My last 12 hrs --

How my most recent 1:1 shift went.

Hey peeps, Cassie again!

I just finished off a 12 hr shift (although I’m pushing this post out into the future some for HIPAA-adjacent reasons) and I thought I’d give y’all a summary(ish) of what went down while it’s fresh in my mind

So, first off, my patient was a 1:1 patient, which meant that I was their only RN (although I happened to have a new-hire/gopher that day, which was great.)

The reason they were a 1:1 was because they were actively dying with covid.

Actively dying isn’t a phrase you’ve probably heard before, unless you’ve worked with hospice. There’s assorted stages to death, which I’m not gonna get into here, but when I use the phrase I generally mean we’ve met the wall: there is nothing more than I, or even God, can do.

In theory, because this patient was dying, they could’ve given me another assignment with them, except for the fact that the patient was on ten different drips, and one of them was insulin. With a patient that busy, it would be cruel to give the bedside nurse another assignment, and it would’ve been inevitable that something would’ve dropped through the cracks, and then ‘actively dying’ would’ve just become ‘plain ol’ dead.’

So, my patient had a breathing tube, we’ve talked about those before — what was ASTOUNDING this time was just how maxed this patient was. Their Fi02 was 100%, which is never good, and their PEEP was….twenty-fucking-four.

Just to illustrate how mad this is, I went around to all of my other coworkers and I was all, ‘What’s the highest PEEP you’ve ever seen?’ and everyone said 22.

Like, 20 is what you start drowning victims off on.

24 is just asking for barotrauma — it’s so much pressure I am literally surprised that this patient’s lungs didn’t just burst.

And then, they were vented to breath at 32 times a minute. (You sit around for a minute and breathe 32 times and see how that feels.) All in an effort to give their lungs as much O2 as possible, percentage-wise, pressure-wise, and frequency-wise.

One of the reasons we had their breathing rate so high is because CO2 (what you exhale from your lungs, what your body expires after taking in O2 to make energy) is an acid. We were physically attempting to help them blow off CO2 in an effort to normalize their pH.

So we were tracking this patient’s ABGs — arterial blood gas — levels, through their arterial line, and they were hellllla acidotic. Normal pH ranges for an ABG are from 7.35-7.45. This patient was a 6.9 when I left right now. Long term, and left unchecked, that’s incompatible with life.

Other labs that were exceptionally bad — their potassium was 6.4 (normal’s under 4.5), and their creatinine was 9-something (normal’s under 1.3).

These are indicative of their kidneys being out of whack, which they were.

This patient was almost thirty liters of fluid positive.

We pour fluids into people (we haven’t even gotten into this patient’s many, many, drips) and those fluids need to come out, otherwise they’re going to (eventually) wind up in their lungs, or the patient’s gonna swell up not unlike Violet Beauregarde from Willy Wonka.

The reason we couldn’t dialyize this patient (or more likely CRRT them) was because they were so unstable we couldn’t even turn them over.

They were proned, so that we could maximize their lung function from the jump, and they were so unstable subsequently that we were unable to ever flip them onto their back again. The fluid that was in their lungs (because of covid) would’ve sloshed around, filling up what functional tissue they did have, and they’d have died before they had the opportunity to gain anything from it.

No one had changed the sheets out from underneath them.

They had been on the same sheets for five days.

So they weren’t going to survive being flipped over for long enough to put in the hemodialysis ports we’d need to successfully dialize them and take off some of that extra fluid.

Where was that fluid coming from?

1) Levophed — a not uncommon blood pressure medication. Used to be called ‘leave ‘em dead’ (because people used it for the sickest of the sick in sepsis and those patients still frequently died) but has now come back into favor. We were maxed.

2) Vasopressin — another BP med. Not titratable. Left on normal dose.

3) Phenylephrine, aka Neo, from its brand name, Neosynephrine — another BP med — maxed. Pharmacy was mixing higher concentrations of this for us so that we could give it in less fluid volume for the pt’s sake.

4) Sodium Bicarb — also high concentrated dose for fluid reasons — given to attempt to combat pt’s acidosis

5) Fentanyl — pain control — not maxed.

6) Versed — an amnesiac — hopefully makes you ‘less aware’ of wtf is happening to you. Also not maxed….because…..

7) Nimbex — a paralytic we give to patients to make them ‘ride the vent’ so that they don’t fight it and can save energy, as the vent does the work of breathing for them.

8) Heparin — blood thinner, to reduce the clotting that covid can cause

9) Amiodarone — heart med, stops arrhythmias

10) Insulin — which requires hourly insulin checks to titrate effectively. Unfortunately, many covid patients are also on steroids, which means their bloodsugars fluctate all over the place.

Our goal with all of these was to keep the patient comfortable, riding the vent, completely unresponsive (intentionally), while we kept their systolic blood pressure above 90, and their MAP (mean arterial pressure) above 65.

Were we successful?

Fuck no.

This patient was a DNR, at least, which was good, because no one wanted to go into a code situation with someone this unstable. (How can you give CPR to someone you can’t even flip over?)

We had no more tools left in our arsenal. There was, quite literally, nothing we could do for them.

The family didn’t want to pull care, and I guess I get that, but like…it’s just sad. Because there’s no ‘there’-there, anymore.

We did all the things we were supposed to, and it was a great learning experience for my proto-RN, but we were drawing labs knowing that there was nothing we could do about them. My trainee wanted to show our increasingly dire lab values to the Dr and I had to pull her back and explain to her that it doesn’t matter, and I very much promise he won’t care. (In fact, he might very well have laughed at her, as he was trying to keep people who had a chance at living, alive, up the hall.)

That patient’s O2 sats were 66% when I left. (Normal O2 sats are from 95-100, and we usually aim for at least 92%.) It had been trending down for hours. There was no setting we could go up on, on the vent. I’m positive that that patient had an anoxic brain injury. And their blood pressure was trending down the last few hours of my shift — same, same. Nothing we could do. Proceeding with care was futile.

I don’t know if they’ll be there when I go back to work tomorrow. I don’t actually want them to be alive, for their sake. No one is coming back from a PEEP of 24. (Respiratory looked at their numbers in the morning and then looked at me and asked, ‘Do I really need to go in there?’ and I was all, ‘Nope,’ and so they didn’t.)

And we held all the bowel care medications we were supposed to give — which was A Lot of them, since the patient hadn’t had a bowel movement yet during their stay. Narcotics constipate you, and paralytics can turn off normal peristalsis too. Do I want to make a patient who is very inevitably going to die, who I have no way to turn over and clean thoroughly or effectively, shit themselves, costing them dignity in their final hours? No.

(Which is to say I got as ‘comfort care-y’ as I felt I could legally get, heh.)

This was definitely one of those situations where having visitors would’ve helped us — I think even in the abstract, over facetime, or hearing it from doctors, it’s just too much for a family to process without seeing.

Anyhow — don’t feel sorry for me, this is just another day at the office at this point. I just thought y’all would like to see how an average-to-busy day can roll and some of the behind the scenes thought processes I put in.

— Cassie

PS: they passed about three hours after we finished our shift.