

The sister was still a mess, crying, and then she asked the dreaded question. She looked me right in the eye, with that horrible glimmer of loving hope and said, "Do you think she'll make it?"

My real thought was, "No, I don't think she'll make it. I think she was as good as gone when we intubated her."

I said, with what I hope was a convincing, comforting tone, "I don't know. I'd like nothing more than to tell you she will be fine, but the truth is, no one really knows in these situations. What I will tell you, is I really hope she makes it, and gets better." (Meanwhile, I'm thinking to myself, where the fuck is the goddamn useless attending--at a goddamn golf game?! Why am I telling these poor little old folks about their relative's condition?! Why am I answering these questions?! What the fuck is wrong with this picture?!)

But the truth is, I wanted to sit with the family, and I wanted to do some hand-holding and talk with them, because in a way, I needed to sit with that family, and I needed to hold their hand. I needed to feel like I did something good for somebody yesterday, because I felt like shit about the situation.

In the end, I think I needed to sit with that family, and comfort them, as much as they needed to be in the presence of someone who actually understood the magnitude and impact death has on the living.

At 3p.m. I hugged the sister and bade them goodbye.

At eight p.m., I heard from another nurse that the family of the patient had agreed to withdraw life support, which is probably the best choice they could have made given the circumstances.

My job sucks.