whitewriter | The week of four night 12s

Night one
Bed 24

First vent in what feels like 2 years.

On handover: you should have the perfect night

In reality: a restless mess sat before me, breathing up on the ventilator to 40 breaths/min (way too many).

He was continuously slumping in the bed (worsening my ability to use upright position to reduce the effect of his huge abdomen on respiratory)
This is what happens when you have treated hepatitis and yet it still ruins your life with ongoing issues post hemi-hepatectomy.

I call it issues, the doctors called it:
Hostile abdomen, peritonitis with fungaemia post ilea resection.
Hostile is accurate.

Looking at this man I see a very good reason not to refuse the hepatitis B vaccination.
There were a couple of admissions overnight and the access of the night was the same one as last week:
She's hostile too. I remember when she was an IP she was much nicer. We even went out for a group breakfast at one stage.
I don't see that happening any time soon (me socialising in her circle and enjoying it).

I come back and he's sedated on midazolam and much more comfy looking.

Night Two
Bed 35

I was next to bed 35 last week in bed 36 and I didn't realise they were carbon copies but due to different reasons and currently undergoing different trajectories.

Bed 36 was necrotising pancreatitis (not sure from what) who is 77 and being palliated

Bed 35 is VF arrest, - which possibly caused a hypoperfused pancreas, which is now necrotising, and meanwhile she's here for her Permanent pace maker, they don't want to put a permanent one in until the necrotising is resolved.
She's been here since 11/12/20 and had 2x
necrosectomies (honestly, never used that word before).
She's just like bed 36.
Multiple, leaky drains.
Not smelling quite like a toilet but certainly unpleasant.
Still for full measures.
She's so odematous I could barely bend her knees to roll her.
Abdomen is almost as hostile looking as bed 24
Drain sites stare at you angrily and just ooze out: refusing to enter the actual drain to leave the body.
There was a respiratory deterioration with aspiration yesterday so here we are, back on the vent tonight.
54 days of going around in circles. Too sick for a PPM, here for a PPM, getting worse and not really getting better, investigations of the abdomen, still cruddy, lets do another op, cut more necrotising whatever, drain the output, stick in a new drain, rinse and repeat back in ICU.

I think I scared my bed-side neighbour (Let's call him Harry) off doing midwifery tonight.
I was explaining how I got questions I didn't think I'd have to face when I was doing it, but basically through on the job experience, learnt to parrot back prepared answers for certain common questions. And he's like what questions and I'm like oh you know: How do I know my breastmilk is going to be enough?

I think I made Harry blush for a few seconds there.

Then there's the back ache from the cots that don't go up or down.

Or the babies in SCN crying at you and becoming a nasty person wishing they'd just shut the F- up, and you turn them on their tummies (number 1 thing not to do to your baby we are trained to teach the women) and shove a dummy in their gob (and we're meant to give direction on here too, like we're experts - though we ain't and most midwives would also leave a room thinking : and well they're going to go home and do whatever the f they want anyways).

And how the male students frequently got kicked out of rooms by the women. But I still think that's related to the demographic of MSH more than anything.

Night Four
Into the eyes of a mother's love.

I have a 22 yr old pt frequent flyer from his group home.

A frequent flyer is what we call someone that comes into ICU frequently, usually for the same reason.

They range from drug addicts or those with mental health disorders of various varieties.

My first ever frequent flyer was Denny (not her real name) . Note to self to write about her in
ICU memories...

This frequent flyer is a young boy who was born with trisomy 28 duplication syndrome which is said to have:
severe global developmental delay, non-verbal, dysmorphic features: hypoplastic genitalia, microcephaly, limb contractures, hypotonia

Dysmorphic features for this gentleman include:
large head,
cone like ears
wide set eyes
a smaller than you'd expect mouth.
but otherwise his face isn't unpleasant.
He certainly has tiny limbs, his legs are about the length of my forearm and his arms are about similar length.
Therefore he cannot walk or move himself (but can wave his arms about and can lift his legs off the bed).

He is non-verbal but he can make sounds. If he understands me or not, I am unsure as he does not follow any commands.
I ask him if he's okay, or ask if he'd like a turn or all manner of things, and he gazes at me blankly.
He cannot eat, he has a PEJ insitu.

He was born in 1998.

I wonder if his mother had prenatal testing done.
I think about all the prenatal testing we do now:
the nuchal translucency,
the NIPs or Harmony test,
(those are the standard set most people get) and the more invasive CVS if the above screens show a high risk pregnancy, should be offered to the woman.

However low risk does not mean no risk, and despite all negatives, somtimes, problems slip through the gap.

I wonder if his mother knew about his genetic defects and decided to have him anyway.

I met her yesterday night and she was intense. Very sweet but also, very firm as to his needs, and how to provide. I hadn't had a BIPAP pt in 2 years let alone face bipap (CPAP is basically frowned upon in neuro ICU due to its impacts on ICP, patients are either intubated, endotracheally or tracheostomy routes but any form of constriction of the head involving ties or velcostraps is a no-no).

The reason for this admission is epistaxis that required cautrising. He then developed aspiration pneumonia. Due to his increased inability to swallow, it is thought that his nosebleed, cause blood to go into his airways: hence the aspiration: hence the pneumonia.

It happened again today despite the cauterising, when the physio was using some machine to help him to cough : the nurse on explained that the physio was rather rough with the machine and pressed it hard against the young man's face. Epistaxsis again, and a desaturation episode.

His mother poped in shortly after this was being explained to me. She explained how during the initial epistaxis episode - she was suctioning clots out of his throat.

I got her to show me how she suctions him. Using a 10Fr catheter cause they are smaller, she threaded it through his small mouth and tight teeth and withdraw a rather large clot from today's episode.

Yikes.

I've managed all night, and got good outputs on suctioning: but I devised the use of a tongue depressor to assist in suctioning.

He's been febrile.

Then cold.

Then alright.

He's been agitated.

He had diarrhea like stools but I wondered on a diet of purely feeds, would his bowels ever be solid.

He's on movicol PRN and given the multiple multiple BO I was handed over (albeit charted in the urine section: impossibly underneath hourly urine measures... I think they just wrote in the wrong row) that perhaps I should withhold it this morning.

I got to see the look on his face when I took out the second nasal pack of soaked long gauze in tranexamic acid (rather cool idea) that had been jammed up his nose after the physio?? caused an epistaxis this afternoon.

Last admission he was sent home with a do not return tag.

His mother laments that ever since he left home to a group home about 1 year ago, multiple ICU admissions have resulted.

She's conflicted to taking him out of the group home because, if she does so -- she will be sole carer again and even though she's fantastic at it she worries that if something happens to her (after all, she is getting older)-- they would have no choice but to send him to hospital until they sorted out appropriate accommodation.

Her wishes is that he has appropriate accommodation now, so that he is settled and sorted until the rest of his days.

I cannot imagine the high level of care she has provided such that he has lasted until age of 22.

She was a pro at suctioning.

type A aortic dissection whilst gardening, Hx usual culprits : HTN.
Third admission to ICU for pericardial effusion - They removed 600mls!
He had a new lease on life I think after that experience, having come out of it fairly well. So it was chats galore.

Then it was Mr Needy day 2 post CABGx4.
He couldn't seem to figure out the buzzer and was buzzing like crazy for no reason, so we put it aside. Then he started tapping instead.
His finger.
On the side of the bed

To help him to turn
Left
then right
then left
then his neck hurt
then his chest hurt
so we ECG'ed (fine) but he didn't want pain relief ?
(but he was moaning and groaning like no tomorrow, very loudly).
He tapped to tell me he couldn't sleep.
(no shit sherlock)
At one point, his back was itchy and he wanted help.

Yes.
I scratched his back (he couldn't reach).

By the morning he was pooped and half asleep.

I didn't get him out of bed for the sheer fact that I predicted that after 5 mins in the chair (if we got that far) he would ask to go back to bed and I don't think I had the energy to both put him back nor resist and hide.

Someone needs to send him to the ward.

I had fun in cardiac. I commiserated with one of the seniors about how after a few years, you feel so relaxed and comfortable in your place in ICU, that it feels like you could work there with your eyes closed. It's almost boring. He felt the same currently in cardiac but was pretty content.

I miss that feeling. I estimate I have 6-12 months 'til I'm back there again.