It?s been awhile, I know.

I have some excuses: High acuity. Long hours. A couple of vacations. I?ve been working hard, playing hard, and writing little.

Add to that a crisis in conscience over patient privacy, as well as an existential crisis over why bother to blog in the first place.

So onto the high acuity: According to some of the senior staff members, it’s been one of the worst winters ever. At one point we had dueling oscillators. For info on what the oscillator is all about, please see Geeknurse’s Getting Good Wiggle, for a thorough description. And yes, we also assess chest, as well as thigh wiggle, to make sure it is functioning as it should. The oscillator is where you go when you are at 100% FiO2 and cannot be weaned down. It’s pretty dire. In our 16-bed unit, the limit for oscillators is two. I think GHOAT only has 4 oscillators for adult patients, and one must be kept free at all times in case one in use malfunctions.

Flashback to February: We had two in use and there was a third patient who looked like he could have used one. The tally now? The two oscillator patients have died and the one who went without it is alive, but still on the vent.
I had the honor of caring for one of these oscillator patients. She was one week post C-section, somehow got septic, and developed ARDS. She was flown in from Bermuda. Her newborn was alive and doing well in the NICU in Bermuda. She wavered from 90% to 100% FiO2 on the oscillator for quite some time. Every time we tried to wean down her oxygen, her sats dropped.

While caring for this woman, I had an eerie sensation that she was already brain dead. I of course had no way of knowing this for sure. She was flown in and they had struggled to get her stable on the vent before settling on the oscillator. The impression that I got was that she was way too unstable to be transported, but that this was her only hope. She was on high levels of sedation and paralytics so as not to breath over the oscillator.
Her husband flew in and was staying alone at a local hotel. He had no family with him. His newborn was in a NICU in another country. His 5 year old was staying with friends.

Can you imagine being in his place?

He was a very pleasant man. Very humble and thankful for the care his wife was receiving. He would thank me and it made me feel horrible, because of this underlying feeling that I had, that his wife was already dead. So I compensated by scanning a small Polaroid he had of his newborn. I blew it up and printed it out to hang in his wife?s room. When I was away on vacation the doctors finally told him that her case was hopeless. She died immediately after they withdrew care. I further compensated by buying expensive baby presents for his children (the MICU sent a care package to him in Bermuda). The family of the patient who didn?t get the oscillator (but who is still alive) also sent him a care package. It is so touching to see families of patients reach out to one another.

But that was ages ago.

There?s been so many patients since then. And the liver patient from the previous entry? She also died while I was away. She made a good effort, though. I had cared her the day before I left for vacation. She even got a visit from the physical therapist, and the two of us got her sitting on the side of the bed. (A HUGE accomplishment after being in bed for 40 days). She was still in and out of that hepatic encephalopathy. I would ask her questions to assess her LOC. (“What?s your husbands name? Where are you?”) and she would answer in numbers (?62, 65 103,? she would say.) By the end of our shift together we had kind of bonded through her confusion. Despite the encephalopathy she had managed to remember my name and was concerned that I would be leaving her at the end of my shift. I was sitting around the corner giving report to the night nurse when I heard my name whispered in this, loud raspy whisper (her vocal cords were shot from all the intubations and re-intubations). It was such an eerie sound. Imagine a loud ICU with beeps and buzzing and loud nurses giving report at change of shift. Above all of that noise you hear a whisper that practically screams. It was so creepy it gave me the chills, but afterward I had to laugh. I felt proud of her for remembering my name, and hopeful that she was enough of a fighter to make her voice be heard.

RIP, SMD. You had a really tough run there. You deserve some rest.