ICU patients from last week

[whitewriter]

Thursday April 21

I initially took handover for a man with a long term high use of alcohol, that had multiple attempts to wean (sometimes with medical assistance, and most recently without) - who had vomited 1L of blood at home, had 1 bout of malena and was in ICU awaiting colonoscopy- due to need for 1:1 nursing for safety in regards to his behaviour. For the first 2 days his AWS was 0 and on the 3rd day (hello) although he answered all the questions correctly the nurse who had him suspected he was hallucinating (but not saying so) and so his score now increased. He didn't like how the diazepam made him feel (probably why he chose not to do medical-assisted detox) - so was trying to avoid having it.

He wasn't a normal looking individual somehow.

Just something was off.

That's what long term alcohol use looks like. It's sad.

If people knew, I think they'd drink less.

A new admission was arriving from OT - the tonsilitis - and the incharge let me and the other nurse decide who would take the double (my alcohol guy plus her current pt) and who would take the new admission.

Turns out the Admission was the easier option. Which I took because the other girl (IP4 who just got offered a spot in small ICU) was on the fence.

We joked for the rest of the next 2 days that "She did me a favour" and now I "owe her". I deny this and said "that's her fault for not taking the easier pt which I had offered" - she later thought that by having 2 pt that day, she could put her name on the 2 pt list and then not have 2 pt the next day -

I know better from experience. You never know what your gonna get, staffing changes, and just cause ur on the 2 pt list one day doesn't mean you won't get 2 pt the next day if staffing requires it. You take what you get and be greatful or you'll just hate work.

The son of the lady with the tonsilitis stayed at her bedside all afternoon asking typical never-seen-someone-intubated before questions. He was polite, spoke really quickly. We discussed how since she was in hospital, she had missed out on ramadan activities at home, and would typically have enjoyed the ritual with his aunts and the like.




Friday April 22: The technical term is hidradenitis suppurativa
It refers to the a chronic (long term) suppurative (meaning, process of discharging pus)
hidradenitis:
hidros: sweat + aden : gland + itis : inflammation
inflammation of sweat glands

Can also be known as acne inversa (see that terminology makes more sense to me).

Honestly. At work, I had zero time to figure that all out. I just read quickly on Up to date the key features of the illness - and it's comorbidities and factors - (obesity and smoking) and their interplay (with how it can last for years- cause great stigma and anxiety - is not related to cleanliness.

And here was a woman who had it so bad she didn't even want to roll in the bed or get out due to the pain from her: literal, and I repeat: lumpy, pus holes that had been surgically drained 2 days before. And now required daily dressings.

Which involved (and I kid you not) soaking ribbon gauze into betadine and stuffing them (yes, stuffing them) somewhat gently(as gently as you can stuff something... is that even possible) into the holes.

It's now Friday and I remember working next to the nurse who had to do it on Thursday and the whole ward heard her screams because somehow: the woman refused pain relief (wtf). Although it was offered and pushed. She claimed it all didn't work and she didn't want something if it wouldn't "knock her out aka. unconscious".

This reminded me significantly of women in labour and their pain relief options and the realistic nature of pain relief options in labour.

It's all about expectation setting, and them understanding what was happening.

She was now so traumatised from having the dressing changed without proper pain relief (come on ... guys... how did we fail this woman so badly)

That was did a burns ward style "PCA" which was an "ICU-A" (cause we never gave her the button, we controlled the analgesia) -- with cardiac monitoring, Sp02 monitoring and oxygen--

And it worked a treat.

There was a lot of talking and explaining beforehand.

She was really depressed.

Post yesterday she started to say she wanted to suicide due to her wounds.

-- and this had been a key feature of her previous presentations in hospital (so not a new thing, but still extremely serious).

She told me point blank she didn't want psych to see her. I explained she could tell them that herself when they came - she told me not to let them into the curtains -- but low and behold they showed up whilst I was doing something and she got the psych review she really needed.

We're not a burns hospital but that doesn't mean she should be denied adequate pain relief for what is an extremely painful looking wound.

She also had crazy BGLs. It felt like the subcut insulin I was giving her, had zero effect. I don't know why she wasn't also on metformin.

The last BGL was 21.5 and I was sorta mad that ICU let it get that high before ordering extra insulin.

We couldn't restart the infusion because she was technically on the ward list (off it now though since she had the ICU-A pain relief, and as we are not a burns unit - the ward staff wouldn't know what the hell do with a ketamine midazolam "PCA" that only staff can touch.

We do special stuff in ICU. It's all hell or highwater-- our level of staffing means that we can do things that the ward can't.
I like it.

The best part of my day (and probably the doc's day) was after the anesthetic he'd convinced her to have: on the promise she wouldn't remember the pain - was asking her how the dressing change went (she still yelled throughout but it was much less) and, most importantly - how did it went.

She said she barely remembered. She remembered having it done. But not the pain or the specifics.

Basically we gave her twilight sleep like the drugs used to give women a pain free and also memory free labour in the 1950s that quickly went out of fashion due to it not being used in a safe manner. (this was pre epidural) Scopolamine is still used today: but under the name "hyoscine" (wtf. I didn't realise) and it does have memory loss and sleepiness as side effects. Oral buscopan is commonly utilised in the community over the counter for stomach cramps due to menstruation or IBS so I think the dosages must be higher for memory loss to occur (otherwise it would be the next daterape drug, no?).

We usually use it for stomach cramps - or as part of end of life care set of drugs that reduce oral secretions that can be distressing for family members to see (and hear)

wikipedia states:
Hyoscine butylbromide is effective in reducing the duration of the first stage of labour, and it is not associated with any obvious adverse outcomes in mother or neonate.Based on this citation That was a rabbit warren I didn't expect to go into...

On sunday at the SJA duty - I enjoyed telling Pete about the "woman with the pus holes" (which is a terribly uneducated, ill informed and dramatic way of explaining what it was -- but seriously - just in your mind imagine holes in your legs, and imagine pus coming out of them: because that's basically what it was). Pete thought it was disgusting and it put him off his coffee.

What can I say. It does take a particular type of person to be a nurse.




Saturday 24th of April: https://whitewriter.dreamwidth.org/294916.html#cutid1

CAL refers to chronic airways limitation.

I spent the whole shift trying to find the time to look that up, knowing it was a lung thing but not remembering what the hell it stood for (This is what 5 years in neuro ICU does to your brain). It's basically the updated terminology to describe the disease COPD chronic obstructive pulmonary disease.

Isn't it funny how terminology changes as disease pathology becomes more understood.

Anyways I guess its CAL because there's no obstruction really - the airways become thicker, less elastic, more filled with mucous and therefore the airways are limited - in terms of gas exchange, and plasticity in responding to changes in requirements.

This man had extremely poor exercise tolerance. So bad he couldn't walk more than 15 meters.

This made him high risk for failing extubation. We extubated onto HFNP and he did very well.

At first they were going to want to do a CPAP mask but with the NGT I couldn't get a seal and after 30 mins of trying, when he said "this is too tight and uncomfortable" I gave up and went to the prongs.

He had AKI-- worsening Ur and Cr and a low output. Hx of stenosis in renal and aorta. So it was treated with fluid boluses and turning on noradrenaline to target a MAP of 80.

I had a good day with him.

Turns out, he used to be a sheep shearer.

Now he spends his days reading novels. Romance, sometimes he says. How cute.

Apparently the diagnostic colonoscopy was in Dec - and 4 months later in April, here he was having it removed. Not a bad wait time (4 months).

The day ended with me helping one of the part time seniors - who didn't have pus lady as a pt - she had handed over at 13:15 but doesn't leave til 16:00 so was free- to do the dressing on her as the nurse that did have her, was throwing up in the toilet (I actually heard her and thought she was the girl who confided in me the day before that she was 6 weeks pregnant

Well.

Anyways. It's a tough dressing to do without guidance from someone whose done it before.

2 hours to write this one.