Code White

If you understand end-stage hepatic failure already, you don't need to look at the prelude post. You know how horrible it is. Otherwise, some of this might make more sense to peruse if you have the time/energy/interest/stomach for it.

A code white is a patient who is bleeding out in my hospital. Though nobody actually called a code white, this is what it was.

This is not the story of Sarah Johnson in room 42. 'Sarah Johnson' is not even close to the woman's real name, and we don't have a room 42. You don't know this patient and you never will. This is the story of what I learned about nursing, what I learned about how nurses learn, as I watched Sarah Johnson's body implode and I watched a team of people Sarah Johnson didn't know keep her alive.

I am bad at fiction, so what I'm telling you is true. Or at least, what I saw. These are the people I work with. It is my hope they don't hate my guts for writing about them. It is my hope, actually, that they never find out. But that's possibly not likely in the long run as I've showed a handful my desert pictures over on Betelgeuse. Dammit. So, in alphabetical order, I give you:

A, the monitor tech/unit secretary
D, travelling ICU RN
M, ICU RN, precepting P
P, ICU RN, orienting
R, SDU (stepdown) RN, who'd been my preceptor

and JustCallMeJo, yours truly, SDU RN

**************

Something big was happening in 42. It didn't take a genius or special spider-sense. I could see men in button down shirts with angry expressions on the phone at the other end of the nursing station. Doctors. Angry. Bad sign. I could see A, whose back was to me, typing furiously with a chart to his side, and the back of his head looked a warmer shade than normal. I could see P, hurrying in and out of 42, brow furrowed. I could hear the phone, and the phone, and the phone. M was calmer, but she was clearly busy...talking to A about paging this person, that person, clarifying with this MD this order, that order. I saw one of the docs I knew, one I'd seen intubate somebody before. She was wearing a scrub hat. Bad sign, meaning intubation was happening again. And I could see R, who was listening to D give him report, but whose eyes kept going up to 42. R is usually in the thick of things of a crisis, and was clearly keeping tabs on what was goin on.

I decided the best thing to do was my job. There was such a clusterfuck of people at 42 that what was needed was not me. Unless shouting and running happened, and then I would run, too. When bumping into P or M in the medroom, I told them, "If you need anything, let me know, my patients are fine and I can help." They said thank you, they're okay. M said this kindly, P said this with dubious belief. Or maybe that was just her stress level. Neither M or P knew me at all.

I noticed that R got his admit across the station from me, and B, the resource nurse was helping him and apparently nobody else. This is a bad sign because it meant that neither P, M, or D was available to lend a hand. Everybody is around to lend a hand when an admit comes. So I poked my head in, though by the time I got there, R had his patient settled.

I tried to stay out of the way of 42. Traffic slows because of rubberneckers. And I don't know enough to be useful. But as the evening progressed, one by one, MDs began to leave and the tension level decreased a little. I listened. I hovered, and I gathered that Johnson was bleeding, had been bleeding. P and M were back and forth, in and out of the room. P: "Where the hell are my platelets?!" M: "A, would you page respiratory for me please?"

(Rehab just called me. Can I come to work there tonight?...Er...sorry, been up all day. Besides, got a hot date with my best friend and her children today.)

D and R were doing their own thing. R busy, D mostly goofing off. I saw R hopping on the phone to page people for M and P. Getting stuff, helping. D hovered and told me that the patient was "bleeding so much that she had a yankauer up her ass". This is horrifying until you see how eminently practical and oddly humane it is. Would you rather have the patient bleeding out of her ass and lying in it because she's so heavy to move, have her family see her in that state...or would you rather find a way to keep her cleaner, even if it's a little, um, unorthodox? It sounds so horrible. It is horrible. So is the alternative.

P came out of the room at one point and I was the only one sitting there. Her expression said that I was clearly not her first choice. "JustCallMeJo, do you know where the blood bank is?" Yup, sure do. "Would you take these units down for me please because I'm only supposed to give them if her crit is x and we may not need them until midnight." Sure, I can do that. So I did, came back, loitered more. Maybe I could do something else. Learn something.

I caught little things. A needed to eat, and with his face that color, clearly needed to step away from the desk. There I was. "Will you watch monitor so I can get some food?" Sure. So I watch monitor, notice nothing more than occasional PVCs on two of R's patients, and take a huge number of calls for P/M. "M, Dr. Somebody is on the phone for you about Johnson." She nods, "Thanks. Johnson is P's patient, and I'll let her know." It was a gentle correction.

And I thought about that gentle correction. Here's a woman who can clearly handle this patient. She'd need help, of course, because no patient this complex gets better because of any one person, including and especially not because of any MD. Don't make me laugh. And what is this nurse doing? Holding up another nurse, supporting another nurse, one with less experience. And she did it....gracefully. I admire that. A good mentor is rare.

P needed more from the blood bank, and I was there again. "I need 2 units of FFP now, and see if they'll give you those two units." "Right. Two of FFP, two units if they'll give them." I returned with my hands full of stuff, which allowed me my first real look into the room.

love of god.

Bright lights, beeping, whirring. The patient was intubated. There was blood, yes, and oozing fluids. She was covered by a gown but she had what looked less like vaginal bleeding as what had been vaginal gushing. She was yellow. She was huge. She was massive, actually. X's marked the place on her feet where pulses would be if you could feel them. And there was a bank of IV pumps no less than five feet wide. Think about how wide five feet is. She had no less than seven lines infusing into her just from the IV pumps. And there were five lines hanging from the ceiling that were run-as-fast-as-you-cans, platelets mostly. Blood products and blood products. On the other side of the bed, there was a small fridge-sized portable dialysis running. (I didn't know this was a dialysis machine, I had to ask.) The patient had a tube down her throat, a ...let's see octo? lumen? subclavian in her right side...what do you call a subclavian with two or three "chicken feet", foley of course, the suction, and a vascath in her femoral, filtering blood, and oh, I think another miscellaneous IV bank in her left arm, too.

She was yellow and unconscious.

And seeping. Fluid seeping from her skin.

It appeared that either the bleeding was under control or the suction was taking it away and dumping it into tanks under the bed.

P and M were deep in conversation about some charting thing when I timidly walked in and handed them the blood stuff. "Thanks," they said, and then I kinda just didn't go away. I put my hands behind my back to not touch anything and I looked at the IV banks. Vasopressors, insulin, a few meds I didn't even know. "Is it, um, okay, if I look?" M nods, smiles. P shrugs, sure. P is focused on learning and stressed because well, this is her patient. She's digging this patient out of a deep fucking hole. I get that. I respect that.

So I try and stay out of the way, and listen. A GI doc is coming and gonna scope her and see if he can stop the bleed. I had to refresh my memory of hepatic failure later, but even as I heard that news, my eyes went huge because I was thinking: esophageal varices. I mean, the GI tract is really really fragile right now, right? This is risky, right? So my eyes popped and I shut up. Probably I just don't know what I'm talking about. I shut up, I listen. This is my job today.

P hung one of the platelet bags, and in a voice I hoped sounded unobtrusive, I asked, "So...P...you can just slam those in? You don't need to do a specific rate...?" She looks at me as if just noticing me for the first time. "Yeah, you can just run it with a bulb like this." "Because we at the opposite of caring about CHF type stuff, right?" "Yeah, her fluid volume is so low right now, it's hard to get a pressure."

And after that, P looked at me with less dubiousness. Maybe it occurred to her I wasn't a toad, nor was I a fluffy bimbo, and she had stuff she could teach me and I was more than willing to learn from her. At least, I hope that was it.

I tried to not get in the way, but I felt like I could watch. D hovered as the GI doc came in. D was having a ball. D was like this imp, buzzing in my ear. "I love this stuff....I love it when I'm so busy I can't even leave the room to take a piss....this is a great learning experience for P."

It wasn't just D that offered to teach me things, either. M said at one point, "You know, JustCallMeJo, she's got a really good example of scleral edema." P nodded, "Yeah, JustCallMeJo, come here and see this." I stood behind her, gloving up. P gently opened the patient's eyelid to show me, and then stepped back to allow me to do the same. My god. Her EYEBALL was swollen with pocketed fluid. There was something comforting to me about just gently touching this woman's forehead. I was careful. Her goddamn eyeball was swollen with fluid. I don't know what it is about things wrong with eyeballs that is just so fucking wrong.

But no time to think on this. We had things to do. Or rather, M and P had a lot to do, and I had getting out of the way to do. The GI doc arrived. Gowned up, machines brought in, things to move out of the way, more blood to get...

It was D who looked out for me. No special reason why that should be unusual, but R'd been my preceptor, and it seemed strange without him. Especially when What's Happening was in room 42, and in my limited time I've been on SDU...R thrives in a crisis. No time to think about it, though. D called me to come stand in a good spot and buzzed in my ear. When the doc would ask for something, D would hop up and get it. M and P were too busy. Handy, as I realized I still don't know my unit so well as to know where to find say, a tongue depressor. Who uses a fucking tongue depressor in ICU? Somebody who needs to open an unconscious patient's mouth, that's who. M and P were so slammed busy with the five foot wide banks of IVs and getting blood, slamming it in, trying to keep a blood pressure...I'm not sure that either of them got to actually see what was happening with the scope itself. P got to look up once. I'm not sure M saw it at all.

D was my running commentary. My eyes were riveted on the theatre happening in front of me, but I was listening. Once in a while, I'd fetch something. I would go eyeball my patients here and there, make sure they were breathing and doing fine. It helped a lot to know that A was at the tele desk. But I tried to be present as much as I could for the scope. (This scope = laproscopic exam from esophagus through duodenum) Some things D said I knew, some things I did not. "They're probably in the pyloric now...I've seen people come back with this and be completely fine after a transplant..." At one point, I think he was watching me and not the scope, and he said, "Welcome to ICU." I acknowledged I'd heard, but I was still looking.

Art school. You learn to look well. You learn to memorize gestures and colors.

I kept wondering to myself why R didn't hang and watch, too. Like I said, R's usually in the thick of things, and I was puzzled but I let it go. I tried to nudge him a little once or twice, but the effort fell flat. Possibly his new guy was a handful and he had a brief moment of respite, or there were already enough cooks in 42. After he'd lended a hand early on, he stayed out of the fray...fray-adjacent. I may be misreading, but there might have been brooding involved, brooding of unknown origin and no doubt not my business. I like R, he's a good guy and a good nurse, far better than me. He's certainly been patient with me. He belongs in ICU and due to life factors, he's not there at the moment. I let the invitation to come see the scope sit there, and then well...back into the fray.

The GI doc closed a bleed and he and his RN left. The scope showed a clot as huge as my hand in her stomach. It had been a helluva bleed. I'm not sure if he got IT, but he got one.

Cleanup time. This was something I felt like I could do, I know how to help, so I did. It took six of us to change the patient's linen, full of blood. And the second we got new sheets under her, the new ones began to darken with more blood. I could also take out the biohazard, I knew where that went. I can take out the trash, too, I know where that goes. More blood tubing? I can bring two types of blood tubing. So now I have learned which blood tubing is needed.

We were beginning to unwind. Sarah Johnson was gonna stop bleeding. Or at least slow the bleeding. This was what was unwinding. We saw the clamp. We got blood slammin in, and plates and expanders, and milk of amnesia so she never knows. Dialysis pumping it out and 14 or 15 lines pumping it in. Sarah Johnson is gonna make it through the night and today was definitely P's day.

Nobody knows that it's P's day but those of us who were there. She nailed it. She really did. I overheard her and M debriefing much later in the night, a really important thing to do after all that. "What would I have done if I had to do that by myself?" And you know what M said? "You would have had JustCallMeJo and R and D to back you up." She's right, and I think that's the best part of everything I learned that day. Had she been alone, I would have backed P up as best I could.

P was bulletproof at the bedside. Yeah, she was stressed, yeah she asked M stuff, her nerves were jangled, and M and D were rolling much better with the situation. But she got the job done, and that is *all* that matters to Sarah Johnson's family.

M was bulletproof because she didn't step in and do FOR P, she did better. She stepped aside and let the RN who will become another awesome person taking care of patients of this complexity do the job. This is not stuff you can learn from a textbook. This is stuff you can only learn by being there, and doing it. Somebody's very mortal coil is depending on you and the team of people you're with, and so this isn't something you can really practice. You do.

Think it's the doctors who "save lives"? Yeah whatever. They play their part, they go home.

Besides, I prefer the term "stopping someone from dying." Life saving is for pastoral types.

I fetched stuff. I took out the biohazard, I watched. I helped turn and asked questions. And what was cool is that D was there to buzz explanations to the least person in the whole group, i.e. me, the chick who took out the trash. And that chick was grateful to take out the trash, ...just to be there.

And A? A kept the chaos at bay. The static and noise of phone communication and flying orders and nonsense of delayed blood product and get me a respiratory therapist and no time to delay because this woman is bleeding to death. A rolled with that and also, by the way, watched the heart rhythms of 12 other patients.

R joined us as the cleanup happened. It's possible that he was having a completely different patient crisis, of which I wasn't even aware.

Sarah Johnson's alive (or was when we left), survived the night and neither she nor her family will know what was involved to make that so.

You have no idea how proud I am to be the person who fetched the extra blood tubing.

During cleanup, D went back to his goofing-off self, munching out of a bag of popcorn. ("I'm really hungry. Is that weird to be hungry after I just watched a GI scope?" "I think it's healthy.") He asked me, "So is this better than rehab?" Rather than answer, I grinned back. A grin that wasn't just 'yes' it was 'hell fucking yes'. It was a dirty grin, an evil grin and I didn't actually intend to flash it at him. So I turned back to fiddle with the biohazard bag, but not before the point was made.

And I didn't sleep. I was awake 23h. And this post is a poor reflection of what happened. I don't think I really caught it all. It's an echo of an echo two days later.

I don't know if Sarah Johnson is alive today. When I told Katie the cliffnotes version of this story, she said, "Well, you can't....maintain that kind of thing, can you...? Putting all that blood in nonstop? I mean, what's gonna happen?"

I don't know. I really don't know.

I know it'll happen again sometime. Liver failure does. And I'll know which blood tubing is the right one, and where to find sharps containers.

That's worth something to somebody, isn't it?