RC/RN 3

Warning: Traumatically long post ahead. This will teach all of you who asked when the next installment would be. Be careful what you wish for.


I was in the middle of a really bad work run. No matter how positive I tried to stay, it seemed like anything that could go wrong was. Bad days can happen to anyone in any field, but I was a couple of months into the abyss and it was really starting to take its toll on me. And it wasn't just one patient or one situation - it was everything all combined.


We had a teenage gangbanger that had been on the unit for almost nine months. That's a ridiculously long time to be in the ICU. He had finally been stable enough to go a med/surg floor, where he spent many more weeks. To say this kid was a pain in the ass is the understatement of the year. He refused his meds (except the narcotics), he referred to all of us simply as "bitch" and he had an out of control girlfriend who didn't mind chasing you down in other patient's rooms to scream about every single aspect of his care. For a while we had to keep a surgical mask on him because he would spit at anyone who came into his room. When we transferred him to the regular floor we all wanted to throw a party. But when he went home we were, in spite of ourselves, really happy for him. Maybe we were just happy for ourselves. A year is a long time to be in the hospital. For all of us.


He was home less than 24 hours when the rival gang came back to finish him off. Two point blank bullets in the head later he was right back where he started. He died on my shift. On my watch. The shooter was the girlfriend's brother. He made our patient watch while he killed his own sister. And then he shot him. It wasn't hard. Paraplegics don't move so fast.


Then an attending surgeon wrote an order for a procedure that was unclear enough that I checked it out with one of his residents before I carried it out. We both interpreted in the same way and I went ahead. Needless to say, what he wrote was not what he meant and he went off on the both of us. I mean went off. His head didn't swivel and he didn't spew green bile, but it was close. This was followed by a nerve wracking week to see if the patient suffered any ill effects from the procedure. Thank god he didn't, but the resident and I did. I'm sure we both still have pieces of that attending's shoe in our lower intestinal tracts. Leather, I believe. Italian.


We were also being inundated by patients with seriously communicable diseases. A large percentage of our population had Hepatitis C, which you cannot be immunized against. A fair amount were HIV+. And on any given day, at least one of my two patients was an isolation patient. There are many different reasons for this, but the big one is MRSA (Methicillin-resistant Staphylococcus aureus). This is the staph infection that is such a problem in hospitals world-wide, but it is by no means the only problem out there. Lots of these "hospital bugs" were lethal when they got their hooks into someone, so we had to be very careful, both for the patients and ourselves.


Each of the rooms had an isolation cart by the glass door. Before you went into the room you had to put on a mask, gloves, a surgical cap and a lovely yellow paper gown, which tied behind your back. When you came out you would wait until the last possible second to take it all off and throw it into the trash can right inside the door. Then you would scrub violently with soap and hot water, finishing (if you were paranoid) with antibacterial gel. Everything in the room itself was considered contaminated. This whole routine was tolerable if your patient was either a) calm or b) stable. It was when they weren't that problems arose.



I had one gal who was on her call light every couple of minutes. Her anxiety level was perpetually off the scales. Quite simply, she didn't want to be left alone for a minute. She was another long-timer, and somehow I ended up with her a lot. She had a trach, so she couldn't talk. She'd hit her light and when you went to the door she'd motion you in. I'd stand in the doorway and ask if there was anything in particular she wanted. Violent head shaking no. Sixty seconds later, all suited up, I'd go in and she'd write me a note that she wanted pain meds. I'd take off all my gear and go get her the meds. Suit back up and go in. Which med is that? she'd write. I'd tell her. I don't like that one, she wrote. I want another one. Take off all the gear and head out to page the resident and pass this on. Waited for call back and her light would go off again. Stood in the doorway and asked if there was anything in particular she wanted. Told her I was waiting for a call back from the resident. Violent head shaking and beckoning me into the room. Sixty seconds later, all suited up, I'd go in and she'd write me a note saying she'd changed her mind and she really just wanted her anxiety med instead. I'd take off all my gear and go get her anxiety med. Then I'd put it all back on and go in to give it to her. About this time the resident would return my page, but I'd be in the isolation room unable to pick up the phone to tell them that I was about to murder their patient, and could they be a dear and write me some orders for that. We did some variation on this dance every few minutes for twelve hours straight.


People in isolation are also, for some obscure reason, more likely than the "typical" patient to pull out central lines and be shooting blood everywhere while you race to get suited up before they bleed out. Jugulars and subclavians gush like big dogs. It's like some demonic obstacle course where you try to staunch the bleeding while simultaneously dodging it and with your third hand attempting to tie your gown which you left open when you ran into the room in a panic. Add in perpetually cracked and bleeding hands (read: susceptible to infection) from all that washing and it's a situation ripe for worry.


It was during this period of time that I got a particular song stuck in my head. I know I've mentioned this before, but it bears repeating. I could not shake this song. It wouldn't go away. It became my own personal soundtrack.




There was the time we had a weather related power outage that knocked out all our vents. Even though it was pretty quick, it felt like forever before the emergency generator kicked in. I got floated down to our Burn ICU for a day, which will go down as some of the more horrific twelve hours of my life so far. Burns are not my thing. I stood by a teenage girl's bed, flanked by neurosurgeons and her parents as her brain herniated in front of us. It basically swelled so much that it descended into her spinal column. As the numbers climbed on the monitors all I could hear was her mother saying frantically, "Why is that number going up so fast? Is that bad?" And I had a patient who had lost control of his motorcycle (helmet-less, of course) at high speed and basically turned himself into a tattoed omelet. The waiting room was full of his Hell's Angels buddies, and they let us all know in pretty uncertain terms that if he didn't survive they would expect some answers. (Here's your answer: Wear a damned helmet. Don't drive 90 miles an hour. Don't drink a case of beer before you drive. And get the hell out of my face. Now).




I had gotten to the point where I couldn't ever forget about work. I'd come home and lie awake for hours trying to relax enough to sleep. I don't think I ever actually dreamed about a specific patient, but I'd have these weird, fragmented stress dreams. Night after night. One of my friends told me she could always tell when she had gotten me on the phone after a day of work. She said I didn't even sound like myself. I knew exactly what she meant, because I didn't feel like myself either. I've had some wild fantasies in my life, but telling a furious Hell's Angel to fuck off was not one of them. Who was that (stupid) nurse with cojones the size of watermelons? Because it couldn't have really been me. I'm a coward by nature. A coward with a very, very big mouth.


But even all of those things weren't enough to push me totally over the edge. It was going to take something really special for that.


It was going to take the neuro patient from hell.


This poor guy had had a massive head bleed. Unfortunately, he was behind the wheel at the time and proceeded to drive his car off of a small bridge. Normally it would have been a toss-up as to whether he was a neuro patient or a trauma patient, but since the Neuro ICU was at capacity, it was a moot point. He came to us. By the time I took over he was critically unstable. He was intubated. He had a central line and a femoral arterial line. He had two tubes going into the ventricles on either side of his brain. This is called a ventriculostomy and is used for two things - to monitor the intracranial pressure (ICP) and to drain cerobrospinal fluid (CSF) off of the brain. Part of the set-up is the tubing and part is the drainage system, meticulously calibrated to drain off exactly the right amount of CSF. One of these ventrics is bad news. Two is above and beyond the call of bad.


His condition continued to decline. He had at least ten drips going. His ICP was going up and his blood pressure was going down. He was not breathing at all on his own and was totally dependent on the vent. Because he wasn't on the neurosurg floor the docs were having to come to us for all his treatment. So when a bed became available on their unit they jumped on it. Next thing I knew my charge nurse was telling me to call report to the neuro ICU.


I balked. Big time. I was afraid breathing too hard in his room was going to send him over the edge, much less moving him and all of his equipment down a couple of floors. My concerns were duly noted and summarily dismissed. The neuro guys wanted him on their own unit. We had a helicopter flying in with a trauma and we needed the bed. Balking is a lot more satisfying when you get what you want.


So I got him ready to move. Big ICU bed. IV drips on pole (with the tubing attached to his central line in his subclavian). Ventilator (with the endotracheal tube in his airway). Two additional poles that had the ventric set-ups on them (each with tubing that attached into his brain). Arterial monitoring system (with the tubing going into his femoral). A transport monitor so I could keep an eye on his vital signs during the trip. The big red crash suitcase, in case he took a dive during the move. I enlisted the respiratory therapist to help with the vent. I got an aide to help maneuver us to the elevator. And away we went, like a herd of really slow turtles.


We were just off our unit, in our lockdown hallway, when his vent failed. It made a really impressive noise and shut down. I've always thought that nurses had the worst mouths in the hospital, but that RT made me look like a slacker. She cussed non-stop while she bagged him and I pushed the bed at breakneck speed back to where we had started from. We waited while the vent was swapped out for a functional one. Take two.


This time we made it to the elevator without incident. Our teaching hospital was not new and the elevators were on the tight side. By the time we fit in a bed, a vent, three poles and two people, there wasn't an inch left to spare. I was in the back of the elevator, squeezed into the wall. The RT was next to the vent pressed into a corner. I was just congratulating myself on having the transport monitor facing toward me so I could see it when the elevator door started closing.


And snagged one of the ventric tubes and got it caught in the door. The RT and I watched in horror as the line got more and more taut and we both simultaneously flung ourselves at it. She ended up taco shelled across the top of her vent. I ended up crawling up my patient's bed (seriously - sometimes unconscious is good) until my feet were right next to his face. And we still couldn't reach it. One of the anesthesia residents was passing in front of the elevator and, alerted by my professional shriek, stuck her hand in and stopped the doors from closing. Without a word she unsnagged the tubing and put it safely back inside the elevator. Later she told me that she had thought she was having a bad day, but reconsidered after that.


We delivered our patient to the neuro ICU without further incident. As we signed all the safety checks and transfer paperwork I felt very grateful that it was done and I went back to my unit thanking my lucky stars it hadn't been worse. I don't remember anything else about that day until about eight hours later, when the medical director of the neuro unit flew onto our unit madder than hell. Next thing I knew he and my boss were standing in front of me with a look on their faces that I knew well, having watched residents get handed their shorts on a daily basis. I was about to receive another Italian loafer enema.


The medical director was waving a paper chart in the air in front of me and demanding to know why nothing had been charted. Hour after hour of columns for vital signs lay empty. How dare I call myself a critical care nurse, had I gotten my degree from a convenience store, and so on and so on. As he shook it two inches from my face I got a good look at the chart up close. And then I sat back to listen to his rant.


Finally, when he exhausted himself, he asked me in an extremely condescending tone why in the world the last time this patient had his vitals charted was at ten than morning. And I'd be lying if I said I wasn't being a flat out bitch when I replied


I couldn't tell you, because I transferred him to your unit at ten this morning. As a matter of fact, if you'll take a look at the chart, all those neat columns of vitals prior to ten this morning have my signature on them.


He turned a shade of purple that made me think he should up his blood pressure meds and stormed off the unit. Not a single word of apology. And as I watched the door swing slowly shut behind him all I could think was


I've had enough.