death becomes her

11 p.m., I picked up an elderly ECF patient, whom I dub "Actively Dying Woman."

OFF SHIFT NURSE:

She's full DNR (do not resucitate); I think she'll be dead by the end of the night.

JAMIE:
Score. Oh, well, that's nice. I haven't done post-mortem care in a long time.

OFF SHIFT NURSE:
[looks mildly disconcerted by my irony]
Continues with report, highlights of which included:

Rousable only to painful stimuli (remember learning "the sternal rub" in nursing school?) Foot drop, possibly bilat hip fractures untreated. Otherwise had lungs wetter than a Florida swamp (I call them "Darth Vader" respirations). Looking at her breathing, you'd almost expect her to start blowing bubbles out her mouth, her lungs were so rhonchrous.

Troponins positive for MI, in CHF (congestive heart failure) with a BNP (CHF indicator) >2000. Tachy in the 110s-130s. BP holding, but probably compensatory. Potassium 7.1 on ER admission, redraw 6.7 (basically incomptable with life. No treatment for the potassium level, but they sent a urinalysis. (What, in case she's uroseptic, too, so we also won't order antibiotics?!) Foley'ed and putting out insufficient amounts of tea-colored urine. Diuresed with Bumex and Lasix X1, but no daily orders for diureses.

In fact, no orders, period, other than an aspirin suppository and a Nitro gtt.

JAMIE:
[diatribe welling up]

Uh, what's the stupid nitro drip? It's not like we're cathing this woman, or something. Isn't that kind of a waste when her potassium is 7.1 and we aren't treating that, either? And what's with sending a urinalysis?! And the aspirin suppository?! For what, a headache? MI prophlyaxis?!

OFF SHIFT NURSE:
I know. It's totally ridiculous.

JAMIE:

Does she have comfort measures ordered? What if she starts really crapping out and goes into major respiratory distress while she's dying? What about scopalamine, or a morphine gtt?

OFF SHIFT NURSE:
Nope, no orders for any of that. You'd have to call the doctor.

JAMIE:

Man, who wrote these fucking orders, a monkey with a typewriter?!

Other notable characters in the ensemble of Crazy Crackers Hospital Acting Troupe:

1) Hydroencephalatic Hemodyalsis Woman, with the Angry Family who needed 1/2 an hour of coddling and case management.

2) Post Cath, CHF "Sputum" Guy, who I found at 8p.m. desating to 60% on 2L NC post cost, throwing PVCs and PACs despite having stable electrolytes. Fun with suction! Fun with doctor paging! Fun with respiratory therapy, whose completely unhelpful intervention was to say, "He looks fine to me" and then disappear! Fun with stat CXR! Fun with annoyed, pissy patient, who, in his hypoxia-induced anger, "Just wants to eat!" despite hawking up voluminous loogies every 15 seconds that could be heard with the door closed, 100 yards away at the nurse's station. All. night. long.

3) Pneumonia Lady, with left sided flank pain, unresolved nausea, vomitting and diarrhea unrelieved by current med orders. More fun with doctor paging! More fun with, "May I please have an order for Reglan and fluids with potassium repletion?"

4) Other Actively Dying Lady, who had been refusing all her po meds all day and was clearly giving up the will to live.

Rock on!