The Time Has Come, the Ladyfox Said

Tonight, I experienced the worst moment in my job.

I know I haven't written for a while, and this isn't necessarily the happiest note on which to return, but, well, let's just say it's something that really struck me.

Let me tell you about it. Fair warning, though. It is a little graphic. But true to life.

Waking Nightmare

      --BD

For six hours we hold a death watch -

for six hours you sleep.

Every second another breath, another

moan, and still you sleep.

For six hours I watch her heart

beat 140 times a

minute, until 2:17 in the

morning, and suddenly the

watch is over.

I run to wake you when her

heart rate plunges to 56, shake

you until you leap off the

cot, tell you that it's time to

say goodbye, pray that in the

dark you don't notice that her

face is already purple, that she isn't

breathing.

You hug and kiss and sob, look

up, murmur “Is she - “ and I

nod, say “She's gone.” Your

shoulders shake, your nose to her

cheek, and I reach to close her

open eye before you can stare

into its empty haze.

As you say goodbye, the only

emotional response I can find for

you is a pounding heart, a flushed

face.

When she is waxen and cold,

when she has been pronounced

dead, I give you coffee and a

blanket, sit you in a rocking chair.

You cry, we clean, and when it is

over you stumble to the elevators with

family -

And even though you

won't remember me, I will probably

always remember you -

I say this is the worst moment because regardless of all the things I hate, of all the things I object to on principle, this was the worst. I woke a man out of a sound, restful sleep to tell him that his wife was dead. He knew it was coming, but when you factor in denial, it doesn't matter. That is one of the worst possible things to wake to. And it was my job to do it. I know he doesn't take it personally, and neither do I. But in a way it does become personal, because it is an experience and a memory that is vivid to me, even if for him it is lost in a haze of grief and denial. In some ways, it's the day I've been waiting for ever since I started taking my own patients, what, 8 or 9 months ago? I think it happened under the best of possible circumstances - we didn't have to code somebody who wasn't going to make it regardless, so instead we were keeping her comfortable.

Almost makes me think we should medicate the family, too...

Don't worry, more to come, that should be on a lighter, more reader-friendly note.

To Whom It May Concern:

WHOEVER IS POOPING IN THE PEANUT BUTTER FACTORY AND CONTAMINATING OUR PEANUT BUTTER WITH SALMONELLA AND ECOLI AND WHATEVER ELSE NEEDS TO CUT IT OUT!!!!!

There are many, many important uses for peanut butter in the hospital.

First, we generally keep saltines and graham crackers and peanut butter around so when people get hungry between meals (not hard since we serve mass-produced plastic-warmed shit), we can feed them.

Second, we also use it as a power food - whenever it's going to be past midnight before we can eat, it's a really nice temporary fix to eat a spoonful between minor disasters.

Third, it's a really important thing for diabetics.

Yes, diabetics. Because we occasionally end up overloading them with insulin and tanking their sugar to 40 or 38, as were the cases tonight. Sometimes we use the IV form of high-fructose corn syrup to bring them back up, but the drawback is that it's about the consistency of maple syrup or warm honey, and small-gauge IVs and especially veins don't really like that. So the preferred alternative is sugar-laden orange juice to bring it up right away, and then peanut butter and crackers to keep it up.

But that doesn't work too well when we DON'T HAVE PEANUT BUTTER.

Therefore, whoever's out there ruining all our peanut butter and related packing supplies, quit it!

Coincidentally, though, you should know that your peanut-butter poo tested positive for blood on our litmus paper at work, so you should probably get checked out. You know, so you don't bleed to death. But I guess on the other hand...

You know you've been at work too long when you start dancing in the hallway and turning the "Hokey Pokey" into the "Patient Pokey" with phrases like "you re-attach your leg leads and you turn the lights back out..."

Or when the funniest thing you've seen in your life is a paper meant for communication with non-English speaking patients that has lots of ambiguous faces drawn on it, with the word for the emotion written above it, in English, including a "stupid" face, complete with dunce cap.

Or your favorite quote becomes "I'd like 37 pizzas." "You'd like what?" "I'd like 37 pieces of water."

Or you have a long, long list of what not to name your children that includes names like Edsel and Belvet.

Or your patients ask if you live there, too.

Yeah.

Let me tell you about an exciting little drug called AT-III.

Actually, it's technically not a drug, it's a component of a human clotting factor called antithrombin III.

And I got to give it last night for the very first time.

Mmmm.

I was checking on a patient, doing my evening assessment and making the first morphine rounds, when a pharmacy tech came up to me and said, "Becky?"

"Yes..."
"Here."
"Here what?"

At this point, she held out a gallon zip-lock bag with seven smallish boxes in it.

"What's this?"
"AT-III."
"Oh really?"
"Yeah. For the patient next door."
"Oh lovely."
"Where do you want it? I have to hand it off to you."
"Uh, ok. I'll just...put it on my cart and take it with me."
"Ok. What's your last name?"

While looking at the boxes, I had a vague memory of watching somebody else struggle with double-sided needles and a painfully slow, precise mixing process that involved doing everything possible to avoid creating bubbles or foam, because they never went away once formed.

With growing dread, I approached the pharmacist who was still in the nurse's station, who looked at it and said, "Oh, I have no idea how to mix that. We don't do that. Oh no. Never. Did you know you're holding about $6000 in your hand?"

I was incredibly tempted to call up the infomercial people who were trying to say that printer ink was the most expensive liquid on the planet on a price-per-volume-unit basis.

After reading through the instructions with the pharmacist, my worse fears were confirmed. A few hours later, I finally was able to make the time to mix and administer the stuff.

First, insert short end of double-ended needle into 10mL vial of sterile water. Remove cap from other end of needle and insert at 45 degree angle into vial of powdered AT-III, ensuring that the stream of water flows down the side of the vial and not directly into the powder. If directed at powder, foam will form.

Then, after removing empty vial and needle, slowly swirl in 4" diameter circle to mix any remaining particles. If large chunks remain, vial may be turned horizontally and rotated.

Once all vials to complete dose have been mixed, attach filter needle to syringe, clean top of vial, insert needle, carefully invert container, and slowly withdraw reconstituted AT-III. Ensure that no bubbles or foam form.

Administer entire dose over 10 - 20 minutes.

Riiiiight.

Seven vials, twelve call lights of people asking for pain meds or coffee with 5 sugars, 1 cream, 3 ice cubes, and a straw, and an hour and a half later, it was drawn up, sitting on the counter, ready to administer.

Just so you know, an hour plus is a lot of time to spend on one medication for one patient whose heparin is working just fine and will be discharged in the morning anyway. And it takes a lot of effort and concentration to hold your hand still and not create bubbles.

Why don't I get a cut of that $6000?

I think there's hope for many of you aspiring musicians out there.

Seriously.

Because if somebody can write a song entitled "I Want a Hippopotamus for Christmas" and get it made and polished to the point that it gets played on the frickin radio (much to the dismay of the listeners, who will subsequently have to listen to at least an hour of music to get that particular song unstuck), then yeah... there's hope.

It was cute for about the first 30 seconds, and then it was stupid. Who let them get away with that? Really?

Yeah. If you think you can top that for dumb Christmas songs, let me know.

Until then, though, I'll be listening to something else - something I don't mind being stuck in my head.

Let me explain to you one of the many reasons I question and sometimes regret being a nurse.

Actually, let me explain to you the post-procedure process of a heart cath.

So you go for this procedure wherein they make a nick in your groin and stick a tube about the diameter of a macaroni noodle into the artery there. Then, they use that macaroni noodle tube to thread a wire up to your heart, where they inject a lot of IV dye, do real-time x-ray, find blockages, open them back up and prop them open with stents, and remove the wire.

Usually, that macaroni noodle gets removed while you're sedated, too, which is a good thing, because all the pressure in the artery means they need to hold really firm pressure on it for 20-plus minutes, depending on how quickly it clots off. Firm, as in, 50+ pounds of pressure on a 2 square inch area. When you're awake, they order 5-10 mg of morphine. The usual dose is 2-4 mg.

While you still have the macaroni noodle in, you have to lay perfectly still and flat. After it's removed, you still have to lay perfectly still and flat for 6 hours (or until "in the morning" which translates to whenever that particular doctor comes in to see you) before you can get up or moved or sit up or reposition yourself because your bad back is killing you.

Yeah.

So last night, I had the joy of having a patient whose macaroni noodle (henceforth referred to as a sheath) still needed to be pulled. And she was wide awake. And you know that part about lying perfectly still and flat? And especially not moving your legs?

Well... Yeah...

There's this little thing called restless leg syndrome that really doesn't cooperate with all this.

There's also this little drug called Chantix, which is to help you quit smoking but has the unfortunate nasty side effect of very strange and very vivid dreams.

Well, when your legs twitch and kick involuntarily, and that's made even worse by the weird dreams you have from your Chantix, it means that I, as your nurse, sit outside your room perched on the edge of my chair trying to chart on my computer-on-wheels while watching your legs and eat a sandwich and talk to my husband (who I haven't seen in three days) on the phone before he gets in bed while hopping up every time your leg moves more than 2 inches to remind you to try to hold your legs still.

Which, in addition to the restless legs and the drugs, is particularly hard because I knocked you out with 2mg morphine and a wonderful anti-nausea drug called phenergan, which has the side effect of making you extremely groggy. On top of all the versed and fentanyl you had to knock you out for your heart cath.

Lots of work involved. Lots.

Did I mention that this was only one patient? And I had 4 more? And I had a brand new admission from the ER? And we only had 3 nurses on the floor to start with? And they both got admissions at the same time as I did, which was when I was trying to get that sheath pulled? And that one of my other patients was a quadriplegic with a feeding tube and a tracheostomy (rather tricky and often disgusting breathing hole cut in the neck)? And another patient with a feeding tube? And everybody wanted pain medicine at the same time? And two broke down and cried on me?

Yeah.

I'm starting to not care about the job security because being this understaffed makes for such a stressful, chaotic time. I don't get paid enough in the first place, never mind on these days where I don't even get to sit down between 7PM and 1:30 AM.

Not. Worth. It.

I know, I know. It'll all seem a lot better after I sleep some. Don't worry. I'm on my way.

Right now, I'm sitting at home with a cup of Candy Cane Lane tea, keeping company with two sleepy yet mischevious cats (and Hawkeye and the rest of the gang from the 4077th), trying to remember what all I thought would be a good blog topic.

While I could rant about how Christmas has come even earlier this year (a post I've been planning since Oct. 31st when Walgreen's put up their Christmas tree display), or about what the holiday frenzy reduces people to, or stupid drivers, or what a small town this is (because I discovered this morning that I graduated nursing school with my new neighbor), or present you with an abbreviated but hilarious list of what not to name your child (Teretha, Mista, Bonita).

But I'm a little distracted by my relief at having survived last night.

It really wasn't an awful shift. It was a fair bit more chaotic than usual at shift change, and I for sure had a patient in contact isolation for who knows what, and another in isolation for the flu. And one with no IV access and a jumpy family. And a few who needed their "nerve pills" more often than they could have them.

After I got them all tucked in, it was pretty good, and I had time to peruse the newspaper and a few holiday catalogs. I was mostly worried because I keep hearing stories about how really weird, really intense things happen on the holidays. Like people coding on the toilet. The worst thing we had was one woman who busted a stitch on her arm (which she busted while drunk) and bled a bunch before the doc came and stitched it up. The, well, the funniest thing we had was a rather confused woman who stripped down naked and laid spread-eagle on her bed, one leg flung over the side, and carried on adamant conversations with herself most of the night.

I just hope tonight goes as well.

And that the boys don't tear down my new curtain in their quest to stalk the birds outside the window.

Um, yeah, I think I need to go avert disaster...

"Wow, y'all eat really well on nights."

"No, we really don't."

"Oh?" (awkward laugh)

"I mean, it tastes really good, but it's terrible for us. The way we eat, you'd never know we're a heart floor."

Last night, in celebration of November birthdays at work, we had Petro's night.

Whoever discovered how wonderful it is to put Fritos with chili is an absolute genius and should be awarded many prizes. Maybe Petro's are just a southern thing, but I so wish they'd catch on elsewhere. That restaurant chain really should be making a fortune.

But anyway, it was a very satisfying cold-winter-night-at-work meal, and an excellent way to cap off the work week (for me, anyway.)

And on that end of the work week note, I'll be taking a few day hiatus from NaBloPoMo for a trip to visit family for the upcoming holidays.

In the mean time, make a Petro if you haven't had one. Enjoy.

You know that whole everything in pairs thing that Noah had going on with the Ark? I don't know if 2 by 2 was just an old testament thing, or if God decided that more was better, too, but things most certainly do not go in twos any more.

They always come in threes.

We always end up with three feeding tubes at the same time, or three in a row. Or people with C-paps, or ostomies, or dialysis patients, or...well, you get the idea.

So yesterday, when we had two DNR patients die somewhat unexpectedly, we spent the rest of the night on pins and needles, wondering who the third was going to be. But it looks like we'll spend the next few days still wondering, because it didn't happen by 0704 when we all clocked out.

I guess it's a different kind of death watch, really. We're not parked outside the door we think it is, but we all jump to look at the monitor a little quicker when it alarms and make sure we know our patients' code status.

Sigh.

High on the list of things you don't expect when you're in nursing school.

The most challenging and taxing thing I did at work last night was putting TED hose on the rather swollen legs on one of my patients. TED, in this case, is not United's little-brother airline or your Uncle Theodore's nickname, but rather something involving the word "thromboembolic."

Basically, they try to squeeze all the fluid out of your legs and feet back up into the rest of you so your kidneys can filter it out and let you excrete it, like good cooperative kidneys should.

But heaven forbid I have a patient with cooperative kidneys.

This little man looked up at me and said, "How do they expect me to do this myself? You can hardly do it, and you don't have any trouble reaching my feet!"

It's like putting on women's hose, except much tighter, and the hardest part is getting the cuff over the widest part, which is the diagonal of the heel to the ankle. I held my breath, stood on my tiptoes for leverage, shimmied and wiggled the thing over his poor swollen tootsie, until I had the heel on the heel and the toe on the toe and realized I had a whole second stocking to put on.

Too bad he wasn't my below-the-knee amputee.

It only would've taken ten minutes instead of twenty.