You are the project

I work steadily on your belly, applying paste under the sterile plastic wrap anywhere I think there might be a tiny leak. The suction catheter tucked inside gurgles away. We are so close now: all day, with each turn the fluid has poured from one place or another. We have changed your linens a million times over. Now we have a plan.

"The skin can fail just like any other organ," our wound care clinical nurse specialist reminded me as we finished up an hour long creative problem solving session at your bedside. I had just shown her your new pressure ulcer.

"It's our fault," I had said.

She eyed me skeptically. Outside, she reminded me about you:

You are 86. You've been living in a skilled nursing facility (SNF), i.e. a nursing home, for about six months already. You've been receiving nutrition solely by IV (total parenteral nutrition, TPN for short) all that time because your body is unable to absorb any nutrients from your gut. They think you have Crohn's disease but no one is too sure. TPN by itself puts you at increased risk for infection. For one thing, there's all that sugar flowing through your central venous catheter 24 hours a day. Bugs love that. Plus, you miss out on all the immune system activity that is normally stimulated by activity of the gut.

You've been spending most of your time in bed since well before your admission to our hospital. A chronically ill 86 year old who is spending more that 50% of his time in bed is unlikely to live more than about two more months.

Then there's the giant abdominal wound you have, thanks to the surgeons who thought an exploratory laparotomy was a good idea when the nursing home staff brought you to our ER with low blood pressure, a firm belly, and increased lactate level in your blood. You've been to the OR 4 times so far, and you will go back again. They have removed your entire colon. The first ileostomy never worked, so they took that down and now you have that cavity, there on your right, about two inches deep that wells up continuously with warm, pinkish fluid. On the left is the newer ostomy. It looks like it might be a keeper.

In our institution, any surgical patient over 80 is an automatic nursing referral to a dietitian, and for good reason. Surgery is a major insult to an already weakened being. The reserve is low.

We turn you religiously, painstakingly positioning your every part. We float your heels, check your many lines, tubes, and wires to ensure they're not pressing into your skin. Still, you break down in areas where we can't completely eliminate pressure. Your skin also has stretched, blistered, and split open from the liters of fluid we poured in to keep your blood pressure up. It didn't stay long in your blood vessels without much protein to hold it in, creeping instead into the spaces between cells and blowing you up like a balloon. Once open, your skin erodes quickly and steadily.

The constant pouring of liquid from your abdominal wounds doesn't help, either. Skin hates to be wet, this is why TV ads pitch high tech diapers to moms and dads.

Back at your bedside, I put down the paste. I have been working intently, so focused. I look up at you from my project, and you are still there, eyes open. I see the tears that come out and roll down your right cheek sometimes. I bolus you with extra pain medication, hover close to you and stare into your eyes, wondering what they are saying. I don't know how to apologize. I can't. I try anyway.

What was this surgery for, anyway? They thought you really wanted a few more great months in the nursing home?

During rounds, I stand firm when the surgery team wants to decrease your pain medication so you might be more awake. I describe your tears, your deer-in-the-headlights look. They relent. I describe my interactions with your family members, offer to facilitate a meeting to discuss "the plan." They agree in words but don't commit to anything concrete. They tweak your antibiotics based on your latest cultures, and move on.

I return to my project.