Jack That Shit Up

                 

                 “Hey, how much morphine should I give my comfort-care patient?”

                The standard hospital dose for intense pain is 2 mg.

                 “Jack that shit up, man, run it fast, make him comfortable, you know?”

                 I didn’t know, which was why I asked. 

                “Hmmm.” I said. `  

          

                I went back into the room. Right now it was running at 2 mg / hr. while the dying man huffed like a gargling bear.

                I’d bolus-dosed the pump for about thirty seconds then stuck the bag with a syringe, pulled 6 ml and pushed it in the IV fast to cover any breakthrough pain.  Twenty dubious family members silently gave me the side-eye.

                The morphine bolus changed nothing. His limbs remained rigid, gaze locked downward, snoring rapidly through his bubbling saliva.  I taught the family how to suction his mouth then left and found another nurse.  “I just hung a morphine drip for my dying patient, what should I run it at?”

                 “If it was me, I’d jack that shit UP, put ‘em in la-la land”, they said in passing. 

                “OK”, I said and returned to the room, bumped it to 4. 

                The family watched in disapproval.  The doctor called, “How’s it going?”

                 “Fine.  We pulled the tube at 5:00. I started the drip.  Family’s all in there, quiet.  Some crying, not much.  Hey, how fast should I run it, do you think?”

                 “Fast.  Jack that shit up.”

                 “Well, I don’t want to… you know, kill them.”

                “Isn’t that kind of the point?”

                “Yeah, I guess.  I’ll bump it.  Thanks, doc.”

                “Thank you. This was a tough one.” 

                “Yep.”

                I returned to the room, shouldered my way through the mute crowd, turned the morphine to 10.  If 2 was normal, 10 would be pretty aggressive, right?

                It was odd that everyone said the exact same thing, like a standard dark-humor catchphrase when someone was actively dying.  We all knew there was a razor-thin line between ‘comfortable’ and ‘dead’ and no one wanted to put a number on that. All I wanted was a ballpark figure but “jack that shit up” gave me nothing.

                My job was to make him comfortable but the only way to tell the morphine’s effect was if he stopped breathing; if that happened too early in the process the family would freak.  They were irrational but they weren’t stupid.  They would make the connection between me tweaking the pain medicine and their loved one suddenly going silent; if they hadn’t processed their grief stages to ‘acceptance’ they might blame me for killing him.  They looked the type.

                I found my charge nurse.  “We withdrew on bed three.  Morphine’s running.  The order is to titrate for comfort – what should I run it at?” 

     “If I was dying I’d want you to jack that shit up, make me happy.  What’s he doing now?”

     “Breathing like a freight train, 40, 50 times / min., drooling all over the place.  I’ve got the family on suction, gets them involved.” 

 

     “What’s the morphine at?”

     “I’ve got him at 10.”

     “Oh god, turn it up!”

     “OK.  To what?  I don’t wanna just kill him, gotta ‘let nature take its course’ and all. How do I know he’s comfortable without shutting him down?”

     “Well, what’s the standard order if you didn’t have a drip?  Isn’t it a 10 ml bolus every 10 min.?  So run it at 60 and go up from there.”

     “Hmm. You’re right.  Thanks.”

                Shit.  He’s been under-dosed for an hour.  He’s been suffering for an hour! Of course I knew that about the injection dose – so stupid!  I squeeze into the room again.  It’s silent but for the struggling rasp.  My fingers fly over the pump’s buttons and the drip increases to 60.  The whir of the pump rises dramatically. I worm my way out, almost to the door when a defensive voice, tight with mistrust, asks me why I keep coming in.

 

     “What you messin’ wit?” Forty dark, angry eyes skewer me.

      “The pain medicine,” I say with confidence I do not feel. “I want him to be comfortable.  It’s what I would want if I was in his place.”  I smile and touch the questioner’s shoulder, part commiseration, part assurance that I know what I’m doing and while I appreciate his astute questions, he should trust me - I’m a nurse, for heaven’s sake!

                The shift changes, my relief comes.  I give report on the dying patient.  “How much morphine have you given him?” she asks.

     “I’ve got him on a drip at 60.”

     “Sixty!  You gotta jack that shit UP!”

                Sometimes I’m not sure I can do this anymore, that I should do this anymore.  I’ve been doing this for ten years and I have no idea what I’m doing.

My shit is all jacked up.