borderline

I'm behind on my next installment of RC/RN, so I thought I'd pull out a hospital story instead. This has been in my drafts for a while and I guess I had just forgotten about it. Oh well, better late than never.


Of all my strange nursing experiences, few stand out more than the patient who followed me to three different hospitals. She didn't do it on purpose, but nevertheless she popped up strategically at two different nursing school rotations and then again, for the last time, at my ICU job. Due to events that will unfold shortly, she won't be popping up anymore, if you get my drift, but she certainly made an impression in the time given.


The first time I met her was during my Psych rotation at the big, bad scary Psych hospital. This is surely a whole other post, but I think the way nursing students are thrown into Psych rotations needs some rethinking. We were supposed to meet our clients (the PC word for patients these days), get their history by talking to them, and then, once that was done, we could go and read their medical chart with their complete history.


The majority of patients (sorry, old habits die hard) in Psych hospitals are totally harmless to anyone (except possibly themselves). Most are completely non-violent. Most are not threatening in the least to green nursing students. But this was a state hospital that had a large population of the violent and criminal patients. More than once, if I had read the chart first I never would have gone into a room alone with them, guard right outside the door or not. (And in hindsight, that should have been a big red flag right there).


This gal had been diagnosed with Borderline Personality Disorder. You can follow the link, but without going into too much detail, in the psychiatric world this is the one you really don't want. It's virtually untreatable and typified by borderline psychosis (hence the name), shifting addictions, narcissistic behavior, self-mutilation and manipulation. (This is, by the way, what I'm absolutely convinced Britney Spears has. Have I mentioned I'm an armchair psychoanalyst?) The classic trait is "splitting", a process that is used to pit people, usually loved ones and health care workers, against each other. These patients are very hard on their caregivers. She was no exception.


When I interviewed her she circled me incessantly, occasionally reaching out and touching my hair. I wasn't thrilled by that, but was trying to be open and encouraging. She didn't talk much, although she answered my questions readily enough. None of the answers tied together, but that was beside the point. At one stage she told me how much she liked my hair and asked if I could do hers like mine. As I was trying to formulate a therapeutic answer she turned on a dime and started yelling at me to get out because she knew I was only there to steal her cigarettes. When I stood up she apologized profusely and told me that when her voices wanted a cigarette they were likely to say anything. In an flash she punched herself in the face (hard) and then looked at me in satisfaction, saying "That'll shut 'em up."


All righty then. I didn't remember another thing about the assignment, I didn't remember another thing about her behavior, but I sure did remember her.



Six months later I was doing one of my last rotations on a med-surg floor (in a town forty miles away from the big bad scary Pysch hospital) and who should be on the unit but my cigarette gal. She was not my patient, so I never knew the exact details (at least not then), but she had had some sort of abdominal surgery and was scheduled to go to a step-down psychiatric facility when she was discharged. She seemed to be improving, from a mental health status, but clearly didn't want to go to the new facility. Evidently she was quite comfortable in the hospital and wanted to stay right where she was. Her student nurse was one of the toughest members of our class. Great gal, but she had grown up hard and fast and I think you would have had to stick needles under her fingernails to make her cry. She had made it this far in nursing school without flinching once, even if the rest of us flinched on a regular basis. (I flinched through my entire Labor and Delivery rotation, as a matter of fact).


Our first clue that something was up was when the student nurse bolted out of cigarette gal's room so fast she nearly tripped and with her fist clenched to her mouth. Before anyone could say a word she ran, gagging, to the bathroom. When she came out (sweaty and flushed) she said


I just saw the grossest thing ever.


Now, of course we should have left it alone, but we just couldn't. We pestered her and whined until she broke down and told us. She was not exaggerating. Even today, with a lot of massive trauma experience under my belt, it still stands as one of the two most horrifying things I've seen or heard of firsthand. It took me a long time to get the image out of my head, but sometimes it still sneaks up on me and says


HEY!! Remember me??


Cut to my first real nursing job in the ICU that I've been droning on about. And damned if this chick doesn't show up again - about a year after the last time. Only this time she's gotten herself into a real mess. She's started swallowing things. (Turns out this was the cause of her earlier surgery). Bottle caps, razors, antifreeze, lots and lots of paper clips - things that aren't really intended to be swallowed. When she was brought in (handcuffed) by the police she grabbed (with her teeth) a pen that one of them had in his shirt pocket and swallowed it whole right in front of two cops. Legend had it that she had taken apart and eaten a medical device that was about eight inches square and made of very hard plastic all while being under constant observation at the big bad Psych hospital. She was clearly in need of some serious watching.



She had swallowed something so caustic that her airway was affected, so she was on a ventilator. She had two triple IV lines running (six continuous infusions of meds or fluids into central veins, like the internal jugular or the subclavian) and an arterial line, which is basically an IV that is in an artery instead of a vein. You don't run anything in through these lines - they are primarily used for monitoring blood pressure internally. Most people on vents have these lines, because in order to make sure the patient is oxygenating properly you have to draw blood fairly often from an artery to test. This hurts like a son of a bitch, so having an art line in place means that you can just take the blood from there instead of sticking them every time. The drawback to an art line is that...it's in an artery. If it comes out somehow you can bleed to death in minutes, especially if it's in a big artery, like the femoral. You can't have an art line on a regular unit. ICU or ER only.



So let's review. We knew that she needed some serious watching. She had a tube down her throat that was basically breathing for her, she had two IV lines in that were dispensing crucial meds and she had an arterial line that could cause her to bleed out if it became dislodged. A simple case if there ever was one.



Any guesses on who got assigned this patient that morning?



I did have a few things going in my favor, though. One was that she was, of course, on a monitor and if anything got out of place I'd see it reflected pretty quick in her vitals signs. She was also restrained. Her wrists were held by soft fabric restraints - one more thing to monitor. But the major thing going my way was that she was drugged to within an inch of her life. Most patients on vents are, since very few people could tolerate being awake with a tube down their throat. She had (in my opinion anyway) the most amazing drug imaginable (lovingly referred to as Milk of Amnesia) running in continuously and she was absolutely flat zonked. The politically correct term is unresponsive, but zonked is far more accurate..


One of my fellow nurses had helpfully collected a bunch of paper clips and other metal objects and put them into a plastic lab sample bag. She taped it to the glass door of the patient's room with a note that said In Case of Emergency - Swallow. (Our manager was unamused and we had to take it down. Some people...).


It was about mid-morning when I was walking to this gal's room from my other patient's room. As I approached the door she sat straight up in bed and, in one fluid movement, swung her legs off the side of the bed (over the guardrail) and whipped her head around trying to rip out her breathing tube. I yelled for help at the top of my lungs and people came running from all directions. (I had only had one self-extubation at that point and was not in the mood for another. I get serious hand cramps when I have to bag someone).


We got her settled back down and she stayed intubated but it wasn't easy. She tried to swallow the metal bell part of someone's stethoscope as they leaned over her. We had a heated discussion about her sedation level, but I'm telling you that woman's vital signs never changed. Her baseline sedation level was...zonked. It was like she did the whole thing in her sleep. I promised myself that this would be my last shift with her as a patient. And it was.


Amazingly enough, she survived. She went back to a medical psych unit and then to some other facility. It was at that facility that she drank a bottle of Drano in one fell swoop and died, pretty much on the spot, of a massive respiratory arrest. Very sad life and a very sad end.


I don't know why this patient has stayed with me, but she pops into my head at the strangest times. And I owe her. Whenever I get into one of those medical weirdo games of who has the grossest stories, she always gets me at least into the final round.

And then it takes me a week to forget it yet again.