crash course.

For the record: the least of my problems is adjusting to night shift.

Sure, I don't really sleep as well during the day, but I also really never slept well at night, so things run about even. I now don't really sleep at night, but somehow, I'm finding this less problematic than last time I worked nights.

My first night off of orientation we had a patient come up from the OR basically dead, with a pH of 6.88 (incompatible with life, to say the least) an INR of 10 and blue and mottled. He'd already been coded four to five times in the OR and why they brought him up to be worked over some more was anybody's guess.

By the time we were done, there was blood on the bed, splattered on the floor and cabinets two feet away, and over our scrubs and shoes. Blood oozed out his abdomen as I did compressions. I've personally never been in a code that bloody before, but ICU veterans assure me that's not the bloodiest they've ever seen it.

Into the same bed, I admitted a cantankerous guy later on that shift, who was walking and talking (although quite ill) on admission but by that same time the next night was also for all intensive purposes, dead.

When I took him back the second night, I predicted the biggest thing all night I'd have to do is get him intubated, and after that, he'd be ever so much easier to manage. Of course he had the potential to tank, but even the most stable-seeming patient in the ICU can crash. I didn't think he was ultimately going to make it, but I did think intubation was going to give us some more time to figure out palliative treatment.

He wasn't so lucky.

By 11:30p.m. that night, he was mottled, purple, clamped down, intubated and his pH was in the toilet, along with his blood pressure and heart rate. And no one--not the MICU team, not the surgical chief resident, not the cardiology fellow, could figure out why he had dumped so badly, nor what the acute cause could be.

We spent the rest of my shift barely keeping him from coding, throwing lines in and bolusing him and almost maxing out his pressors. By the 0600 last-ditch-diagnostic emergency run to the CT scan, he was and had been so unstable I insisted the resident come down to CT with me (I'd already been down to OR for an emergent induction intubation earlier that night) because I was almost certain he was going to code and was surprised he hadn't yet.

At 0730 that morning, I was calling his elderly, frail mother to tell her she needed to come in and prepare herself because her son wasn't going to make it.

I left at 0745, having helped day shift set up for the code we knew was coming, and about fifteen minutes later, as I was on the bus riding home, thinking about that horrible phone call, he coded.

I was scared shitless the entire night, but eventually, I had to turn down that part of my brain that was insisting, "Run away! Run far, far away!" and get the job done. The charge nurse's patient started to crash, too, so after about midnight, I was essentially on my own, in a room full of docs unable to figure out why the patient had tanked so quickly.

At some point that night I realized based on his clinical picture, that he was eventually going to die, no matter what we did. It didn't make it any less scary or surreal, but it gave me an ironic determination and calm born of futility. When you're back is up against a wall and you have no choice, you can surprise even yourself at what you can do in a shitty situation.

Of course, there is no consolation prize for working to save someone's life when that goal is impossible. You feel like shit the next day. After all, I'd admitted this guy and developed a rapport with him. He was talking to me at the beginning of my shift, and by the end of it, he was almost dead. But, you also realize you can only do the best you can do, and some patients are so sick they are going to die whether they are in the hospital critical care unit or not.

I think the scariest thing for me was that I'd never had to manage a crashing patient without help. You can have all the orientation in the world, and nothing is quite like that moment when you're on your own, and your skills and quick thinking and ability to remain calm are the only things between what is often in an ICU not the patient's life or death, but "dying now or dying later."

It's a strange rite-of-passage ICU nurses go through, but the old cliche is quite true: there is only one way out, and that is through to the bitter end.