Another Day in the Life of an Intensive Care Nurse

7:10 a.m.  I got report on a 43 year old alcoholic, comatose from liver disease, and a 73 year old woman with emphysema and heart failure brought on by an adulthood of smoking and obesity. When she stopped smoking, she got fat. The poor woman couldn't win.

7:30 Checked hemodynamic monitoring lines and vasoactive infusions. Probably the two most crucial elements of critical care nursing are obtaining accurate data and ensuring accurate medication delivery. Well, okay, making sure the person is breathing really comes first, then seeing they have a blood pressure consistent with life. Move on from there.

The 43 year old alcoholic is in isolation for possible clostridium difficile, a bacterial infection that causes tremendous diarrhea. The best part of c. diff. is this: you can't stop the diarrhea, because that would retain the toxin created by the bacteria and potentially kill off the bowel and contaminate the bloodstream, leading to sepsis and death. So you have to let the person crap their eyes out. Fortunately, a new device that seals off the rectum and channels the runoff into a long wide flexible tube helps contain the mess. The charge for this low-tech device? $1100. That's right, folks: an $1100 poop tube.

Breathless Lady's face is contained in a mask that seals off her nose and mouth completely with a set of tight-fitting velcro straps. This allows a breathing machine to apply constant pressure to her airway to ease her breathing. It's called BiPap. Some people use similar devices at home for sleep apnea. The odd part of this treatment is that it makes people feel like they are smothering. So almost everyone wants to remove the mask, which makes their oxygen levels drop and their carbon dioxide levels rise.  Carbon dioxide is sedating, so Breathless Lady becomes calmly oxygen-deprived whenever she removes the mask. When you think about it, it wouldn't be a bad way to die: of oxygen deprivation, carbon dioxide keeping you comfortable. There is a sort of natural mercy in that combination. But my business is sustaining life, so I spend a fair amount of time putting the tight mask back over her face. A person dependent on a BiPap mask cannot eat. So malnutrition becomes an inevitable aspect of this treatment. Breathless Lady had not eaten in 3 days.

Mr. Liver Failure is not being fed either. He is on a ventilator, so he cannot eat. This is problematic because the liver synthesizes protein, needed for tissue healing, from nutrients. Even if we were feeding him, he would be undernourished because of his broken protein synthesis mechanism. And he is physiologically stressed, increasing his caloric needs by about 30%.  They tried putting a feeding tube through his mouth into his stomach twice, but both times his fragile esophagus bled too much. Two reasons for this: one is that he has grown a network of frail, tortuous vessels in his esophagus to offset the high pressures generated by his diseased liver, sort of like building new roads to relieve highway congestion. The second reason is that the liver makes clotting factors, and his sick liver isn't up to the task.

9:00 a.m. I ask the physicians on rounds what the plan is for Mr. Liver Failure's nutrition. I am told we wait until his lungs improve and we can get him off the ventilator. In other words, don't stand on one leg waiting for it. This is not the answer I wanted. The answer I wanted was: we continue to correct his clotting disorders, then try again to pass a feeding tube. Or we get a consult with someone who can pass the tube under xray guidance or direct visualization. But I think I know why they don't choose those options: it's only nutrition. Study after study has shown the importance of initiating nutrition in ICU patients, but still some ICU physicians fail to value the simple necessity of nutrition. That's why I always ask about it.

12:30 I grab a cup of coffee on my way back from dropping off Breathless Lady in angiography for a permanent line placement. The intravenous device she is getting today accesses a large vein in the chest so she can go home on a potent vasodilator that will keep the pressure in her pulmonary vascular system down, thus controlling the strain on her heart. The lungs and heart should not be viewed as separate organs; sick lungs make the heart sick and vice versa - that's why she started this grim journey with emphysema, then developed pulmonary hypertension and heart failure.

The circulation in both the lungs and the gut is meant to operate at low pressures. As Mr. Liver Failure's pressures rose because of a stiff, cirrhotic liver, Breathless Lady's went up from fibrosed lungs. Different location, different cause,  same fundamental problem.

The drug Breathless Lady is receiving, epoprostenol, has a half-life of about 6 minutes, so if the infusion is interrupted for more than a few minutes, she goes into heart failure.  I made extra sure she had enough to last through the procedure in angiography.

Soon she will be seen by the "Remodulin nurse" (Remodulin is the brand name of a similar drug that is less tricky to administer than epoprostenol. First instance of a nurse being named for a drug.) The Remodulin nurse visits pulmonary hypertension patients in the hospital and then follows them home to be sure they know what they are doing with the infusion.

1:30 Ahhh....lunch time. Cafeteria fare today: panini with avocado, spinach, tomato, bacon and cheese. Pretty good with a Snapple diet peach iced tea, the only fluid I've had except that cup of coffee at 12:30. Every nurse knows drinking fluids only makes you pee, and that takes time. So I don't drink fluids on the job, though I was sweating like a pig in my isolation gown, gloves and face mask.

2:15 Back from lunch, I notice the nurse covering me didn't get vital signs on my patients, so I have to catch up. Then it's time to give an enema to Mr. Liver Failure. This enema is not for constipation (obviously): it's to deliver a drug that removes ammonia-based toxins through the GI tract, in the hope that this will improve his brain function. When the physicians  say he is doing better because of these enemas. I ask, "How bad was he?" because now he is not responding to anything but noxious stimuli (like pain.) Hard for me to view this state as any kind of improvement, but perhaps my observations are keener because the docs do not enter the rooms of people in isolation on rounds. They rely solely on what they observe through the door, the junior resident's exam, and what the nurses tell them. So their best information is secondhand, from a physician in training or a nurse who may have never seen the patient before today, like me.

2:30 I check the last set of labwork and see that the labs are improving on my alcoholic friend. In the medical record, I find an order to repeat the labs. I page the doc and ask if he really wants them redone - and remind him that a set was just sent and that he ought to look at them. He comes back and scratches out the order.  Miscommunication causes serious errors, but fortunately this one was just a nuisance.

3:00 Breathless Lady is doing better. The respiratory therapist and I agree to take her off the BiPap and see how she does with a high-flow face mask that delivers close to 100% oxygen. The night RN said she had difficulty swallowing water, so I give her pills with a spoonful of gelatin. She chokes anyway. I had asked the physicians to order a swallowing evaluation, and the speech pathologist arrives to do that. We decide it should wait a few days, until the lady can tolerate being off high-flow oxygen for a while.

4:00 Wrapped up in my own world, I haven't noticed that two other patients have arrived in extremis  in the 9 hours I've been here. They both crashed on the floor (the acute care unit, where people go after they improve enough to leave intensive care.)

Now we have another admission, Lifeflighted from southern Oregon with a massive heart attack. An intra-aortic balloon pump, a device inserted into his aorta, pumps in sequence with his failed heart to strengthen its output. He is on a powerful anti-clotting drug; his right eye oozes blood. Before we can move him off the nasty sheets he's been on for 4 hours, we straighten out the invasive lines in synchrony with the removal of the Lifeflight cables so not a beat is missed  - literally, a heartbeat. He lies on dirty, wrinkled sheets for another 20 minutes, hardly conscious but able to hear everything going on. I wonder if we sound as if we have no idea what we're doing:

Marlene: "Rebecca, do you have the a-line over there?"
Rebecca: "Is this the a-line in his femoral? Looks like a venous line."
Teresa: "Yes, but it's through a side port so the waveform is bad. Are you synching the balloon pump to his EKG?"
Lifeflight nurse: "Yes, leave our EKG on for now. We have Nitro, Integrillin and dobutamine going through the CVP and PIV."
Marlene: "OK, let me know when you are ready to switch over. I'll connect the PA to our monitor. I'll send off labs, Rebecca."
Physician: "Get a mixed venous, too. Is that his blood pressure? Do you need access?" (The wavy red line on the monitor showed a blood pressure of 68/41.)
Teresa: "The a-line is not zeroed yet. Read the NBP."
Rebecca: "The balloon pump is in his right, a-line left, and we have a PA so we have plenty of access."
Physician: "Okay, thanks."

And so on. What would likely sound to the uninitiated like chaos is actually exquisite teamwork. Two or three simultaneous conversations are occurring while hands whirl around him. Occasionally, someone leans down to whisper reassurance to him. I think, this is some amazing work.

By 5:00, my day is winding down. Breathless Lady is breathing pretty well on the face mask. To give that much oxygen requires high flow, so the air is blasting away at her face. High air flow is good because that sensation stimulates the facial nerve, which sends signals to the brain of relief from breathlessness. A nifty built-in mechanism for tricking the brain into giving the person some comfort.

Mr. Liver Failure is stable, but I decline to say improved. Tomorrow's nurse will have to reintroduce the notion of feeding in the hope that some action will take place. Some battles are fought gradually and politely. I send off the last set of labs in the hope his clotting times will continue to normalize and then we can talk about a feeding tube.

7:00 Whew! Same RN who had these two last night. I update her, sparing all the detail that a new nurse would need. On the road to home and a glass of wine by 7:40. We all did good work today, and that keeps me coming back.

(Names in stories from my nursing practice are always pseudonyms.)