Tuesday, October 25, 2011

It's almost noon; I need to go to sleep.

‘Just got home from an overnight-overtime shift. Looking back over the past few years, I wish I had taken better advantage of all the overtime opportunities in the unit. Almost every time there were staffing spots to fill, I could always think of something I’d rather do: sleep in, homework, go out to eat, facebook—you name it. Anything but go to work. Now, with a wedding to budget and the prospect of being in between jobs for a little while, I’m eager to take in a few more hours while I can.

Last night was worth it. I got my same pair of patients back (same as my previous shift), so things were pleasantly predictable. (Well, as predictable as things can be in an ICU.) It was busy but not crazy, and I only left 18 minutes late. Leaving on time only happens when things are randomly-ridiculously-easy-squesy, so I’ve learned not to count on it.

The unit was a little different this past week. It seemed every other patient was a trauma; a bit of a change up from the typical older-person-with-sepsis/UTI or heart failure, pneumonia, etc. Maybe with this clear autumn weather everyone wants to take his motorcycle out for a ride.

This weekend reminded me why I don’t ever want to ride a motorcycle.

Example #1: A “trauma yellow” (hospital code for: probably going down the shitter—better act fast) was admitted and immediately went off to the OR for reconstruction. We in the ICU were fixing to receive him when he came out. We waited for hours, anticipating a new amputee. This patient was hit by a car while on his motorcycle. The right leg was literally shredded, with the foot dangling off the leg’s stump. I was amazed when, after a 10+ hour surgery, he came to us with the foot reattached—a bloody, mangled mess but with a bounding pulse! Surgeons—especially vascular ones—are so incredible. It reminded me of when little Jesse Arbogast's arm was sewn back on after beingretrieved from a shark’s gulletGod bless Dr. Rogers! may he rest in peace. (Swimming in the Gulf was never the same after that.) Nevertheless, this fellow isn’t out of the woods, and in the end he may still lose the foot.

Example #2 is another motorcyclist with both arms smashed. Nothing like bilateral hard casts. You can wiggle the tips of your fingers, and that’s about it. Want to go to the bathroom? Count of taking ten minutes to get out of bed and having someone else arrange your private parts in a urinal because your arms can’t bend that far.

And then there’s my young friend, the 17 year old with a bleed in her brain, and the picture-perfect reason why high-schoolers shouldn’t be driving at night with friends. Have you ever stubbed your finger or your toe and it became swollen? Not a big deal. However, when your brain gets injured, it wants to swell too. But inside the lockbox of your skull, there’s no room for expansion. So patients like this kid have a “decompressive craniotomy.” A piece of the skull gets cut out and allows the brain to expand further out. (For safekeeping, the bone piece gets sewn into the abdomen for a few weeks.)

Every hour I go through a routine of medically-sanctioned torture to determine if the brain is deteriorating or improving. I need to see the patient as responsive as possible. Any unexplained sluggishness or failure to react warrants a $1,000 STAT trip down to the CT scanner to take some pictures (and I hear brain CT’s are the cheapest CT’s to get). No nurse enjoys a CT scan. It means an expedition of at least 3 people to push the bed, the ventilator, oxygen tanks, the multiple IV pumps and poles and portable monitor up and down the hallways and in and out of the elevators. Sometimes you have to pack a goodie-bag of epinephrine, fluids bags, syringes, etc. because you never know what can go wrong while you’re isolated in the elevator.

Ok, so we don’t do the following because we want to avoid a CT scan; it’s because we must accurately know what is going on in that noggin. But the threat of a CT scan is always good motivation to do your job, which is . . .

Every hour I’m the neurosurgeon’s really expensive babysitter. I go in and start yelling at my patient while slapping her shoulder, “Samantha*, CAN YOU HEAR ME? MOVE YOUR ARMS!” No response. Just a stupefied, flaccid body in a bed with her eyes closed. So I move to step two. I take a flashlight or some other rod like object and press it hard against her fingernail. She shrugs her shoulders, but her eyes are still closed and her legs are motionless. I do it again, harder, and she pulls away ever so slightly. That’s a start,  at least she’s moving something. I go crunch a nail from every extremity until I see each move.

But I know she can do more than that, so I rasp my knuckles hard against her sternum. Her arms shift around in bed, and she gets a little restless. But that’s not good enough. Higher brain function should show purposeful movement. “C’MON SAMANTHA! SHOW ME YOU CAN FEEL THIS! PUSH ME AWAY.” Which is what I want her to do. I’d jump for joy right now if she’s just ‘wake up’ and grab my arm, or push me away or something. But she doesn’t, so I keep rasping my knuckles on the sternum and pinching hard her trapezius (that shoulder muscle by your neck). I’ll keep at it for a while, trying to avoid the last resort of nipple twisting. Finally, one arm then another arm reaches up off the bed and makes a gesture across the chest in my direction. Then they fall flat again. The eyes never open. That is about as good as it gets for this gal.

And there’s nothing like patients' families to liven things up on the unit. The dad of 16 year old boy (with another vehicle related injury) came up to me and asked if we could limit visitors to his son. The parent wanted to keep things calm for his boy, but one of his son’s baby-mommas was a bit of a loudmouth. One of the baby mommas? I’m trying to keep a straight face. Were there more?

Two, apparently.

I’m not really surprised. Just impressed.

* not the patient's real name, of course. Throughout this post, some ages and genders were scrambled for privacy.

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