At 5:39, I was dreaming. At 5:40, hoping the alarm was only a remarkably realistic dream feature, I tried to resist awakening. I failed.  So I crawled out of my queen-size haven and headed for the coffee pot.  Waking early is actually a good thing; today I'm working in the Trauma ICU. I like this stuff. 

By 7:10, I have my assignment for the day. Yes! A real Trauma ICU patient, not someone waiting for a bed on the ward, not someone with a perfectly normal neuro exam who just needs another head CT to confirm the absence of a brain bleed. No, this is the real thing today: a 35-year-old man who, drunk, fell from a 2nd-story balcony. Subarachnoid hemorrhage, intraparenchymal hemorrhage, left bone flap out. I would explain this to a layperson as bleeding and swelling in his brain - so much swelling that the surgeons had to remove part of his skull to relieve pressure on his brain. He's got a ventriculostomy catheter, a small plastic tube that is threaded through the skin into his brain to drain cerebrospinal fluid, decreasing the pressure inside his skull. This tube also allow me to measure the pressure in his skull, called intracranial pressure. This number helps me calculate blood flow to his brain, or cerebral perfusion pressure. Although most sources will tell you that number ought to be at least 60-70 milimeters of mercury, this guy's is in the mid-50's.  It's the best he can do right now.

A line of surgical staples snakes around his head where the bone flap was removed, and no less than 4 things are coming out of his mouth: breathing tube, suction tube, feeding tube, and an oral airway so he doesn't bite down on the breathing tube. What a fearsome sight he must be to his family. I try to be sensitive to the fact that these people have never seen such a thing; but I also want to convey confidence, assuring them that this is not at all unusual to me.

Around 9 a.m.,  the charge nurse tells me that another nurse, Amy, is ill, and we will have to double up this guy and his neighbor, now being cared for by Cheryl, my colleague.  Cheryl's patient next door has been vomiting, and his dressing is leaking, and his family is watching all this go on, worried.  Then his bowels let loose and a team of nurses assembles to clean him up and change the bed.  Cheryl and I decide that these two cannot be paired, and there must be another solution to our dilemma.   Ed volunteers that his one patient is "doubleable", so we conclude that my patient will move across the ICU to the empty bed next to Ed's patient so Ed can pick him up, Cheryl can stay where she is, and I can take Amy's two patients. 

Amy is pale-skinned, with pink cheeks and strawberry blond hair. When past patients send thank-yous to the unit, Amy is often mentioned by name. She takes part in quality management, and she filled in when our nurse educator was absent. She's really good. But now she's wretching every few words, holding a basin in front of her, yet insisting she's okay as she reports off on her pair. She apologizes repeatedly for nearly hurling up her breakfast as she describes these two people and their problems.

One 76-year-old lady who had a kidney transplant years ago developed a bowel obstruction, a fearful problem in elders. The very worst complication of bowel obstruction had happened: her small bowel perforated, spilling its contents into her abdominal cavity. This dreaded event causes peritonitis, infection in the abdominal  cavity. This often progresses to sepsis and death in older people. Her transplant anti-rejection drugs made her more susceptible to a disastrous infection. Now she is on a ventilator with a forest of IV pumps behind her, delivering a sedative, a narcotic, and a slew of assorted fluids and antibiotics. 

Although about a third of elders with a significant case of sepsis succumb, this lady is not ready to die; using an alphabet board, she carefully spelled out "Am I getting my kidney medicines?" She was concerned about the immunosuppressant therapy that prevented her body from rejecting the transplanted kidney. When her surgery scheduled for that day was postponed, she informed me that she'd overheard in the operating room, just as they were about to roll her in, that the postponement was due to an emergency with another patient.  This woman was clear-headed, communicative, and watching out for herself. She was not going down to a bout of peritonitis.

The other person Amy's turning over to me is a healthy 40-year-old woman with a thoracic spine fracture.  She was messing around on a chin-up bar with her boyfriend when the bar lost its grip and fell, and she went down with it. (You get one guess whether or not alcohol was involved.) She fell on her back, and fractured a vertebra through-and-through, like slicing a nut roll. When vertebrae fracture, often the muscle and ligaments that help keep the spine stable are stretched, so she needed surgery to prevent this injury from potentially becoming much worse. Her spine was stabilized with metal rods and plates and screws, and this very fortunate woman came out of it with no neurological problems.

It did hurt, though. After I'd taken over her care, I got busy controlling her pain. She could eat, and speak, and even walk if she were so inclined, but she preferred to lie stiff in bed, terrified,  in spite of the intravenous narcotics.  In the 2 hours I took care of her, she asked me three times if she was going to be paralyzed (no) and if she had a brain injury (also no). Amy had reported this odd behavior, too. It was, in part, a fear response. She needed much reassurance. And perhaps the drugs made her forgetful. But it was also an attempt at manipulation: she refused to rate her pain on the 0-10 scale because "You might stop giving me the good stuff." She wasn't buying my explanation that transitioning from IV analgesics to pills was a step forward.  She begged for a sleeping aid at 11 a.m. through half-shut eyes.  It seemed avoidance was her favorite coping mechanism. I must admit it was a relief to transfer her out of the ICU at noon.

Sometimes I understand completely why those who get injured got that way. A fondness for mind-altering substances, daredevil behaviors, poor coping skills, and plain old bad judgment all come into play. This pattern seen in some people does not end when that person enters a hospital. Others know what they need to heal, and they ask for it firmly yet politely.  Just as in the outside world, some shut out reality and others remain alert and engaged, much to their benefit. A lifetime of paying attention and taking positive action on one's own behalf pays off in the ICU, where new risks arise with each passing minute. Yet another reason to practice those healthy coping skills.