Where Night Is Day

The World of the ICU

James Kelly

• Publisher: ILR Press
• Year: 2013
• Print ISBN: 9780801451683
• eBook ISBN: 9780801467646
• Topic: Social Sciences
• Subtopic: Social Science Biographies
• Index: Social Sciences

"There is no night in the ICU. There is day, lesser day, then day again. There are rhythms. Every twelve hours: shift change. Report: first all together in the big room, then at the bedside, nurse to nurse. Morning rounds. A group of doctors moves slowly through the unit like a harrow through a field. At each room, like a game, a different one rotates into the center. They leave behind a trail of new orders. Wean, extubate, titrate, start this, stop that, scan, film, scope. The steep hill the patient is asked to climb. Can you breathe on your own? Can you wake up? Can you live?"—from Where Night Is DayWhere Night Is Day is a nonfiction narrative grounded in the day-by-day, hour-by-hour rhythms of an ICU in a teaching hospital in the heart of New Mexico. It takes place over a thirteen-week period, the time of the average rotation of residents through the ICU. It begins in September and ends at Christmas. It is the story of patients and families, suddenly faced with critical illness, who find themselves in the ICU. It describes how they navigate through it and find their way. James Kelly is a sensitive witness to the quiet courage and resourcefulness of ordinary people.

Kelly leads the reader into a parallel world: the world of illness. This world, invisible but not hidden, not articulated by but known by the ill, does not readily offer itself to our understanding. In this context, Kelly reflects on the nature of medicine and nursing, on how doctors and nurses see themselves and how they see each other. Drawing on the words of medical historians, doctor-writers, and nursing scholars, Kelly examines the relationship of professional and lay observers to the meaning of illness, empathy, caring, and the silence of suffering. Kelly offers up an intimate portrait of the ICU and its inhabitants.

1

THE VOYAGE INTO THE SEA OF CRITICAL ILLNESS

There is no night in the ICU. There is day, lesser day, then day again. There are rhythms. Every twelve hours: shift change. Report: first all together in the big room, then at the bedside, nurse to nurse. Morning rounds. A group of doctors moves slowly through the unit like a harrow through a field. At each room, like a game, a different one rotates into the center. They leave behind a trail of new orders. Wean, extubate, titrate, start this, stop that, scan, film, scope. The steep hill the patient is asked to climb. Can you breathe on your own? Can you wake up? Can you live?

Day is procedures: bronchoscopies, lines, taps, chest tubes. Day is traveling: MRI, CT, to dye the blood, radiate the organs, look inside the body. Then the plateau of the afternoon. Post-ops. A heart comes out. In the evening, the families. Then night to knit the raveled sleeve of care. Nights are quieter. But there are admissions, codes. The lights are always on. In the day you make progress; at night you keep them alive. Until day.

The ICU could be said to have begun in 1854 on the Fields of Scutari during the Crimean War. Of the 1,650,000 soldiers who fought, 900,000 died. Most died not from wounds but from cholera, typhus, dysentery. Florence Nightingale traveled with thirty-eight nurses from England, separated out the critically ill patients into a Monitoring Unit, and reduced the deaths of hospitalized patients from 40 percent to 2 percent. It may have begun in 1928 at Johns Hopkins Hospital, where Walter Dandy created two two-bed rooms for craniotomies and critically ill patients for the first twenty-four hours after surgery. Or in 1952, when Peter Safar, who invented mouth-to-mouth breathing, CPR, and the mannequin Resusci Anne, opened a six-bed Urgency & Emergency room at Baltimore City Hospital.

The ICU is pure medicine. The patient is a network of systems. Nine: neurologic, cardiovascular, pulmonary, gastrointestinal, genitourinary, integumentary, renal, hematologic, endocrine. Systems are the language, the code of the ICU. The progress notes in the chart are organized by systems. When they round, the residents present by systems. Nurses give report to each other by systems. For a patient to be in the ICU, a system has to fail. The principle of the ICU is actually simple: single-organ-directed interventions to support failing organ systems. A ventilator for the lungs, dialysis for the kidneys, a balloon pump for the heart. Death is indexed to organ failure. For every organ that fails, your chance of dying increases 20 percent. If more than two fail, you have MODS, multiple organ distress syndrome. MODS is unique to the ICU, like saguaros to the Sonoran Desert. MODS was discovered in 1973 and is sometimes called the disease of medical progress.

The ICU is pure medicine but like the hospital in general, it is a nursing world. The intensive care is intensive nursing care. Florence Nightingale’s Monitoring Unit meant moving the most severely injured soldiers to beds nearest the nurses’ station. Walter Dandy’s neurosurgical unit had a trained nurse in constant attendance. Medicine comes and goes. Doctors come, write orders, leave. You find an order in the chart: Avelox 400 mg q day. In the afternoon, they are gone from the unit and, like a tide that goes out and leaves behind exposed coral reefs, what is left behind is the eternal terrain of the ICU: nurses with patients.

It is seven o’clock. The room where we get report is long and narrow, the size of a small trailer home. The two kitty-corner doors at each end are closed. The blinds are drawn. Outside, the western wall of the Sandia Mountains is in shadow. The streets of the city, with their Spanish names—Candelaria, Osuna, Lomas—are filling with cars. The room quiets when the night charge comes. It feels as if beyond the drawn blinds, the closed doors, is a storm and this room is a refuge.

“Bed One,” Kate begins, “Bed One is…

…Cory Granger. Fifty-one-year-old patient of Critical Care and Neuro. Chest pain while up in the mountains, hiked out. One hundred percent occlusion of the right coronary artery. Stented in cath lab. Was on a heparin drip after and had an intracerebral bleed. He’s got a left hemiparesis. He’s been hot: 39.7 temp. He’s gone from 40 percent to 90 percent oxygen on a nonrebreather mask. He’s going for a CT this morning. He’ll get sick before he gets better.

Bed Two. Dakota Yazzie. She’s Hopi. Forty-two. New admit. Occipital bleed. Probably nonoperative. She’s awake, alert. Moves everything. Left visual deficit. Room air. She had her CT this morning. Neurosurg hasn’t come by yet. She might go out.

Bed Three is Valentín Sanchez. Sixty. He’s from Guadalajara. Came up to visit his family. Presented in the ER with weakness, weight loss. Was on Med-Surg. Went into respiratory distress. Came to the ICU. Emergently intubated. They’re ruling out TB. He’s on propofol for sedation. Big family. They want a conference today.

Bed Four. Leroy Guzmán. Fifty-two. Found down, unconscious. Hit his head. Status post craniotomy for a subdural hematoma. No deficits. He’s a drinker. Extubated yesterday. Nasal cannula. He’s still withdrawing but not getting much Ativan. Restrained. His wife calls in the afternoon, totally drunk.

Bed Five is Nancy Vigil. Forty-nine. She came from Española for a higher level of care. Sepsis, renal failure, afib. Heart rate was in the two hundreds. They put her on a Cardizem drip. She converted to sinus rhythm at twelve thirty. She spiked a temp last night, 39.2. Pancultured: blood, sputum, urine. She’s vented. Propofol’s at thirty. Stage-two decub on her coccyx. Chest X-ray shows a pneumonia behind the cardiac silhouette. She’s sick.

Bed Six is open.

Bed Seven. Lena Begay. She’s from the Jicarilla Apache Reservation. Twenty-eight-year-old patient of Internal Medicine. Idiopathic pulmonary hypertension. End-stage. Awake, alert. Flolan drip at four. She made herself a DNR/DNI. She’s very sweet. She’s a mom. Two kids. Her family’s all here.

Bed Eight is James Cushman. Fifty-six. Came in with upper-GI bleed. Scoped and banded. Went septic. Unresponsive. Hypoxic. ARDS. Lots of comorbidities. No family. He needs to die.

Bed Nine is Ricky Lucero. Ricky Boy. Twenty-one-year-old patient of Neurosurgery. Fell, was hit, or was thrown from a vehicle—take your pick—big, deep laceration on the back of his head. Restless, agitated. Extubated himself in CT to everybody’s horror. He follows a couple of commands. He’s on mannitol q six hours. Nasal cannula two liters. He took off his cervical collar. His C-spine’s not cleared yet. If he doesn’t paralyze himself, he can go out. He’s a little lloron. His mother never leaves the room.

Bed Ten is Carolyn Britt. Meningitis. She was exposed to it in her dormitory. Was started on Cipro but stopped taking it. Go figure. She came in with a classic presentation: confused, fever, stiff neck. Trached two days ago. CPAP since four o’clock this morning. Doing okay. They’re going to try her on a collar today. Awake. Alert. They had to take off both legs below the knee. It was going after her kidneys. She’s seventeen.

Bed Eleven. Code name Tucson. Found down in the desert. Dehydrated. Acute renal failure. Rhabdo. CKs coming down. He’s still intubated. He’s on Levophed to keep his systolic pressure above ninety. They’ve got it down to two micrograms a minute. Normal saline’s at two hundred to get his kidneys going. He gets fentanyl and Versed as needed for sedation. He’s a little guy but he’s wild when he wakes up.

Bed Twelve. David García. Alcohol, IV-drug history. Status post hiatal hernia repair. His stomach was in his chest. They nicked his esophagus. Got repaired. But he had a GE junction tear, so his esophagus is not connected to his stomach. I’m not making this stuff up. He’s got three chest tubes, a jejeunostomy tube, a Jackson-Pratt drain, and a nasogastric tube to drain that we are not to touch. They’re going to connect everything later. He’s on a vent. Fentanyl drip.

Bed Thirteen. Maria Leyba. Sixty-four. GI bleed. Cryptogenic cirrhosis. Came in through the ER. Third of four units of blood going in now. She’s a frequent flyer. She’ll be scoped today.

Bed Fourteen. Peter Richardson. Sixty-eight. Motor vehicle accident. Fender bender. Came in with right hemiparesis, facial droop, drift. CT showed a large basal ganglia tumor. He’s going for a biopsy today. He’s still a full code. There’s an abdomen in the OR. Four may be able to go. The ER is empty.”

When she leaves, Kate leaves the door open.

Sue is the day charge. “How many nurses do we have?” She bobs her head as she counts around the table. “Eight nurses, thirteen patients. I’ll be free. Who’s back?”

Assignments go quickly, as though at an auction. A hand lifted off the table, a nod. Lori pushes her chair back. “I had Seven and Eight.”

It’s between Kay and me. She looks at me. “I don’t care.”

“You decide,” I tell her. She takes Five and the admit. I get Two and Three.

Lacy is the night nurse. She has Sanchez. “This guy came to the ICU on the fourth. Yesterday. He was admitted on the second for shortness of breath. Went to the floor. Crumped. Sorry. Let me start over.” She looks at handwritten notes on a yellow piece of paper folded in half. “He was admitted to the floor, went bad, came to us, and got intubated. I’ve got him on propofol and fentanyl. He doesn’t do anything. We need one more sputum to rule out TB. I don’t know what they plan on doing. He desatted last night so we bumped his oxygen to seventy from fifty. He’s not making much urine. His creatinine’s climbing. He might need to be dialyzed. He’s got a femoral line. He’s got a big family and they’re all here in the waiting room. I think there’s a thousand of them. Good luck with that. Questions? I’m back.”

Nights are long. Some of the nurses sleep, in turns, on the one couch in the lounge, so in the morning the room has a trapped, tangy human scent, or they rest their heads on the white patient blankets on the roller tables where we chart outside the rooms. You can see a trace of their profile like a petroglyph. It must be a jolt at seven o’clock, the day shift coming at you like a car with its high beams on.

We call the bedside report a handoff. It can be good or bad. Things get left out, forgotten. It’s like you’re standing on one side of a crevasse and you have sand cupped in the palm of your hand and you’re going to pass that sand to a person on the other side. Every twelve hours this is done and what happens is that the sand slips through your fingers and there is less and less each time, like when they came in, how many days on the vent, you need to check all stools for blood.

I find the history and physical in the chart. It’s typed on blue paper. The progress notes are yellow. Everything else is white. Past medical history: diabetes, hypertension. Was vomiting blood—coffee-ground hematemesis—for two weeks, abdominal pain, 40 pound weight loss, positive cough and fever. Admitted to the floor with a differential diagnosis of aspiration vs mass vs community-acquired pneumonia vs TB.

And then the trapdoor in the floor of the hospital opened—respiratory distress, unresponsive, transferred to the ICU, gets intubated, they do a pulmonary angiogram to look at his lungs and the dye wrecks his kidneys.

He’s like a pebble crack in your windshield that spreads and spiders until the whole glass is shattered but still there and all you have to do is touch it and it will crumble into pieces. Because we’re ruling out TB, I have to put on a special face mask—it looks like a duckbill—before I go in. He looks much older than sixty. His flesh is loose on his body and thin like the skin of rotten grapes. Like it would rip if you touched it. The bones of his face are sharp under his skin and his cheeks are sunken. There is a creamy haze over his pupils. Cataracts. His pupils are pinpoint from the sedation. He doesn’t do anything when I pinch his trapezius or press my pen into the nail bed of his finger. He’s riding the vent. He’s on sixty-five of propofol. Propofol’s a sedative-hypnotic. We use it in the ICU because it has a rapid onset and a short half-life; you stop it and ten minutes later they’re awake. It’s white. It comes in a glass bottle. Some nurses call it the milk of amnesia. He’s completely snowed...

Table of contents

• Introduction
• 1 The Voyage into the Sea of Critical Illness
• 2 Diagnosis, Diagnosis, Diagnosis
• 3 Nursing Isn’t a Journey
• 4 One More Day
• 5 The Dream of Cure
• 6 Nursing: What It Is and What It Is Not
• 7 Caring
• 8 Medicine as Ghost Rain
• 9 Dying
• 10 Poetic and Tragic Murmurings of the Everyday
• 11 They Tell Us Everything
• 12 Can They Hear?
• 13 Leaving Ends the Love
• 14 The Horizon
• Epilogue
• Notes