Recipe for a bad day

For the first time in more than a year, I have had a bona fide bad day at work.

It's rare to have a truly bad day. I mean, the day the medication dispenser went down and I couldn't get antibiotics for a patient with fulminant meningitis was pretty bad. The day a patient's family member assaulted me was pretty bad. And yesterday was pretty bad. Three in three years, though, is a good ratio.

Start with a pimple. Put it somewhere sensitive, like between your upper lip and your nose, and make sure that it's painful. It doesn't have to be big, or noticeable, or ugly, but it does have to be painful.

Then, when you wake up, make sure you're not feeling up to snuff. Something must've blown in on the wind night before last, because when I woke up yesterday, every cell in my body was poisonous to every other cell. It felt like a hangover without the alcohol.

Add one patient who seemed determined to seize, code, and die. Before 8 am.

He'd come in with a particularly nasty aneurysm that was snuggling up against his brainstem. Three hospitals had told him the thing was inoperable, but we figured we could either go in through his basilar or femoral artery and at least coil the thing. Turns out that genetic roulette had cursed him with arteries so torturous that we couldn't get to where we needed to be remotely; we had to go in and clip the damned aneurysm in an open surgery.

Which was a success, and not just in the "the operation was a success, but the patient is now trached and tubed and gorked" sense. It was a success in that he could move everything better when he came back than when he left, he knew where he was, and things were looking up.

Until that seizure. I didn't see it; the aide was feeding him breakfast and, for a split second, thought he was choking. She wisely yanked the emergency cord out of the wall and we all converged on the room. By the time I got there, the patient was already post-ictal and nonresponsive even to pain, but with a blood pressure in the high 200's.

And respirations of less than eight a minute. And a number of other little quirks that made the aide roll the cart down to the room, just in case.

I'll spare you the details of labetalol, large-bore IVs, and external pacing.

His daughter, when I called her, immediately asked me if the seizure was a result of her not coming to visit the day before. Yes, she's one of *those*. I went with the resident when she went in to see Daughter and tell her what was up with Dad; I figured somebody had better be there to stem the tide of hysteria and keep the resident from getting stuck in the family room. And yes, it was just as bad as you might imagine. Thanks for asking.

Shortly after I got him to the ICU, I got sent to another floor. Not because of my skill in keeping other people from going to the light prematurely, but because of staffing issues.

I was immediately presented with two patients fresh out of the unit after inguinal lymph node dissections and assorted other things. One guy had had a penectomy (yes, that is exactly what you think it is) for cancer; the other had had his bladder removed for the same reason. Urology is okay, it's interesting and fun, but I hate cardiology.

So when Mister No-Bladder Person started throwing PVC's (this is a very bad thing) in couplets and triplets and generally making the monitor sing pretty songs, I started hating things. A dose of IV metoprolol regulated his rhythm and made me hate things less...until his blood pressure started rising. And rising. And rising some more.

It came down after forty milligrams of hydralazine. To 185/100. An improvement, but not enough of one. So here we go again with the bleeping labetalol and the monitor going nuts and now the patient is sundowning and trying to get out of bed, uncapping drains and yanking catheters and generally being difficult.

At some point in the middle of all of this, Chef Boy called with the news that his gate had blown open and his Dachshund was somewhere in the city, wandering. Somehow this was my fault, he implied in a snarky voice mail message, even though *he's* the one with the house and the gate.

Did I mention the particularly painful and distracting pimple? I thought so.

Finally things calmed down. Mister No-Bladder Guy got his Haldol and went to sleep. Mister Penectomy Guy quit sending his obnoxious wife out to the station with demands for more pillows (you have eight in the room; how many more do you need?) and I got his potassium running and his blood sugar (480) dealt with.

Just then somebody asked me when my baby was due.

I'm not pregnant.

Yesterday was an actual, real-life, nonstop Bad Day.