Even the Sickest Still Need a Bath

Its been over a week since my last post. I have been working, and I have to say, its been the most challenging week of my career. I decided, for whatever reason, that I would step it up and start taking some sicker patients. I have a lot to learn and although there is always room for improvement on time management and organization, I feel like I have straddled that horse for long enough. I am finally ready to exercise my critical thinking skills, open my "never done that" doors, find my limits and break them. I decided I needed to challenge myself. What was I thinking? My first night, a really sick burn patient. I didn't do much but sit with her niece and wait for that long inevitable moment. I didn't get to change her linens or give her a bath. She was too sick, too unstable. She was on all the drips; epinephrine, norepinephrine, vasopressin, LR at 750ml/hr.... We weren't going to code her, but we were trying to keep her "chemically coded" until the family could arrive from out of state. I tried; maxed out my drips, maxed out my fluids, maxed out my vent, maxed out her heart, her lungs, her body.... She waited until I could do nothing else but call the doctor and say, "There's nothing else I can do." Her niece held her hand. I turned off the monitor. She died at 0555.

The next two nights, I took the sickest medicine patient. I don't know why. Maybe its because nobody else wanted to take him. Maybe its because his leg was rotten, and I had a stuffy nose, so it didn't really bother me that his room smelled striking like a bag of 3 day old dead fish stuck under a pile of sun ripened baby diapers... Maybe its because I knew he was sick and I wanted to keep up my goal of self destruction, I mean self challenge. Whatever the reason, I got him, dead leg and all....

What I found out was that "all" turned out to be way more than I bargained for. He dumped his pressures, right off the bat. 80/40. Then he went into arrhythmia, A flutter, then A fib...I got his labs back--K+ of 2.0. Mg++ of 1.0. iCa of 0.74. Metabolic acidosis. No urine output. No A line. Crappy triple lumen. Unreadable CVP. Depressed ST. Bradycardic to 30!! Atropine given. ...and this was all in the first 4 hours. Time management and organization went out the window. Critical thinking skills, oh my. "Never done this before", oh my. Found my limits, then broke them, oh my, oh my, oh my... I stepped into a whole new world of "what the hell do I do now?" He survived the night. I corrected his lytes. With that, I brought him back into a sinus rhythm. He pressures came up, with a liter an hour bolus. He stabilized out. I went home exhausted.

Day three, same patient. RN report, "he went to the OR and had an above the knee amputation." OR report, "we did this, we did that, he got a ton of blood and even more fluid. He has no pee. Boy did he smell bad." General surgery took over his case. Although he is a DNAR, we will treat him they say. More fluid. More drugs. More blood. More lytes. I work my ass off for the second night with this guy. I feel like I am fighting a loosing battle, knowing he probably will not survive his extreme sepsis. I know he has a very slim chance of surviving the next 24 hours. But, with all of that, I know the most important thing I can do for this man is not titrate his drips or give him more fluid. The most important thing that I can do for him is simply give him a bath. He has smelled like rotten flesh for three days. We have treated him, medically, surgically, and chemically. Now it was my job to treat him compassionately. If I were in his position, what would I want the most? I would want to be clean. I would want to die smelling like a human, not a dead animal. So, I set aside my swan cath setup and put down my flow sheet. I got out my soaps and lotions. I bathed this man as I would my own child. I cleaned him and washed his face. I combed his hair and shaved his week old stubble. I cried as I did it, because I knew that I was giving him the one thing that medicine often overlooks, his dignity. Whether he lives or not is out of my hands. I cant say I saved this man, but I can say that I did give him the compassion and humanity he deserves, that we all deserve...