You can indulge your curiosity about the significance of low diastolic blood pressure (DBP) in ICU patients.
Did you know that DBP rises to its peak at age 55 and then declines?
Work has been shit lately. Covid is still surging in my ICU, and we’re busy with other things too.
Last week was an especially difficult week for our heart failure service, as every patient on service was deemed “not a candidate” for advanced heart failure treatment. Bottom line: this is end-stage heart failure and hospice is the next step. For many patients, this means removing a piece of equipment that’s been helping their heart do it’s job (like an intra-aortic balloon pump, or an Impella). This can mean almost immediate death, but many patients do go home from the ICU to die there. It’s emotionally exhausting but incredibly important work.
And it’s so important to spend some quality time with these patients. Last week, I helped a gentleman who was just days away from getting his Impella out to go home on hospice. He was itchy from laying in bed. I washed his back with real soap and water and washcloths. The put on lotion with a little massage. 20 minutes including gathering supplies. And it made his day! We chatted about traveling and life’s simple pleasures. These are the important moments at the end of life, and I was so happy to be there for him.
But despite that part of my job being so meaningful, there are other parts that are nearly unbearable. There is a day shift charge nurse who is mad at me no matter what I do, and who demands a ridiculous amount of report on our patients. She wants a full head to toe but the 90 second version. Do you know how long it takes me to prepare a cohesive and comprehensive 90 second head to toe report that also includes the plan and updates from when she was last on shift??? It takes about 5 hours to do it for 30-36 patients. And when I don’t give her all the info she wants, she asks for it in aggressive tones. If I don’t know the answers, she will eye roll, sigh and slam turn the pages of her printout. Actually, she does that sometimes anyways if she’s annoyed by something, anything.
I find this to create a workplace so toxic that it gives me panic attacks. I dread giving her report. I get short of breath talking to her. I often cry after interactions with her.
So what do I do when I tell my managers about this and nothing changes? That is the million dollar question facing me right now.
Oh, I almost forgot my dream. I had a left ventricular assist device (LVAD) in my dream, but it became dislodged internally. FYI, I’ve never ever seen this happen in real life… I was bleeding to death, surrounded by work mates. They could do nothing. And finally, as I was about to die, one of the help pressure on the bleeding spot as the warm feeling spread through my chest and I lost consciousness.
Whoa. Is that symbolic? I hope not.
Well, I think this week finally broke me. The state of California is removing the stay at home orders in the Bay Area, as they project 25% ICU bed availability in the coming weeks. I just want to know WHAT ICUS HAVE BEDS???? Because its not us. We don’t have any. Any time a patient leave, we replace them immediately with another patient from the emergency department, from another unit on our hospital, from another hospital in our system. Our nurses are getting pulled to go take care of ICU patients in random places all throughout the hospital as we wait for the ICU rooms to be available, but we’re already short staffed. So, we’re basically screwed. Plus, the patients are sick. We’re talking multiple code blue events in the ICU per shift, multiple deaths, overtime in the high single digits. And that’s not great, because research shows that shift workers in the 12th through 16th hours of their shifts have the mental capacities of someone who is legally drunk.
So, the nurses are the equivalent of crabby, sleep deprived, hangry drunks. It is a nasty atmosphere sometimes. A lot depends on the mood of the head doctor (the Intensivist) and the Charge Nurses. The nurses need a lot of emotional support. That leaves a charge nurse like me–who seeks to be supportive emotionally and intellectually as well as an upbeat and positive force in the unit but also suffers from being an empath (as well as her own depression)–in a really hard spot. I can get drained. I have the support of wonderful friends and a great therapist, and it takes me a long time, but I get drained.
And last night, I found myself outside the hospital, sitting on the ground a homeless person has probably slept on, letting the cement cool my legs, crying and smoking a cigarette at 4:45 in the morning. This was not my most glorious nursing moment. It was dark and painful. But those tears needed to come out so I could finish report on well over 30 patients and prepare for what I expected to be the oncoming shift’s foul mood leftover from yesterday’s day shift.
So here I am, after a not-sufficient amount of sleep, trying to process some of last night’s feelings. Being a nurse is exquisitely difficult some days. In addition to all the pressures I’ve already mentioned above, we had a traumatic patient admit that ended after what was essentially a five hour code blue. Another nurse and I pushed ACLS (advanced cardiac life support) drugs regularly, gave units and units of blood products in a massive transfusion, started the patient on CRRT (continuous renal replacement therapy, ie dialysis), maxed him out on ALL the cardiac meds you can imagine. After doing everything we could at least twice, more likely four times, a discussion with the family led us to make the patient comfortable with some morphine. The previous five hours had been filled with such pain and chaos–blinding lights and shouting. I put on some soul music. Don’t ask how I choose what music to pick for patients, but the second “Sitting on the Dock of the Bay” started playing, our patient just seemed more alert but relaxed. I sang to him, held his hand, and told him it was ok now and that we’d take care of his pain. He died while “Ain’t No Sunshine” by Bill Withers played. And that’s not what that song is about at all, but maybe it should be. Maybe its a better song that way.
Here’s a Spotify playlist I started for end of life music. I’ll keep adding to it, but I put this two songs on it for a start, in case you need a listen…
Trauma is something that nurses just accumulate, and its hard to release it. Moments like last night’s sidewalk meltdown are bound to happen for me, as I absorb and process all the emotions of the ICU. Would I change my life if it could be less traumatic? Would I change jobs? I’m not sure. I’m starting to consider the idea that I can’t just continue to accumulate trauma and other people’s emotions. I’m just not sure I would love my job as much if I couldn’t help patients at the end of their lives.
WTF?!? Once again, I’d like to remind you that I work in an adult ICU.
We have a patient here in the ICU whose been admitted to the hospital for two months. That is a long time to be anywhere that’s not home, especially when you’re sick. She has been in the ICU for more than a month.
During the course of her hospitalization, her mother has become her rock—as you would expect. But what the mother has become to the health care providers cannot be described so nicely.
Is she controlling? Yes. Is she demanding? Yes. Is this understandable? Yes.
But has she turned her adult child into a will-less person who can’t speak for herself? Also yes. Does she coddle her and tell the nurses she won’t get out of bed because she’s tired when getting out of bed is literally the only thing that will help her get better at this point?
Does she ask the doctors for opiates and benzodiazepines on behalf of her daughter’s severe pain and anxiety? Does the daughter as a result always looked totally out of it and unable to participate in her own care?
I can actually feel myself getting angry as I write this. Then why am I even doing it, you may wonder? Because today, we were presented with a list of unacceptable and acceptable nurses to care for this patient. And we were gifted with a daily schedule from her mom, in coordination with our supervisor.
So, apparently the mom has caught on that the incentive spirometer is important. But she doesn’t seem to realize how important anything else is, nor does she seem to care that nurses may be off schedule due to their other patient’s medical condition or unavoidable delays in pharmacy or dietary.
Also, giving a critical care nurse a schedule like this insults the years they spent an education and training in order to become skilled enough to take care of patients who are trying to die all day every day. Not to mention that each critical care nurse usually has their own internal clock, rhythm and way of doing things. It follows the same trajectory as all the other nurses but also has individuality.
In the end, do you know what’s really happening here? This mother, who can’t come and be with her daughter right now, and who feels very lost because she cannot control the diabolical illness affecting her child, has chosen to lash out at the only thing she feels she can control. The nurses.
But we are not her employees, nor her slaves. We do our best to accommodate the families of our patients but in the end, WE DO WHAT’S BEST FOR OUR PATIENTS.
And in this case, it might be forcing her to get out of bed, go longer in between doses of Ativan and the big D Dilaudid so she can wipe her own face and FaceTime her own mother. Because, just to remind you, I work in an adult ICU.
We are having a record-breaking year for deaths from drug overdoses. There are many factors playing into it–synthetic fentanyl and its rapid spread from East to West coast; the silent pandemic of loneliness and despair that underlies covid and brings with it more drug use and abuse; a financial crisis leading to more homelessness which sort of closes the circle on the previous two factors. It’s hard to separate one thing from another as the bad news this year just kept piling on, and ultimately everything seems related in some way to the worldwide pandemic and the fallout from it.
So here we are. A record year for drug overdoses. An article from New York Magazine points out not just how we’re going to break records for drug ODs but that here in San Francisco, overdose deaths actually outnumber covid deaths. Maybe we should just add OD deaths on to the covid death totals… But then again, that is a slippery slope. We could say the same for heart attacks and strokes, and diabetes and decreased exercise tolerance. Maybe “pandemic syndrome” should be a new diagnosis. Let’s spitball a formal diagnosis criteria–it would probably involve 1) financial, housing, food, and/or racial insecurity AND 2) a concurrent development of a chronic illness, plus one of the following two categories 1) depression and/or anxiety; 2) alcohol and/or drug use disorder. I’m sure we don’t need this diagnosis–what we have covers it since this probably falls into the territory of a psychological diagnosis.
My fictitious diagnosis would be covered easily by “adjustment disorder” from the DSM V, but we’d all run into trouble when our adjustment problems go beyond 6 months. But you know what? Perhaps we’ll see a lot of PTSD or cPTSD coming out of this pandemic. I can only speak from what I see or read, and I know that many healthcare providers are being severely traumatized over and over by this pandemic.
They are taking care of patients who are isolated and lonely and sometimes, dying alone. There are times when the only visitors are Zoom calls with family, and the nurse usually is the one holding the iPad, absorbing day after day of each family’s sadness and overwhelm.
There are the days when even though they are sick, the patients still lash out at the nurses and other medical staff violently, sometimes causing permanent disability. Even though my hospital has done all of the things discussed in this article, we still have violence from patients and visitors: Cash-rich hospitals have done little to prevent violence against nurses and other medical staff — from The Milwaukee Journal Sentinel (the last of a five-part series called “In the Shadows” about violence against healthcare workers)
And none of this takes into account the high risk healthcare workers are at to actually get covid. This story of an ICU nurse in her 60’s who gets covid and ends up in the hospital for 8 months fighting for her life and then relearning how to walk is inspiring. But not many souls would fare so well with such a challange.
Could you imagine going to work, thinking that could be you? That was my previous 9 months. I did get my first vaccination, but I won’t consider myself safe until about two weeks after my second dose. Then–approximately February 1–I will consider my fully vaccinated, which wiull give me about 90% protection from covid.
But until then, everyday I go to work, I am still at risk. There is more covid than ever. And at my hospital, I personally see the high number of drug overdoses. Its like they come in waves… when the fentanyl hits the street, we get between 3-8 cardiac arrests “found down.” A complex cycle of homelessness, mental illness, drug abuse, and trauma all coming to an end in the ICU.
Today, I was giving a lunch break to one of our nurses. While he was gone, his patient who had just undergone repeat femoral endarterectomy and stent placement woke up. She was thirsty, hypertensive and bore a passing resemblance to Suzanne Crazy Eyes Warren from the HBO series Orange Is the New Black. She had an infectious laugh and easily showed appreciation as I took her through some standard post-op tasks…
One of the things we needed to do was get her blood pressure under control. We were targeting a systolic less than 160mmHg in order to prevent bleeding from any of her surgical sites. She did not believe that any blood pressure meds would work for her, however. She explained that even though she knew she should, she just didn’t take her meds.
So as I gave her some intravenous anti hypertensive, I turned the monitor towards her. & instructed her on how to watch her blood pressure, changing second by second via arterial line. She was amazed when 10mg of hydralazine successfully lowered her BP from the 180s systolic to the 140s. As she watched the numbers changed, she expressed her amazement and newfound commitment to taking her blood pressure medication— now that someone had finally shown her that it worked!
I spent a few more minutes chatting with her about how high blood pressure can damage blood vessels leading to the type of clotting and clogging that required the type of surgery she just had. I could see little light bulbs coming on in her eyes
As I was preparing to leave her room, she expressed her gratitude for showing her that medication can work. I thanked her for her openness to learning about her health. The truth is that when I can make a difference for patients like her, I am more grateful to be a nurse.
There’s nothing I love more than memes, puns and wordplay! Ok, I might be exaggerating a tad bit… but I like these things a lot a lot. Like, I’m ready to go steady. (You see? I made a funny rhyme?!?!?!)
In a related note, a wordplay meme. I hope you enjoy it even 1/4 as much as I enjoyed making it…
Best part is, the cake was delicious. But it always is at 03:00…
“You can’t tell me what to do; the is MY room. I paid for it”
—anonymous patient
My response? “This is a hospital, NOT A HOTEL.”
(Note: it was probably her steroids talking but oh. my. god. She gave her surgeon a slow clap while saying bravo bravo the morning after surgery.