Ah, back amongst the Undead

It's good to be home.
Isn't it odd how something completely terrifying becomes routine over time, and then a Comfort Zone after about, say, fifteen years. I'm talking about the ICU. These patients are actually interesting. INTERESTING. As opposed to, let's say, triage in the ER- "It's 3 am and you have acne on your ass? Gosh, that IS an emergency. Wait, you wanna tell me about all your personal problems too? YAY."
It may be difficult for some who know me (or saw my pictures playing in the graveyard) to believe, but I actually like to use my brain. Anyhow, last weekend I worked MICU (Medical ICU) Neuro, and Trauma. The Trauma patient was an unfortunate and grieveously misunderstood fellow who was fleeing the police after beating up his girlfriend when he wrecked his car, leaving him in the VERY unfortunate position of brain dead, or as we like to say, Undead. You know, like a banshee.
Anyhow, the interesting part is trying to figure out what's going on when the patient starts crashing, because there's multisystem organ involvement and about 300 things to consider. Said patient is on a ventilator, intubated, paralyzed, and sedated. He has three vasoactive drips , an orogastric tube with a tube feeding, two chest tubes and a mediastinal tube (evacuates blood from the chest cavity); a foley catheter; a continuous EEG; a bolt in his brain; an arterial line to measure blood pressure, a PA catheter (which is floated into the chambers of the heart to give filling pressures) a ventricular drain, and a bolt in his head that looks like Frankenstein.
He also sports Nazi, White Supremacist, and Satanic symbol tattoos. Charming.
He's hooked up to a heart monitor, a blood pressure monitor, an arterial blood pressure monitor, a monitor for the PA catheter, the EEG machine, a BIS monitor to check sedation, and a pulse oximeter (to measure his oxygen levels)
So his oxygen levels, which weren't good to begin with, start dropping alarmingly for No Apparent Reason. We hate this. It's unexpected and awfully rude.
It also inspires panic in the heart of all first-year and most second-year residents, who are rounding at night; and really really really hate to bother their house officer (an advanced resident) and admit they haven't the teeniest, tiniest clue what's going on. So they decide to figure it out. This is quite frightening indeed. In fact, it is mortally terrifying; except for the fact that I can scare them into submission with just one of what my children call "Grandmarti looks".
Nurses are Patient Advocates. That means we keep people from killing you.
Oh, forgot to add the patient also has HIV; a nasty chest injury, a massive head injury, and fractures of his cervical spine. The C-spine fractures have been fixed (operated on and stabilized) but he's still in the collar and on Spinal Precautions, which means they have him lying flat.
First Year Resident and Intern (picture Doogie Howser and his younger brother) begin madly foaming at the mouth and flipping desperately through the chart. This is an easy way to tell a new doc from, say, a fourth or fifth year resident. They literally Run For The Chart as if their asses are on fire. They run so fast they almost trip over the cord to the ventilator and yank it out of the wall. They have GOTTA HAVE THAT CHART! And they need those nurse's notes, too, so they can scribble down the vital signs and read what the nurse has written. They don't actually EXAMINE the patient, for heaven's sake. Apparently this involves Advanced Assessment Skills far, far beyond the reach of mortal man. (of course the nurse does this continuously throught the night, but what do we know?)
So resident (we'll call him Dr. Cluck-see his ID photo here) and intern (we'll call him Doogie Jr.- see his ID photo here begin their panicked page-turning and frantic monkey babbling to one other.
Dr. Cluck: Yesterday he was okay! Today he was okay! WHY DOES THIS ALWAYS HAPPEN AT TWO A.M? If I call Linder he'll KILL ME! THIS F**ING SUCKS!
(Sits down on MY CHAIR and puts his head in his hands)
Me (ominously): If you spill my soda I'll kill you.
Doogie Jr: His chest Xray wasn't that bad! What's WRONG WITH HIM? His lab work's all normal except the low potassium!
(The two of them look accusingly at me, hoping to find a Responsible Party who isn't them)
Me: Well, it WAS. Before it was corrected by that electrolyte protocol we have on EVERY PATIENT, remember? He got 40 meq and a follow up that was within normal limits.
(Despair etches their countenances and Cluck grasps the bedside table like a lifeline)
Me: So, I asked RT (the respiratory therapist) to draw some blood gases and he's switching the vent mode from APRV to Assist Control and adding some PEEP.
Doogie and Cluck together: Yes, yes. Good, good. (Nod heads, as if they understand this)
They leap up and bumble out the door together to consult their medical books.
Twenty minutes later they return, attempting to look officious.
Dr. Cluck: Well? WHERE ARE THOSE BLOOD GASES?
As a new nurse, I was so scared of physicians I could hardly open my mouth. This wears off after, say, five years. After fifteen years, they're dead meat.
Me: They're in that chart you're clutching so desperately to your chest you're going to have a rib fracture. You might try looking there. It's amazing what they put in charts these days.
Cluck and Doogie furiously scan the blood gases, which, to put it rather rudely, Suck Ass.
Together: "THESE GASES ARE TERRIBLE!"
(They give me another accusing look. Apparently I have the power to decrease oxygenation with my mind)
Me: His sats were bad on 100%. (oxygen, that is. Room air is 21%, oxygen so, this is Very Very Bad) What were you expecting?
Cluck and Doogie look at each other desperately to see if either one knows What They Should Have Been Expecting.
Me: We need to sit him up.
An elevated patient always gets better oxygenation than one lying flat.
Cluck: This man is on SPINAL PRECAUTIONS! (Gives me a look of mortal offense and outrage) Has NEURO been here?
Me (getting irritated with them) Nope. They haven't been here all weekend. And his fractures have been repaired- he doesn't need spinal precautions. He needs to SIT UP.
Doogie (ignoring this): We could put in another chest tube!
(i.e., Doogie wants practice putting in chest tubes, or, more likely, wants to watch Cluck put one in)
Cluck (looks horrified; does not want to attempt chest tube on crashing patient- first smart move he's made all night) Yeah. Umm. Yeah. We'll run that by Whosit in the morning. We need to LOOK at that chest XRay!
(What a brilliant idea. Might I add, at no time have they gone near the patient)
Looking at XRay:
Cluck: It's an effusion. Yes, an effusion. (fluid collection in the lung)
Doogie: It's a pulmonary embolus. Yes, a pulmonary embolus.
Me (threateningly): It's a consolidation. HE HAS PNEUMONIA. (which presents as a consolidation on an XRay) He NEEDS TO SIT UP.
(Patient's Sat alarm has been dinging throughout this conversation, indicating Damn Near Dead guy is about to become Actual Dead Guy.)
Doogie: We can do a CAT SCAN! YAY! A CAT SCAN!
(Apparently he watches House)
Me: Well, that's a good idea. (It was) (Doogie beams, squeals, and jumps with delight- he's done something right!) But he's too unstable to go.
Cluck: Is he WORKING AGAINST THE VENT? PERHAPS IT'S AIR TRAPPING.
(Apparently he looked this up on line during the twenty minutes he was gone)
Me: Umm...he's paralyzed, remember? He's not working against anything.
(Except Cruel Fate, which has placed him in this situation- I'm really sure he was misunderstood as a child)
I look across the unit and see Unknown Doctor strolling leisurely into the room of a brand new trauma pt just off the helicopter. He stands in the doorway, looks unconcerned, strolls in, intubates the patient, and wanders out yawning. I know an experienced doctor when I see one.
Me (pointing): Why don't you get that dude to look at the XRay?
Doogie and Cluck: Yeah! YEAH! He's a FOURTH YEAR SURGERY RESIDENT! YEAH!
They break into a tap dance of delight, and then exchange frightened glances.
Doogie and Cluck, to me: You go ask him.
I ask said doc if he'd mind giving an opinion on a chest XRay (they LOVE to give their opinion)
Doc: "Sure." (Strolls over and glances at film for three seconds) "It's a right lower lobe consolidation. This guy's got pneumonia."
Doogie and Cluck (in desperation) His Sats are TERRIBLE! HIS GASES SUCK!
They fall on their knees and grovel for mercy at his feet; crying bitter tears of anguish.
(okay, not literally, but figuratively)
Super Doc actually LOOKS AT THE PATIENT. Wow. He also LISTENS TO THE PATIENT'S CHEST and CHECKS THE VENTILATOR SETTINGS. I'm completely impressed. An actual doctor.
Super Doc: "He needs to sit up."
Doogie and Cluck (screaming in despair) "HE'S ON SPINAL PRECAUTIONS!"
Super Doc: His fractures are fixed. Nobody wrote an order discontinuing the precautions because it's rather obvious they aren't needed now. (gives them a severe look)
Doogie and Cluck look so mortally ashamed I feel sorry for them.
Me (elevating head of patient's bead to 90 degrees) Well, that's what we were discussing. Neuro hasn't been in all weekend.
(i.e., they DO know something, I swear! Don't get them in trouble! and, let's blame Neuro cuz they're not here)
Patient's Sat goes from 83% to 95% upon elevation of patient. Super Doc strolls out yawning and Cluck and Doogie appear on the verge of embracing me. I back away quickly around the patient's bedside, because I know they aren't going anywhere near the scary scary patient.
Cluck: (officiously) Well, let's go CHECK OUT SI. (Surgical Intensive Care Unit) There's patients THERE we haven't killed yet.
(okay, so I added that last line)


If you find this frightening, keep in mind- 1) They can't do anything too invasive without asking their senior resident, who will tell them they are stupid 2)Nurses who work critical care, especially in large trauma centers, know what they're doing and will call retard doc's supervisor if they attempt to do anything stupid. Actually just threatening them with this works. 3)A more experienced resident will round on the patient later in the shift; or you can call him, if the retard quotient is just getting unbearable. 4) The patient has had the benefit of state of the art surgery, a Super Special Vent that can do fancy things other vents can't, and many specialties which will wander in during the day, with Actual Doctors- fellows, attendings, etc; and he would most definitely be dead if he weren't in a Level 1 Trauma Center. Even WITH Doogie and Cluck. It's much scarier at the outlying hospitals, believe me.
Here's hoping Doogie and Cluck did not encounter a new graduate nurse with an unstable patient in SI.