PixelRN

I don't think I would admit this to my colleagues, but I find some of the expressions used in the ICU to be kind of heartwarming, if not downright charming.

For example, when someone is about to be extubated and the nurse might say, "I really don't think he's gonna fly." The vision of a coughing, sputtering extubated patient turns into this:

Or when someone is "bucking the vent" (which means the patient is breathing over the ventilator) the sick, struggling patient turns becomes this:

Or my absolute favorite, "The Renal Player." This simply means a patient who has kidney problems. Whenever I hear this, I picture a bunch of dialysis patients sitting around playing poker in Las Vegas.

For more interesting ICU imaginative stimuli, check out Bob's Dreams. This patient actually recorded his dreams after being vented and sedated with ARDS.

I dreamt that my patient went into V-tach, or something like it. As commotion ensued, I was trying to remember everything I could about ACLS (which isn't a lot). What kept going through my head was that you have to shock V-tack, but for almost everything else you start with drugs (atropine, epinephrine, etc.) So the essential theme was: Shock? Or drugs? Shock or drugs?  Shock or drugs?  WHICH IS IT??? Then my patient got up and ran away before we had a chance to do anything.

In real life, I got to work and in morning report heard that the patient I had previously admitted did, in fact, go into V-tach, then received amiodarone, and synchronized cardioversion, and was stable now. And it gets better.

The docs were about to round on my patient when the resident from the previous night told me what had happened. She was trying to insert a central line in him and as the catheter got close to his heart, he started in with this crazy arrhythmia. The residents collectively decided it was Supraventricular Tachycardia and decided to give amiodarone. Meanwhile the charge nurse was yelling at her "You have to shock him! It's V-tach!" The resident was very upset with the nurse for yelling at her, particularly because the patient at the time had a pulse.

So it was a lot like my dream, except that my patient never got up and ran away. Instead he flew away. More on that later. Meanwhile I think it's time to go out and get my ACLS certification.

If you haven't already, you might want to read A Baby Story, first.

I just happened to be 20 minutes early going to work when I got the phone call that the baby was born. I was so excited; I mean, what are the chances that I would actually be early for work on that particular day? So I was able to visit with them in the morning and during lunch and share their first joyful moments as a family together. They are both very close friends of mine; you could actually say I was instrumental in getting them together, so I was very grateful to be able to share these moments with them. I went back to work, absolutely beaming with happiness.

Then the second set of troubles started. Before you read further, please don’t anticipate that there was any trouble with my friend’s baby. He is healthy and thriving. No, the trouble was with me. It is after all, my blog.

I will preface this by saying that my husband and I have been trying to conceive a child for the past year and a half, without success. It’s a very frustrating situation, but I guess I didn’t know just how frustrated I was until the afternoon I was deluged by a mob of pregnant women at work.

To set the scene: It was a half hour before shift change and I was receiving a new patient. Picture 5-7 people in a tiny ICU room, each person doing a different task in an amazing display of teamwork, in order to get the new patient settled in. It was my admission, but everyone was so competent and quick and more experienced than I, that they kind of took over. I tried to absorb everything and contribute what I could. It was so second nature to them that they immediately fell into this animated conversation that had nothing to do with the patient. It in fact had everything to do with…pregnancy.

One of the senior nurses has this odd psychic habit of dreaming of fishes each time a nurse on the unit finds out she is pregnant. She had recently dreamt of fish and the charge nurse was telling us that she believed the dream was about her. Squeals of delight ensued, everyone was ecstatic. I looked around the room and realized that out of the group of nurses that were helping me, two of them were already pregnant, another one had just given birth a month ago, and the charge nurse was announcing that she was pregnant.

Well. That was just a bit too much for me. I could feel the tears about to come, the flood gates were about to open. But like Tom Hanks says, “There’s no crying in baseball.” Thank god for the face shields that we wear when our patient is on isolation. No one could see that my eyes were welling up.

So I swallowed it down and continued about my business. Eventually the patient got settled in and everyone left to go get ready for shift change. Now that I was alone I couldn’t stop thinking about what had ensued. The events from the past few days flashed through my mind: the brain dead mother with the expelled fetus, my friend’s baby downstairs, and now this. The floodgates broke. At that exact moment, the charge nurse (who is a wonderful person, by the way, and I felt horrible for inwardly raining on her parade) came back around to see if I was okay. She saw my tears and immediately handed me some tissues and sent me to the back office to let it all out. Then she set about tying up my loose ends for me.

So let it all out I did, wiping my eyes down with the sandpaper-like hospital tissues. The charge nurse came back and I explained the whole awkward situation to her. Coincidentally, she just happened to be the one who guided me through the whole deceased pregnant woman situation, and she was very understanding.

Later that night, I had a premonitory dream about the patient that I had just admitted.

There was a 26 year old patient that I took care of the night before I left for a long weekend in San Francisco. She was found unresponsive in her home with her 18 month old baby running around the house naked. Her insulin pump was off. She had a history of poorly controlled diabetes and she was 12 weeks pregnant. It was unclear how long she had been unresponsive, it could have been as long as 48 hours. The night that I cared for her, she had just had an MRI which showed cytotoxic edema and  a good portion of her brain was no longer functioning. In short, not a good prognosis. The death of brain cells is almost always permanent. And the fetus was simply too young to be sustained, even if the woman was kept alive on life support. Although interestingly enough, this had just happened with a Virginia woman.

So it was a very sad night. Her husband and some family members were at the bedside. They had been explained the MRI results and the poor prognosis, but it hadn't seemed to sink in yet. For myself, that was the most heartbreaking. I watched them trying to wake her up and falsely interpret her eye movements as hopeful signs that she would get better. Later the husband slipped her baby's shirt under her still hand and went to the waiting room to try and sleep. The shirt had a tiny little baby food stain on it.

On the upside, I got to perform neuro checks on her every two hours and was able to see some features of brain injury that I had never seen before including decerebrate posturing, doll's eyes, and positive Babinski reflex.

So I went to San Francisco for a few days and when I came back to work I was given this patient again, only she had died fifteen minutes before the start of my shift. This meant that I was responsible for her post-mortem care. I was somewhat apprehensive, as I had not done post-mortem care during my orientation and so this was, in fact, my first time. The unit was somewhat busy but I managed to find another nurse to help me lift the patient onto the stretcher to take her to the morgue. When we entered the room to do this there was a strange but somewhat familiar odor. We pulled away her sheets and saw that she had expelled the fetus. The site was both disturbing and mesmerizing. How often do you get to see a perfect thirteen week old fetus? I certainly had never seen one. The perfection of it was amazing. So tiny, and yet each little toe and finger were perfectly formed.

Then the troubles started. No one really knew what to do about the situation. In the whole history of my unit this had never happened before. What do you do with the fetus? I told the team of physicians who were rounding at the time. The matter was further complicated by the fact that they hadn't yet asked the family if they wanted an autopsy. And this factor would determine where I sent the fetus – either to pathology, or to the morgue. And what do I put the fetus in? One senior nurse said to just wrap it up with the mother and take it down. But what if the fetus was missed, or got thrown away by accident? What if the family wanted to bury the fetus? All of these issues had to be dealt with and yet I had never even done post-mortem care on a regular deceased patient! And I was caring for another patient the whole time this was happening. Everyone involved from the charge nurse to the attending was quite unsure what to do, and it wasn't exactly a priority considering the rest of the unit was filled with patients who were still alive. I was frustrated, confused and kind of in a state of shock.

Finally, like an angel, the palliative care nurse swept through the unit, came and grabbed my hand, looked me in the eyes and said, "You shouldn't be going through this alone. Let me get you some help." I almost burst into tears. I felt like a small child who doesn't cry when they fall if no one is watching, but the minute someone takes notice, they cry. I did not cry, however. Not at that particular time, anyway.

One by one, all of my questions were answered, and I was able to properly take the mother and the fetus to the morgue.

24 hours later, a very good friend of mine gave birth to a beautiful, healthy, baby boy in the same hospital, 5 floors below my unit.

And on that note, I'll end with a lovely picture I took at Big Sur.

PS: Tommy died in the MICU last week with his headphones on, listening to Radiohead.