Tuesday, July 3, 2012

Guest post: nursing in the ICU

You may not realize this, but your veterinarian wouldn't be able to behave nearly as badly without the dedicated support from his or her veterinary technicians. These dedicated nurses are often the ones who carry out the veterinarian's diagnostic and treatment plans for your hospitalized pet. Today, AnonyTech speaks out:

Everybody desperately wishes you could tell us what happened. After a quick stop-over at your regular vet, you’ve landed first in our emergency department and now the ICU. Glancing at your fluffy, worried face (but noting the undefeated tail, still gently thump-thump-thumping), it’s easy to see why. You’re trying hard to shed your intestinal lining. It spills out, gelatinous and threaded with crimson, around your tail. Your family agrees for you to sleep-over, but hesitates to let us uncover WHY you’re doing this, “No diagnostics, just fix him. We’ll do that lab work tomorrow, please.” The receiving doctor was worried enough to put you straight into the ICU, but nobody knew for sure until your tail stopped it’s thump-thump-thumping.
 Phone call number one: Diagnostics truly cannot wait until tomorrow. It’s diagnostics and treatment tonight, or time to stop. Permission given, your ICU sleep-over party swings into action: Lab work is ordered, and it reveals to your doctor what tricks your body has been up to. You’ve forgotten how to stop bleeding. This explains why thermoregulation and peripheral circulation are not high on your body’s priority list. Red and blue bruises spread across your soft belly and, obtunded though you are, your small body curls reflexively inward to protect itself from the pain. We can help you there, and do. Fentanyl, kissing cousin to morphine, provides some measure of relief. You breathe easier, no longer grunting with each breath. Warm air blankets provide the heat your body has disregarded. Ever determined to discharge the insult, your intestines redecorate the bedding with what could be strawberry jam. That is… not ideal.
 Textbooks say that dogs’ shock organ of choice is the gut. Insult the canine body enough, and the guts will rebel. Cats take their post-shock anger out in a much more civilized manner. You clearly have no such plans and unlike cats, your body is following the text book to the letter.  Scooping your small form in one blue gloved hand, I remove more shreds of your gut rebellion. We hope to help you through this crisis; it should be a fixable situation. Uncover the underlying problem, stop the insults, recover, and then discharge. A guarded prognosis is better than grave or poor prognosis, right?
Tonight you have your own team, not just a doctor and a nurse. The intensivist and the hospitalist, the floor nurse and the critical care nurse. We are your entourage. I gain more experienced hands, when the critical care nurse picks up where my training leaves off. It’s apparent that peripheral access isn’t enough: Orders up, and the critical care nurse throws in a venous central line. Fresh plasma so you can keep the fluids we’re pouring into you, plus artificial colloids (fancy starches, to keep your blood where it belongs), and crystalloids to help address your lack of volume. To complete the party you bask in the heat support and ride the gentle wave of analgesia. For a few fleeting hours, you uphold your end of the contract. What we pour in? You only leak some of it back out. Blood stays where it belongs. You even wake up enough to be called “depressed but responsive” and remember how to shuffle about. You’re caught rearranging the bedding to fit your whim. We take turns cooing at you, more willing to cuddle and cradle now that life seems to be back on the map. Your body, unfortunately, has other plans.
 “The death bounce” is the morbid and offhanded way to describe the hours of calm-chaos-calm-chaos before the rest plays out. Shock already did its damage before you came through our doors, and you don’t play fair for long.  Maybe your guts didn’t approve of the blanket fort you’d burrowed into, or maybe you were just building a warm place to end it all. You could not have known that in the ICU, we only become crueler as you fall away from life.
 The first time you just stop breathing, but respiratory arrest can turn into full CPA if not caught and aggressively treated. We don’t mess around here. “CODE!” and your body is literally run the short distance to the crash station. Your entourage has again grown in numbers; all available hands help run your code. Orders are automatic and fast. Tube, breathe, monitor, and hopefully labs. Somebody forces a tube into your trachea and another begins breathing for you. What feels like minutes must really only be ten or fifteen seconds. Then you remember and get on with breathing. We breathe. Fool us once, shame on you, but fool us twice? We know you’re not playing along. You’ll have to keep the new tube. The doctors do not trust your stomach-- it is snuggled right up with the traitorous intestines. Until we know, the ET tube stays. Forcing another piece of plastic into your recumbent and sedated form, the doctor pulls back on the syringe and a coffee-like liquid flows into the vacuum. Your stomach was in on the trick, churning out the dark soup for the doctor half of your entourage to frown over.
We’re all watching you even more carefully, scrutinizing your every intake and output. Our machines dwarf your small form. Your pupils constrict in reply to the light shined so rudely into their depths—somebody is still there. We pull you along slowly, nursing your prone form towards life. It is too much trouble to argue with us, and for three tenuous hours it seems you’re again convinced to stay. Even with drugs, you try to chew at the tube in your trachea, sniffle at tube in your nose, shift away from the unwanted touch of the doppler, and flinch at the sharp end of a needle. Or maybe you’re just waiting for an opportune moment to escape. Not allowed, sorry.

 It is no longer worth it to you. You’ve had a good run of it, right? There’s been too much loss, too much pain, too much unwanted interference. We refuse to let your heart give up and when you go off, we crush at your tiny rib cage and pummel you with epinephrine. Then, when your end-tidal jumps, your team holds a collective breath. Somebody works to get your family on the phone for the doctor, they’re worried and waiting. Seconds after the end-tidal spike, your heart takes notice and steps back into action. ROSC can be a very, very low bar. For now though, you are back. A half-forgotten breath escapes from the whole team. The doctor carefully talks with your family, explaining that slipping away very briefly, once, is manageable, but twice has moved you to a very grave prognosis. They desperately want to keep trying, too far in their fear of loss to hear. We frown at the clock, watching the minutes tick by without a clear decision from the phone. You’re less subtle about it this time, and we watch your blood pressure march steadily downwards, ignoring all the crystalloids, colloids, and ‘pressors we throw into you. Once you’ve made a decision like this, it’s very hard to change your mind. We try to soothe each other, “Good job, smooth response, clear communication, doing all we can…” Check and recheck orders, making sure nothing has been missed, no magic life-saving step somehow overlooked. In sixteen minutes, you’ve checked out. Your pupils give up the game-- large dark empty holes, yawning into oblivion.
 In case it wasn’t obvious where you planned to go, pinkish foam burbles up from your endotracheal tube and sputters against the ambu bag until it’s suctioned by yet another (smaller) plastic tube. Jam, coffee, and now peppermint foam. Your lungs have redoubled the escape attempt, and it’s probably a matter of seconds. I wince as your ribs crack under my hands during compressions. I’m sorry for this, so sorry. It’s not fair to you; it’s not kind. It’s certainly not an ending any of us would choose. Then my two minutes are up and I gladly count down to swap out with your next tormentor. We pump more adrenaline into you, and for five pained minutes we’re worried you’ll continue this pattern all night long. The doctor makes another phone call to your family-- The Phone Call, the one nobody wants. This time your family understands what they’re asking you to endure. They hear how you’ve tried to leave life three times already, and give the choice back to you. You’ve been rescued from our resus. You’ve become a DNR.
 We watch, silently, as your heart slows to a jog, then a walk, then a shuffle. Until finally it’s just throwing electricity around without purpose or result. Silence. We remove all the bits of plastic and metal from your limp form. The monstrous machines are pushed back, clearing space for your family to caress your face and limbs one last time. You don’t curl into yourself when I lift you in my hands, to swaddle and shroud you in clean blankets.
We did all we could for you, except give you peace sooner. We cannot brood over these cases, or we’ll all end up burned out and useless. Softly we thank each other and carefully pick up the pieces scattered around the crash station and ICU. One of the doctors orders pizza (most of us forgot to eat amidst the stress and chaos) and the gentle teasing begins. By the time the pizza has arrived, so have the morbid jokes. Warm food helps us move, and we reintegrate onto the main floor. All bleeding stops eventually, right? The ache remains for me to deal with later, after my shift. You’re one of the ones I’d hoped to see walk out of our doors. And right now? Other patients need us, and they are warm and alive.


  1. I appreciate my technicians and the talents they have that enable me to care for more patients during the day. And I'm certain I wouldn't have nearly the amount of opportunities to behave badly without my skilled technicians.

  2. From a human nurse (who is still mourning for a dog who lost his battle, despite the ICU army fighting for him, 3 years ago) to all the veterinary nurses, thanks for all you do. I know how hard it is.

  3. This post was so honest and *real*. It brought me right back to when I used to work as an ER veterinarian, and reminded me why I walked away from clinical practice. I could only have my heart broken so many times. Kudos to those still in the trenches - you're stronger than I was.

  4. Ditto to the Polite Vet.

    It is not easy to find good ICU techs. I would be much grumpier without them.

  5. This broke my heart. That poor dog. The poor techs and docs that worked on him. Emergency medicine can be so cruel in the pursuit of prolonging life.

    Thanks for sharing, AnonyTech.

  6. There is a special place in heaven for the likes of you and your colleagues.

  7. This text is fascinating. By 'four' I was already completely choked up with tears. I would like to know who the author is?

  8. And yes, yes, we keep moving forward.
    We place our pain and tears on the back burner. Because, the jokes, the morbidity, the teasing, the SURVIVAL all come in to play. Because, while we loved you and did what we could to help you survive, there is another, coming right after, that will need our attention. Our skills, our devotion is put to the test once again.

    And that night, or the next, or the next, when we step in to the shower, the tears will fall... because only in the shower, can no one see you cry.
    And we keep our tears to ourselves. Not because we feel no pain, but, because we are SELFISH with our pain. It is OURS. It is the only thing that is.
    We give our hearts, our souls, we give our devotion and our skills in abundance to our patients and our clients and our doctors. We give them anything they need, anything they want.... Except our tears...
    Those are for us.

  9. Oh, how I have survived nights like these I just don't know. I feel for your AnonyTech. Amazing writing though.

    This made me wanna cry, remembering all my past patients.


  10. I concur: does anyone know the author of this piece? It's heartbreaking and true, and it's phenomenally written.