Wednesday, December 31, 2008

My Code (final post)

I go outside of the room to look for the flowsheet. Mrs. Wilson arrived at 11:00 am and it is 5:00 pm now and I have not had time to write down a single vital sign. The charge nurse comes by and we turn to look at Mrs. Wilson’s monitor as her blood pressures go soft and her heart slows. “She is coding again,” I say. “Stop saying that!” he says, but her pressures keep falling and her heart slows to a stop. We call for help, I take up position by Mrs. Wilson’s IV access, chest compressions are started. Maria comes and looks at me, waiting for a task. I make a gesture of writing in the air and she takes up the code documentation again. The charge nurse calls for the second code cart; we have used up all of the meds in the first one (the unit has two for 16 patients).

The code gets up to full speed. One of the nurses asks how many times we are going to do this. “Someone needs to bring the family!” I call out. This time my words find purchase. Eyes turn to the fellow. The rest of the team does not know about our conversation. Will she take this as a challenge to her authority? There is a moment of tension in the room. “It’s alright, go get the family,” she says to one of the techs quietly but audibly. The tech leaves the room immediately. We resume the code. In a minute the daughter returns. Right away, she starts saying “No, no, stop this, stop this.” With a signal from the fellow we stop. There is no heartbeat. Mrs. Wilson is dead. The daughter weeps. One of the nurses turns off the IV pumps. The respiratory therapist turns off the ventilator. The room clears out. The daughter leaves to tell the other family members.

My work is not done. It is time to prepare the body for viewing. Another nurse and I fill three garbage cans with used sterile drapes, packaging, empty syringes etc. Two laundry bags are filled with bloody sheets. I suction the drool from Mrs. Wilson’s swollen, lifeless face and wipe blood from around her mouth. The breathing tube and other lines need to stay in place in case the family decides they want an autopsy, but I remove what I can. I turn off the hissing suction at the wall and toss the canisters, half full with blood and mucous, into the trash.

I want the body to look as natural as possible. A small IV on the inside of Mrs. Wilson’s elbow catches my eye and I decide to pull it. It is a mistake though; blood pours out from the puncture and does not stop. I put a piece of gauze on the site and fold her arm over it to contain the bleeding. We put a fresh sheet over the body, up to the chin, and I leave Mrs. Wilson’s other hand uncovered incase someone wants to hold it.

The daughter returns with two younger siblings, but the site is too disturbing for them. The daughter asks if the tube can be taken out of her mother’s mouth. I explain about the autopsy issue and she brushes it off. “We do not want that.” I find Dr. Lew speaking with some other doctors outside of the room and tell him. I expect the customary resistance to the proposal, but Dr. Lew readily agrees. Maybe he does not want an autopsy either. I am disconcerted. What if the family regrets this later on? I reason with myself that if they want to pursue some kind of legal action that there will be plenty of information to work with in any case. I decide not to disturb them with my concerns and I tell the respiratory therapist that the family wants the tube out and the doctors are okay with it.

I return to the room and tell the family that the respiratory therapist is on her way. I disconnect the breathing tube from the ventilator circuit in the hopes that it will look a little better that way. The family is already on their way out though. A frothy pink foam starts making its way out from Mrs. Wilson’s lungs and dropping onto the bed. I am glad that the family did not stay to see this.

As I start to work on taking down the network of IV tubing from the pumps, a young doctor comes into the room. He must be the neurosurgery resident. It is as if he is trying something out on me as he starts saying things like, “She was doing well when we brought her down here. How could I have missed the early warning signs?” I am not having any of this though. Without looking up I say, “She was critically acidotic from 6 o’clock this morning.” This silences him. By now I have decided not to bother separating the IV tubing and I am cutting though the tangles with a scissors. Some of the lines have not been clamped and I tie the ends off to stop the fluids from pouring onto the floor. This kind of cutting could never be done in life and watching it seems to drive things home for the resident. Mrs. Wilson, a reasonably healthy middle aged woman, walked in for an elective procedure yesterday and now her body lies before him dissected and dead. The resident mutters loudly “Shit!” and exits.

The tube is out. The room is clean now, save the overflowing trashcans off to one corner. I turn the lights down and go to the waiting room to invite the family to return. At first I am not sure if they will come back again or not. After a few minutes the daughter returns with her younger sister. They are in the room alone together for only a minute. As they leave the younger sister is crying, “It does not even look like her!” I try to imagine what Mrs. Wilson’s face must have looked like in life.

It is 6:30 pm now. Finally, I sit down to write my nurse’s note and chart vital signs. Another nurse asks if I need anything and I ask her to print out the record of Mrs. Wilson’s vital signs so I can copy them to the nursing flowsheet. The computer data is not saved. The nurse returns looking nervous that I may become angry and informs me that the computer data has already been deleted. The asystole (no heart beat) alarms go off every two minutes until the patient has been discharged from the system. Discharging the patient erases the data. People usually ask the patient’s nurse before doing it, but not everyone knows what to do. Anyways, it does not disturb me. Maybe I am braver or more foolish, but I just do not see this being a problem for me even if something legal happens with the case. The code documentation is there and I put in a few estimated vitals from memory. I write an explanation in my nurse’s note along with a summary of the day’s events.

My shift is over now. I was tired at the beginning of this day, and now a peaceful sort of exhaustion is taking hold of me. I ask the night charge nurse if it is okay if I leave the tagging and bagging for them. Everything else is done. It is okay.

I get a few pats on the back as I am leaving. I think that calling for the family during the third code was particularly appreciated by the other staff. “I know you make more money as a floater, but you should come and work with us,” says one of the techs, a black woman with whom I have had some friction in the past, “We need more men here.”

Thursday, December 25, 2008

My Code (continued from previous post)

Dr. Lew has cut through to Mrs. Wilson’s abdominal cavity now. A clump of fatty tissue, the size of a squashed loaf of bread, is removed and placed to the side exposing the intestines. Dr. Lew probes with the suction, looking for pockets of blood. He sucks out 2 liters, but they had been expecting more. Through a translucent membrane at the bottom of the abdominal cavity we can see a large pocket of blood that has collected in Mrs. Wilson’s thigh (where the catheter was inserted for the original procedure). The doctors decide not to go after it. We have not found the cause of Mrs. Wilson’s decline here. “How is her lung compliance now?” Dr. Lew asks the respiratory therapist. “It is much easier to bag her now,” she replies. At least we have taken some pressure off of her lungs.

As the young doctors gather round, Dr. Lew rummages hand over hand through Mrs. Wilson’s guts like a boy digging in a sandbox. He takes her large intestine in his hand and shows his students the areas that have been denied blood flow – “this area is normal… this area may recover… this area will not recover and will need to be removed, but we will come back and do that later.”

As they finish, Dr. Lew takes sterile towels moistened with saline, lays them across her intestines, and tucks them in around the edges of the incision (an opening about two feet long and one-and-a-half wide), “so she does not eviscerate while being turned.” A plastic vacuum dressing is then applied and attached to the wall suction unit with plastic tubing. A steady trickle of pinkish fluid begins making its way over Mrs. Wilson’s shoulder on its way to the canister on the wall.

The whole procedure is over in less than half an hour. My dreamlike feeling returns as I watch the OR nurses counting out their instruments, making sure nothing has been left behind. “5-6-7 of this kind of clamp I have never heard the name of before, 5-6-7 of that clamp,” etc. I conclude that OR nurses are entirely different creatures from unit nurses. These two middle aged ladies are cool, calm and collected. As they focus on their work, they seem to see only an operating room around them. The OR must have sent their best.

Mrs. Wilson’s blood pressure has remained high throughout the procedure. I have been slowly backing down on the pressors and her systolic pressures are now below two-hundred. I have not had time to check orders since the code, what to speak of documenting vital signs. Labs must have been ordered after the code. I draw the blood from Mrs. Wilson’s arterial line and hand the tubes off to another nurse who labels them and sends them to the lab through the tube system.

Mrs. Wilson maintains for the next half hour or so. The charge nurse asks me how she is doing now. “She will code again soon.” I reply. “Don’t say that!” he says, but I need him to know I will need him to stay around. The fellow hangs around also, catching up on other work on the computer just outside the room.

The first labs come back just as Mrs. Wilson’s blood pressure drops out and her heart slows to a stop again. Her blood PH is still below 7. I call for the fellow and the charge nurse, max out the pressors on the IV pumps and take my position at the head of the bed where the IV access is. I lay out saline flushes and use them to chase the code drugs in. Maria, he nurse who was pushing the meds last time asks me if I want her to do it again. I shake my head and ask her to fill out the code documentation. The charge nurse continues to assemble the syringes of code drugs and hands them to me when it is time. I call out, “Epi is in, Atropine is in, Bicarb is in.” as I push them. Maria writes it all down. I call out, “Her PH is 6.97,” again, but it falls flat again. Compressions go on, the bagging goes on, more liter bags of saline are hung on pressure bags and infused wide open. After another ten minutes we get her back again.

The room clears out again as Mrs. Wilson holds her blood pressures of over 200 again for now. Soon it is just me and the fellow in the room. “What do you think is going on?” she asks. “I think her acidosis is stopping her heart and that it is also causing massive tissue death which is feeding her acidosis in a viscous cycle,” I reply. She seems to agree. I had assumed the doctors were on top of this, but I begin to wonder if I was wrong. “So what do we do?” asks the fellow. “Well, I think the bicarb is what is bringing her back, but it is only going to be temporary. She is going to continue to code. I think you need to talk to the family.” She agrees. I suggest turning the bicarb drip up to buy time. She agrees to that also and I turn the rate up to one liter an hour.

Soon the fellow and the Mrs. Wilson’s daughter are in the room talking. I go to a computer to check orders and to give them space. From the hallway I hear the daughter, who appears to be in her late twenties, protest, “What is going on here!? First they told me her heart had only stopped for a minute and now you are telling me it was stopped for ten minutes! What is happening here?” The fellow must be telling her that there has probably already been a lot of brain damage and that it might not be the best thing to continue trying to save her.

The fellow leaves the daughter in the room. I go in to check the pumps and clean up what I can. Mrs. Wilson’s body is covered with a sheet to hide her incision. “Oh Mom,” says the daughter, her voice cracking a little, “I’m sorry I did not come around more.” She asks if pink fluid in the suction tubing is coming from the procedure that was just done. I tell her that it is. She stays for a few more minutes in silence before returning to the waiting room.

To be continued.

Friday, December 19, 2008

My Code (continued from previous post)

The nurse who was taking care of Mrs. Wilson in the Neuro ICU seems a little reluctant to leave, but she tells me what she needs to and goes. I keep busy getting the room organized. I am still getting acquainted with the tangles of IV tubing when Mrs. Wilson’s blood pressure drops out and her heart quickly slows to a standstill.

I call out for help and the room is soon flooded with staff. The code cart arrives and a nurse opens the drug drawer and begins screwing together the syringes of epi, atropine, bicarb, etc. I am with the IV pumps, on the opposite side of the bed from the IV ports that need to be used for pushing the code drugs, so another nurse starts pushing the drugs the doctors are calling for while I increase the doses on the drips that are already running. The epinephrine drip was already over the suggested maximum dose. Following the doctor’s instructions I max out the levophed as well. Mrs. Wilson is a big lady, so two of the techs perform chest compressions in tandem – one on each side of the bed pumping in unison. The respiratory therapist takes Mrs. Wilson off the vent and uses an ambu bag to ventilate her by hand. She says Mrs. Wilson’s lungs feel stiff. The nurse documenting the code keeps track of the timing of the doses of code drugs, calling out every two minutes when another round can be given. I call out to the room that Mrs. Wilson’s PH is below 7, but it does not seem to register. The pumps are now taken care of and I am feeling uncomfortable that I do not have an active role in the code any more. It is my patient. I should be pushing the drugs. It is like someone else is doing my job for me. The other nurses may feel I am not up to the task. Nothing to do now but endure it though. We keep pushing bicarb every two minutes. That should help if anything can.

We keep going for ten minutes or so. Suddenly Mrs. Wilson’s heart starts to beat 120 times a minute. Her blood pressure shoots up to the 230’s. The chest compressions have pumped the code drugs to her heart apparently and it has resumed its function. There is still no pulse-ox reading. Everyone stops and watches the monitor for a few minutes. When it becomes clear that the rhythm is stable for the time being, the room begins to clear out. One of the doctors tells me to start backing down on the levophed, but I do this conservatively. He seems to think she will be fine now, but with her low PH I am not so confident.

Soon word comes that the surgeons will be performing an operative procedure on Mrs. Wilson. They will do it here in the room since she is too unstable to transport to the OR. A team of nurses will be arriving from the OR shortly. I am to get the room and the patient ready.

It is just me and Hal in the room now. I pace up and down the room trying to clear space and do anything else I can think of while repeating out loud to Hal, “This is beyond my experience. I have never done anything like this before.” Eventually Hal replies that he has only seen it a couple of times himself. Apparently what mainly needs to be done is to pack absorbent pads under the patient’s body so that the bed does not become entirely soaked with blood. I help Hal get the pads tucked in from mid thigh to mid chest on both sides. They will be opening Mrs. Wilson’s belly.

Someone calls in that all the OR nurses need is an extra suction set. The charge nurse has been staying nearby and he goes of to get the supplies. While he is gone, the OR team arrives. Two OR nurses wheel in a cart full of instruments and begin to set up shop. They ask about the suction and we tell them it is coming. Dr Lew, the attending, will perform the surgery. Suddenly the room is full of doctors. The residents and interns will watch. A new fellow is also in the room. She ran the code, but her background is apparently not in emergency surgery. The attending jokingly invites her to do the surgery and she puts up her hands and takes a step backwards. Maybe by the end of the year she will be ready.

There is a dreamlike sensation for me as the world of the OR, which I have never really seen before, now invades my room and my territory. Standing at the side of the bed, I watch as Dr. Lew, who I have worked with before but never seen in surgery, takes a scalpel and makes a deep incision from just below Mrs. Wilson’s sternum down towards her navel. A faint smell of barbeque wafts through the room as Dr. Lew uses an electric cauterizing probe to stop any bleeding. We have the suction set up now, but when we hand the end of the tubing to the OR tech he barks at us, “This is not sterile tubing!” We stammer, ashamed “All…All we have up here is clean tubing…” One of the OR nurses has an idea and cuts the one section of sterile tubing they have brought with them in half. We use a connector to hook it to our tubing and the OR nurse gets the suction into Dr. Lew’s hand just a moment after he reaches for it for the first time.

I am pushed out of my bedside spot by a surgical resident who feels more entitled (fair enough), and I find myself standing in the second row, next to the fellow. As we observe Mrs. Wilson’s dissection, a thought occurs to her. “Have we given any anesthesia?” she asks me. I look into her eyes and shake my head slowly. For just a moment we both shudder, but it passes quickly. You would not, could not give such an unstable patient anything that might have a depressing effect on her physiology. Besides, Mrs. Wilson is not moving a muscle. She has been as still as a stone since she came from Neuro.

To be continued:

Sunday, December 14, 2008

My Code

There had been a question as to whether Hal (another floater like myself) or I would take the patient that was coming down from the Neuro ICU. I was assigned the empty room, but Hal, who was both more experienced and better known to the nurses on the SICU, had initially been given the patient and had taken report by phone already. I do not know what kind of calculations went on, but it was decided that I would take the patient after all.

Hal sat down with me at a computer and pulled up the patient’s chart. As we looked through her labs, Hal told me her story: Mrs. Wilson had come to the hospital for treatment of a brain aneurism. A catheter had been inserted at her groin and passed all the way up into her brain. When the aneurism (an out pouching of the blood vessel) had been reached it was “coiled” or filled with some kind of springy string (that is what it looks like in the pictures anyways). This had gone smoothly, but when the surgeons had tried to treat another aneurism they had found just past the first one, they “lost the coil” (in Mrs. Wilson’s body) and she had been spiraling down since then.

The exact cause for Mrs. Wilson’s rapid decline had not been determined, but she appeared to be going into multiple organ failure. She was coming to SICU to be started on continuous dialysis for treatment of a metabolic acidosis. Hal and I looked at her blood gasses (labs that show blood oxygenation, PH, etc). The metabolic pathways of the body require a slightly alkaline environment. Normal PH is 7.35-7.45. Anything below 7.20 is generally considered critical. At 7.0 the heart will stop beating.

It was 11:00 am. At 6:00am Mrs. Wilson’s PH had been 7.06. The latest blood gas had a PH of 6.98. Mrs. Wilson was about to code and die. “They should not be transporting her, they should code her there.” I say. Hal and I discussed what was going on. The neuro ICU is generally slow and they do not generally have a lot of codes. Perhaps they did not feel up to it. It is an ICU though and they should have been able to handle it. A nurse could be sent from another unit to help them with the continuous dialysis machine if they were not comfortable with it. Perhaps the doctors were trying to spread the blame. Mrs. Wilson would die under the care of General Surgery instead of under the Neurosurgery service.

The charge nurse, Mark, headed into the empty room to make sure everything was set up properly. “What is going on with that neuro patient?” “It is a dump, (on us by Neuro ICU), she is about to code.” Hal concurs “It is a dump,” he says. We will need backup.

Mrs. Wilson arrives with an entourage of two nurses, a neurosurgeon, a respiratory therapist pushing a ventilator, and a tech pulling two IV poles packed with at least 6 IV pumps - all running fast. Her blood pressure is low, her heart rate high, but the levels are alright for the time being. There is no pulse-ox (blood oxygenation) reading. We rush to get her settled in the room. I check Mrs. Wilson’s IV access. She has a central line in her neck and one on each side of her groin. There is a femoral arterial line also. I make sure I know which is which. There is no dialysis catheter. One will need to be inserted before she can get dialysis, if we ever get that far. I find the IV ports I will use for injecting the code drugs and another two ports that will be used for fluid boluses and blood products when they are ordered.

I turn to the pumps. Dobutamine, Levo, Epinephrine, (pressors for low blood pressure) all running near of above maximum allowable doses. At normal doses, a bag of these drugs can last a couple of days. These bags will need to be changed every couple of hours. I check to see that they have brought me spare bags. They have. Sodium bicarbonate is hanging. It is running at the standard rate. It is used for treating acidosis, but it will be like a garden hose on a forest fire at this point. I make sure there is a spare bag. Still no pulse-ox reading. No way to know if she is getting air or not. The mechanical ventilator is on high settings with 100% oxygen. That will have to do for now. Epinephrine causes vaso-constriction and can shut down peripheral circulation. The pulse-ox reads from peripheral circulation, so we may be out of luck. We can send blood gasses to the lab instead – it just takes half an hour or so to get the results back.

To be continued:

Sunday, December 7, 2008

If All You Have is a Hammer...

“No open heart patient, especially a fresh open heart, dies in this unit with a closed chest - that’s our motto.” This is from my orientation tour by an assistant nurse manager of another CTICU (Cardiac / Thoracic). She was pointing out which code carts were equipped with “chest trays.” I have not seen this so far, but a chest tray will be including some kind of scissors for cutting the sternum and an instrument for spreading the ribs. The idea is to have quick access of the heart in case a complication develops after surgery. The motto is about the ones that die. You can add something like, "whether there is any chance it will help or not," if you like. It is there silently already.

“When all you have is a hammer, everything looks like a nail.” That is my motto. I have noticed that all codes are not equal. In MICUs (Medicine), the codes are generally chemical codes – the doctors look at the patient’s labs and inject drugs to try to get the heart going and to correct any imbalances that may have caused the problem. I favor these over the other types because the doctors are more able to determine whether or not there is any point in continuing. MICUs tend to have the highest mortality rates in their hospitals because they get the endstage, inoperable cases. When death is expected, there is less need for dramatic gestures or heroic attempts.

In case my readers are not aware, I should mention that the statistics for meaningful survival of a real code are dismal – like why do we even bother dismal, maybe we are doing more harm than good dismal. By “meaningful survival” I mean a return to anything approaching normal consciousness and by “real code” I mean when there has been full cardiac or respiratory arrest. If memory serves, it is under 5% of those who are “saved” who ever leave the hospital (just like on TV).

In SICUs (Surgical) the surgeons seem to feel compelled to open the patient’s belly. This makes the least sense to me of all the interventions, but I gather they are looking to release pressure that may be constricting the lungs and for bleeds. I have seen this done a few times with no impact of the final outcome.

Trauma ICUs seem to favor chest tube insertion and their codes tend to go on and on. I saw one where the patient’s heart was stopped for fifteen minutes. We finally did get it going again, but what was left after that I would not care to speculate. After the code the charge nurse, Matt, gathered the rest of the nurses on the unit in another patient’s room to debrief. This is the only time I have seen this, although it really ought to be done after every code. I guess Matt was trying to seize the moment, but the choice of venue was unfortunate. The patient was totally out of it, but a relative was visiting. Matt had his back to the family member, who was standing just behind him. I have often wondered if the Matt realized the family member was there or not. The woman was so close to him, it is hard to believe Matt did not know. Maybe he thought it was another nurse.

Matt asked if anyone saw room for improvement. Not wanting to be too obvious with the visitor right there, I held out my arms and pantomimed ineffective chest compressions. Two male nurses and two female nurses had been doing the compressions. The patient had an A-line, so you could see the blood pressures they were generating. The men were generating systolic pressures in the 60s, which is pretty good for chest compressions, but the girls were only going through the motions, not even putting their weight into it, and they were not generating any pressure at all.

If you are wondering, I did not say anything during the code. I was just there for the day and the attitude was that trauma nurses were better than anyone else. Matt had been in there (he was one of the men who had given good compressions) and if he was not saying anything there was no place for me to. I was glad of the opportunity that came with the debriefing, but Matt just nodded and acknowledged, “The chest compressions,” without elaborating. Apparently he did not feel up to confronting the girls either. He moved on, listing his observations.

We had taken too long to put the back-board under the patient (this gives a solid surface to do compressions against instead of the bed mattress), and we had taken too long to bring the chest tube insertion tray. I watched the discomfort grow in the expression of the family member.

It had taken about ten minutes for the chest tube insertion tray to show up. The fellow who was going to do the insertion had called for it repeatedly with mounting frustration. Apparently it had not been in the usual place, but the task had also not been properly assigned and no one had taken ownership. Matt tried to put some gentle pressure on the nurses to do better next time, but the nurse who had brought the tray in the end felt accused and became defensive. Matt met her forceful renditions of various versions of “It wasn’t me!” with versions of “I am not trying to assign blame, we are just doing this so we can improve…,” but the nurse could not back down and the debriefing unraveled. The family member now seemed even more unsettled, but had no one to talk to. We disbursed and went our separate ways. I guess that is why we do not do the debriefings more often. Too much headache.

Sunday, November 30, 2008

Waiting for a Miracle

At a glance, Mrs. Brown did not look so bad. Something about her face seemed odd, but the breathing tube distracted from that. Her body had no open wounds or oozing punctures. It was not blown up with fluids and there was no foul smell. Everything looked normal, but the first touch told a different story.

I touched her wrist to feel her pulse. It was like touching a piece of wood. Mrs. Brown had advanced sclera-derma, a progressive disease that causes the gradual thickening of the skin. It was as if she were made of wax – frozen fingers, elbows, knees. There could not have been much blood circulation. I do not know how the tissues remained intact. I looked more closely at her face. It was as if she was wearing a mask or even as if she had been dead for a couple of days already. Her lips were dry and leathery, her cheeks flat, frozen and tight. The disease attacks the internal organs too, thickening, stiffening. Mrs. Brown could no longer breathe on her own and was therefore in the MICU for ventilator management. She was fading fast and was on IV pressors to keep her heart beating.

As I took care of her through the day, the opinions were all equivocal. She would not last long; hours to days. The family took everything in, nodding quietly. I explained the basics of the ventilator to them, letting them know the implications. Her brother listened intently, but seemed to be drawing his own conclusions inside.

As I left the hospital at the end of my shift, I met the brother again in the parking lot. “Is she getting better?” he asked. After all that had been explained to him, I was surprised at the question. I told him gently that she was still declining. “It is really not too soon to start thinking about when you might want to say enough is enough.” The brother thanked me politely and headed back into the hospital. I went home feeling the family’s strangeness was deeper than I had first thought.

The next day in group report we heard that Mrs. Brown’s condition had continued to deteriorate through the night. Her final code was expected sometime during the next shift. I requested the assignment again. As I approached her room I heard an exchange between the night nurse and the resident. “She is not oxygenating. You are not going to be able to do anything for her,” said the nurse. “But the pulse-ox is reading 98%,” protested the resident. “Listen, I can make it read whatever you want it to,” replied the nurse (he had presumably rigged it to read high so that he would not have to listen to alarms all night. You could not really get a proper pulse-ox reading on Mrs. Brown).

A little later, another resident called the family. “I really feel that all we are doing is prolonging her suffering now. Please let us stop.” I have never heard a resident be so direct, before or since, but the call ended with the resident frustrated and disturbed. “I am sorry, but we cannot do that,” was all she could get out of them. I have seen a devout catholic woman with brain cancer spend her last months in a deep coma while the family refused to withdraw care out of religious conviction, but this was something else. This Mrs. Brown’s family seemed to believe that she was going to get better somehow. I contemplated and in my mind saw the family sitting on Sunday in church as the minister went on about God’s miracles and Mrs. Brown. It is all speculation of course, but I do not have another explanation.
On rounds the doctors discussed Mrs. Brown’s predicament. There was nothing more to do. The family was not coming. When the time came to code her we would push epi and atropine to show a response, but we would not do more than that. It was so clearly hopeless; there was not much need to make a show.

Mrs. Brown must have heard them somehow. As the doctors moved on to the next patient, Mrs. Brown’s heart stopped. Maybe she was waiting for her family to show up and gave up when she heard they were not coming. They did not come after she died either. The resident called the family to give them the news. They hung up on her. A few minutes later they called me to ask about her condition. “Mrs. Brown has expired.” (CLICK). She let them down I suppose.

We tagged and bagged the body and pushed it on the stretcher through the old tunnel to the old elevator and rode up to the 11th floor - the morgue, or as we liked to call it, the MICU annex.

Friday, November 21, 2008

How to read an X-ray

I had been off of orientation for a month or two in the second MICU I had worked in. Early on in the shift my sepsis patient crashed and needed to be emergently intubated. Everything went smoothly. As the doctors wrapped up, one of the senior nurses on the unit said what I was thinking – “Aren’t you going to put in a central line? This patient needs access.” The doctors were unmoved. They wanted to get back to rounds.

Central lines are IVs with multiple ports which are placed directly into the large veins leading to the heart. They are much more reliable and secure than peripheral IVs, which can become dislodged at any moment. In a code situation it is vital to have good IV access so that any drugs, blood products, or fluids can be administered quickly and effectively. In the MICU where I started you could pretty much take for granted that any patient who had the slightest potential to become unstable would get a central line right away. In this new hospital however, there was a push to minimize their use because of the increased risk of infection that comes with insertion and maintenance of the lines.

Even taking the hospital initiative into account, I was unhappy that the doctors were not taking the need for a central line seriously. With the commotion of the intubation my patient’s blood pressure had gone up, but I had seen this before and was concerned that this would be short lived. If his blood pressure fell too low, he would need pressors. I had been trained never to infuse pressors through peripheral IVs. If the medicines leaked into the surrounding tissues at the IV site, the powerful vasoconstricting effects could cause severe damage to the pateints limb. I watched as my patient’s blood pressure slowly dropped towards dangerous lows. I needed to act now while there was still time.

I went to the doctors as they rounded on other patients. I was rebuffed again. I got lucky and caught the night attending on his way out. He stayed to put the line in. He seemed to take pleasure in refreshing his skills (usually the residents put in the lines under supervision of the fellows). The night attending was expert. Within half an hour of hitting the door, the line was in. The order for a stat chest X-ray was actually executed in short order (sometimes it takes hours for them to show up). An X-ray is necessary because the lines occasionally take a wrong turn and end up near the brain instead of the heart. Proper placement of the central line has to be verified by a physician before the line can be used. My patient’s blood pressure continued to drop.

There was an X-ray viewing room at one end of the unit. I caught an intern and urgently requested her to read the film. As we walked down the hallway towards the viewing room the intern asked me, “Do you know how to read the X-rays for verifying line placement?” Me, agitated, “Nurses don’t do that. The doctors do. Weren’t you trained to do it?” “Well, I was trained…..” Ugh. I abandoned the intern and caught a nurse practitioner. She came to read the film, but the end of the IV was all the way into the patient’s heart. She was not sure if I could use it or not. I circled back to the patient’s room and got lucky and caught the night attending again. The patient was now in need of pressors. The night attending assured me I could use the line as it was. I scrambled to get a bag of Levo mixed (ICU nurses get to do that) as the night attending went back in to the room to pull the line back a couple of centimeters.

I was feeling quite shaken by this point. In the patient’s room with the night attending I expressed my concerns. “I feel very unsafe in my practice.” He seemed to be the only one who understood the urgency of the situation. He responded by teaching me the basics of reading a placement X-ray – “If it is in the heart, you can use it for meds. If it stays there long term it may cause some damage, some erosion, but that is not an urgent thing. You can use it. It is safe."

The Levo was running now and the patient was responding to it. I did not feel very reassured. I did not want to know how to read an X-ray. That was not my job and I would only get myself into trouble if I thought it was. I wanted to be able to rely on the physicians and was not feeling very sure that I could. I reiterated my concerns. “I feel very unsafe here now.” The attending paused for just a moment and looked at me. “I know,” he said, “Imagine how I feel.”

Monday, November 17, 2008

Fight or Die

MICU rounds. A dozen or so doctors - interns, residents, fellows, pharmacists and the attending – are all in agreement that it would be better to not intubate the patient with advanced, aggressive, metastatic brain cancer. He can die now or after a couple of weeks or so of ICU hell. The resident has had some preliminary talks with the family and they are open to the option.

Just as the team gets ready to enter the patient’s room, the oncologist shows up. The resident updates him and is taken off guard as the oncologist says something to the effect of, “don’t worry, I will take care of this,” and goes alone into the room. He sits down with the family and, using the finest unintelligible jargon, explains to them that the patient has no chance for survival, but they can still give their permission to do everything. He lays it out in plain terms – they can give up if they want, or they can fight. The resident, a caring young woman who perhaps thought that she was poised to do just a tiny bit of a good deed in this dark world, watches in quiet dismay from the doorway as the family rehearses their chant of “fight, fight, fight!” Now she would get to practice her intubation skills.

From my perspective, there is nothing particularly praiseworthy about wanting to fight as death approaches. When Ted Kennedy received his cancer diagnosis, the media was full of praise for him as a fighter. In our popular culture people die when they give up fighting, but this is not really true. Everyone dies. Sometimes things can happen faster when a person gives up, but then there are plenty (really) of patients who are praying for death. Death often does not seem to be in any rush to respond.

What about accepting death as a part of life and embracing it with dignity? We cannot accommodate that in our culture. Punishment must be related to guilt. “They must have done something wrong, or else why did they die? I am a good person, so surely I will live.” This seems to be a common subtext. An ocean of resources down the drain. Nothing for the person on the street while in good health, but millions of dollars on the verge of death. No questions asked. Or is it really all about teaching and experimentation? A little bit of both maybe? Somewhere someone is getting rich. Death is starting to feel a little insecure I think though…

Friday, November 7, 2008

Too Late

“But it’s too late baby, now it’s too late…” sings Carly Simon from the portable CD player in Mrs. Kent’s room. You might think you are in California as John, her partner of three years or so, tells you about how she has taught him to love nature, to garden, to compost everything that can be composted. He seems to love her, but he does not appear to be feeling the anguish and grief that I have seen when spouses of many years face the loss of their partners. It is more like he is a stranger trying to do a good deed for someone by looking after them- at least in that regard.

Mrs. Kent’s cancer was in remission, but the doctors recommended an extra round of chemo and radiation to try to extend the period of remission. It may have made sense statistically, but the treatments fried her lungs and she was now on her deathbed. You try talking about it with John and he bristles. Immediately you see that you are not the first nurse who has tried this dance. “I am not trying to take your hope away,” you say as you think about how that is exactly what you are trying to do. Sometimes hope is the meanest, cruelest feeling in the world.

There is a copy of a research study in Mrs. Kent’s chart that talks about the type of treatment reaction she is having. If it occurs at all, mortality is 90%. If the patient has to go on a ventilator, death is virtually certain. One of the residents has gone so far as to present John with a copy of the paper. Mrs. Kent is not just on the vent, the pressure settings have been turned up so high that air is seeping out into her chest. You can feel pockets of air under her skin around her collar bones. John talks about how much more comfortable she is now compared to when she first came in. He thinks she is making progress. You try to gently educate him about ventilators. He listens. It is not that he is unwilling to hear. The oncologist has recommended giving her two more weeks to turn a corner. He tells you about his talks with Mrs. Kent before all of this. If there was no hope of recovery, she had not wanted to be maintained artificially. If John’s connection with Mrs. Kent was deeper, would he feel more conflicted? Would he push harder for better answers?

The Medicine team is clearly uncomfortable with what the oncologist is saying, but there are invisible lines that don’t get crossed. Giving John the study paper was definitely pushing the envelope. Where is this oncologist coming from anyways? Is he trying to manipulate survival statistics? Where did the two weeks come from? It does not seem to be based on Mrs. Kent’s condition. Oncologists, as a rule, do not think of ‘hope’ as a dirty word; quite the opposite. Is it possible that this guy somehow imagines that he is doing a good deed?

When the influence of the sedation lightens, Mrs. Kent reaches out in panic and distress. She is clearly disoriented, but she is seeking human connection. Comfort. She might have a lot to say if she could talk, but she will never talk again. All there is to do is turn up the drips. Ah death! The sea of silence!

Care was withdrawn on Mrs. Kent after a week or so. I was off that day.

Saturday, November 1, 2008

Juice please

“Is there anything I can do for you Mrs. Smith?” I say as I finish my morning assessment. “Can I have something to eat? I have not eaten in three days.” Mrs. Smith is calm and polite, but I hear a building distress in her voice. It is not unusual for a patient in the Surgical ICU (SICU) to be NPO (nothing by mouth) for a few days, particularly if a surgery has been performed on any part of the GI tract. Mrs. Smith’s procedure two days ago had been elsewhere though. I went through her orders. No diet. All patients are kept NPO for twelve hours or so before procedures. Anesthesia sometimes causes vomiting and keeping the stomach empty minimizes the risk of choking. Did they just forget to restart Mrs. Smith’s diet after the procedure? I cannot think of any other explanation, but I have just floated to the SICU a few times before this and there is a lot I still do not know. I turn to MK.

MK is one of the surgical residents. She is a rare one and well loved, especially by the nurses. One of the charge nurses, a young man, first introduced her to me saying shyly, “This is MK. We do not like her a lot or anything like that.” What is uncommon about MK is her mood. She does not use her position to elevate herself above others. She is not here to fix it all, just to do whatever she can to make it better. She is cool calm and collected and she brings her full attention and skills to her work when it is time. She does not ask for any breaks. As a floater, I particularly appreciated her openness. When the unit staff does not know you, it is often hard to get anything done. Even the techs will not listen to you, what to speak of the doctors.

MK listens and does not give the standard “We will address this on rounds,” reply. She goes directly to the fellow. “Is there any reason why Mrs. Smith needs to be NPO, or did we just forget to give her a diet?” “She can eat,” is the answer.

The SICU does not have much around for the patients to eat and it will take a while for something to come from the kitchen even with a request for a late tray. I scrounge some juice and give Mrs. Smith the choice between apple and orange. She chooses apple, happy that her fast will soon be ended. Some patients would be furious at this point, but Mrs. Smith does not seem to have any interest in going that way.

I get a cup, a lid, a straw and some ice and empty two of the small plastic containers of juice into it. When I return to the room, Mrs. Smith’s surgeon is there speaking with her. “Here is your apple juice Mrs. Smith.” The surgeon stops me in my tracks, “She does not like apple juice.” “She said that she wanted it.” “She does not like it. It is too acidic.” I look at Mrs. Smith. She waves me over. Her gesture says, “Its okay, just give me the juice!” “Don’t you remember telling me you do not like apple juice?” booms the surgeon. Mrs. Smith does not engage him. She probably did say it at one point, days ago maybe. He continues to block me. “She has been NPO for three days,” I protest. “I know,” he answers proudly, missing the point entirely, “I made her NPO.” (Me big doctor, You little nurse.)

Okay. So this little nurse knows that the big doctors never hang around for long. Mrs. Smith only had to wait another minute for her juice.

Friday, October 24, 2008

Tie Me Up, Tie Me Down

One of the surprises of the job of being an ICU nurse for me was how often I had to restrain my patients. Almost every patient that is on a ventilator has both arms tied. The exceptions are those that are not physically able to move (organic restraints) and those who have been intubated for some time and have demonstrated trustworthiness. The second group are often subjected to the nurses whims. If the night nurse for instance sees such a patient scratch his nose at the beginning of the shift, she may decide that it is not worth the risk and she may tie the patient up for the night and be done with it. There are also quite a few patients who sundown. They may be okay during the day and then become erratic at night.

Then there are the so-called ‘social’ intubations. These are usually large men who come into the ER intoxicated and in need of treatment. Their belligerence interferes with their treatment and more and more sedatives are prescribed. At a certain point the doctors begin to worry that when they do finally fall asleep they will stop breathing because of all the sedation. A-bing’n-a-bang’na and they are smoking plastic.

Patients who have recently had feeding tubes inserted through their noses also usually need to be restrained. It takes a fair amount of self control for a patient to not pull them out. I once watched as my large male patient wiggled down in bed to try to get enough slack on his restraints to get his hand around his NG (naso-gastric tube). “Sir, please do not do that,” I said. “I got to!” he replied.

What about self determination?

What about it? It is not that patients get to dictate their care. If they are in the hospital, they need certain things. A patient cannot be allowed to starve to death simply because they pulled out their NG. Generally speaking, they do not want to be starved; they are just annoyed by the plastic tube in their nose. In the end, it is usually an all or nothing scenario – you get it all (by force if necessary) or you go home. If you cannot go home (if you could you probably would not be in the ICU in the first place) then you just sort of have to get it all. No one really has much choice in this regard. The patients do not, but the nurses and doctors do not really have much leeway either. Protocols have to be followed. In this way I have seen many a patient suddenly find themselves with a sterile drape over their heads and a large needle plunging into their neck (central line insertion) without so much as a “do you mind?” And the docs do not always get it on the first try. Sometimes it takes three different doctors and three different sites. Sometimes they cannot get it at all.

Then there are chemical restraints. Ativan tends to put patients to sleep. Particularly needy patients tend to get a lot of it because the nurses get fed up with them. What else can you really do for them anyways? When a patient makes an angry disturbance (banging on the bed for attention for instance), the nursing joke is to say “I think he is saying ‘give me ativan.’”

The hands down favorite drug of ICU nurses is Propofol. This milky white IV infusion induces a coma like state and can only be used on intubated patients. Propofol turns the nightmare patient into a turn-water’n-feed patient. I have heard one nurse refer to it as ‘the milk of the gods.’ Doctors also like propofol because the effect of it wears off in about ten minutes once it is turned off. A patient’s neurological status can thus be assessed briefly periodically whereas the patient who has received large doses of ativan may take days to wake up. There is a hitch though. Propofol is fat soluble, so if the patient is on it for more than a few days it absorbs into the tissues and may take weeks to clear after it is turned off.

One day I heard a commotion and went to the room of a newly arriving patient. Two teams of doctors and a large handful of nurses were settling the patient into his room. It was sort of an ad-hoc gathering. The patient did not really need much attention; people had just happened by and ended up in the room. The patient was tied at both wrists and both ankles. Four point restraints are illegal, but not uncommon. The patient was yelling, begging and pleading, “Please! Please! I do not want to die tied down like a dog! Please untie me! Please!” With the exception of me, everyone in the room was laughing at him. It was not malicious laughter it was more of the way people laugh at a child who is asking for the moon. Such a ridiculous suggestion! How could we possibly? The man was obviously crazy.

Friday, October 17, 2008

How shall I die?

A sage of ancient India, when he felt the end of his days approaching, left everything he knew to wander in the forest. Coming across a forest fire he entered into it and gave up his life in this way. I have always been attracted by such stories. When I contemplate my own death, I imagine wandering around Govardhana alone and anonymous. I would cover myself in dirt or ash to disguise my complexion and then walk here and there, barefoot and without self consciousness, leaving myself in the palm of Krsna, suffering or not according to His sweet will…

I stand with two other nurses around the bed of a young man who was shot through the head while sitting in his car. It was done by a passenger, presumably an acquaintance, but no one was sure who. Our patient was paralyzed from the nose down, able only to blink his eyes. When asked to blink once for no and twice for yes, he consistently blinked twice when asked if he was in pain, but this was the extent of his communication. I tried running through the letters of the alphabet with him to get the name of who had shot him (It was not really my place to do so, but I felt compelled), but I did not get the same letters twice and had to conclude that he was not present enough to be able to answer the question.

We had come to his bedside to pull him up in bed and turn him. We contemplated his predicament. One nurse mentioned that he had seen a movie that had been shot from the perspective of a person in the same kind of condition. “Well that is very interesting,” replied the third nurse, “but if it was a movie of my life, the screen would just be black.” She would not accept life in such a condition.

I felt she was missing something, but did not say so. How often do we really get to choose the circumstances of our death? Some people definitely do. Some definitely do not. The rest are somewhere in between.

Nurses fear hospitalization.

In my first year of nursing a male nurse ended his report on a patient who had been in miserable condition in the ICU for months by spontaneously confessing that he kept a syringe full of insulin at home and that he had instructed his wife to inject him with it if he ever ended up in the ICU. Independently, a second male nurse made a similar statement to me under similar circumstances. Female nurses are more likely to say things like, “I hope my family doesn’t love me this much.”

Some trauma nurses do not wear their seatbelts. They would rather die than end up as a trauma patient. Burn nurses do not allow their children in the kitchen while they are cooking. Curiously, respiratory therapists tend to be smokers. I have yet to meet a nurse who says they would definitely get a liver transplant if their liver failed. “I would have to think long and hard about it,” is the closest I have come. (I have always asked the question in the context of caring for a patient with a failing transplant).

As far as I am concerned, I am not so worried about air hunger or avoiding pain. I think death is intrinsically painful and I am not so convinced that covering up the external expression of this with drugs really makes for a better death. I am speaking for myself now. Why drag it out? I would rather just get it over with quickly and naturally. I hope that when the time comes that I am able to make these choices for myself. If I am helpless, I hope I am still able to express myself. And if I am able, I hope that I will be listened to.

Friday, October 10, 2008

Transplant Hell continued

I try to remind myself that transplant surgeons are not intrinsically evil. I have seen almost exclusively the 20% of liver transplant patients that die long and horrible deaths. Perhaps if I saw more of the other 80% I would feel better about it all. It is all somehow ghoulish though. I am not able to get comfortable with it. Has Mr. Jones been reduced to the mentality of a caged animal by the influence of his disease, or has he realized too late that he is being flushed down the drain of modern medicine with no expense spared? Why shouldn’t he see us as his enemies? He was not told of this possibility which is now his hellish life. I have spoken with a few patients whose liver transplants did not go bad. They had no idea how things could have been. What were the statistics for Vioxx? One in how many hundreds of thousands died? For liver transplants it is one in five. And the Vioxx people dropped dead suddenly. They did not suffer over weeks and months like these transplant patients do. Yet we never hear about the transplant patients in the media - just calls for more donors.

Here is another concern – Mr. Jones was probably still in fairly good health before his transplant. The healthier the patient is, the better his chances after transplant, so the surgeons do not like to wait for their patients to get ill. When laboratory tests and scans show that the liver is likely to fail, the patient is encouraged to sign up for the transplant. The transplant takes place while they are still in good shape which leaves open the question as to how many good weeks, months or years they would have had without the procedure.

Then there is the donation process. Nurses I have spoken with who have assisted with organ harvest express deep discomfort with it. It is by all accounts a bloody mess. The nurses complain that the doctors are not properly respectful of the donor bodies. I wonder if it is possible to respectfully cut a liver out of a functioning body. There is also generally a lot of joking around that goes on in the OR. I imagine that this could seem very different when you do not expect the patient to get better at the end of it all.

A lot of money generated from these organs. Transplantation must be a billion dollar industry. The surgeons are no doubt well paid, but the industry also supports a host of coordinators, “counselors” who speak with the families of potential donors (do they get to keep their jobs if they are not good at getting families to donate?), nursing staff, clerks etc. The ICU nurses also care for the donors bodies as one-to-one or even two-to-one patients because of all of the extra lab work and medications that are required for maintenance and preparation of the bodies. Again, these nurses would generally rather be spending their time on a patient that has a chance of getting better - and that is without even considering that the recipient might not do well. So many livelihoods are at stake. Shall we pretend that no one is influenced by this?

I once saw a candidate for organ harvest being evaluated by a surgeon. The patient had been a two-pack-a-day smoker for twenty years and the surgeons were considering taking his lungs for transplant because he had a small frame and small lungs are in high demand for young cystic fibrosis patients. The patient had suffered from a heart condition, but they were considering taking his heart as well. In the end it did not happen. I heard the surgeon talking on the phone saying that he would do the harvest, except that he had never done it before and had only observed once. He did not feel comfortable doing the procedure on his own and there was no one else available at the time.

The unfortunate liver transplant recipients suffer through liver failure and organ rejection at the same time. If they stabilize, they may be confined to bed, weak, of disturbed mind, swollen and in pain. These are the patients who beg for death and their pleas are almost always ignored. The surgeons seem to live with themselves by not contemplating the cases that go bad. They make their daily rounds and encourage the family members to remain hopeful. ‘We just have to get on top of the latest infection. Maybe he will only need dialysis temporarily.’ The family members somehow keep their faith in the surgeons and become callous to their loved one’s pleas (he is feeling weak, who could blame him? but I will be strong for him). These patients pull on anything they can get their hands on. They will rip the feeding tubes right out of their stomachs. The nurses, who are often the most sympathetic to their wishes, are also the ones who have to make sure they are tied tightly at all times.

Once I found myself yelling at one such patient whom I had untied for a short period in the hopes of giving him more freedom. “Stop pulling on that! If you don’t, I am just going to have to tie you up again!” I felt someone watching me and turned around to find the adult son of the woman in the next room giving me an icy stare. How could I explain it to him? The next day I was filling out a job satisfaction survey. I was surprised to find the question, “Do you feel your work is hardening you emotionally?” I was even more surprised as I found myself clicking on “strongly agree.”

Saturday, October 4, 2008

Transplant Hell

I hear a call on the overhead paging system requesting all available hands to help with a turn in room 4. My hands are available, so I go. I join two other nurses and a tech at Mr. Jones’ bedside. I can see right away it is another liver transplant gone bad. We see quite a lot of them.

If you go to the patient information websites for liver transplant programs and click on “waking up in the ICU” you generally find something like, “you may have some pain from your incision, but your nurse will take care of that.” The same site will tell you that 80% of patients survive for more than 5 years. That means that 20% do not; but try to find information about what happens to that 20% and you won’t find anything. So, here goes.

Mr. Jones was deranged and panicked from toxins (chiefly ammonia) that had built up in his blood due to liver failure and organ rejection. Had he not had a plastic breathing tube in his airway, he would probably still not have been able to speak more that a word or two and groan. As we go to turn him, he resists everything we do. His bed is full of blood, stool and bodily fluids. We need to clean him up and change his sheets.

He is in four point restraints – tied at the ankles and wrists with cloth straps that stop him from trying to get out of bed (he would fall) and from pulling out his breathing tube or his various drains and lines. As we undo the restraints to turn him, Mr. Jones claws at us. He makes a fist and tries to hit us. He tries to kick us. As soon as he gets slack, he tries to grab his breathing tube. We are used to this type of behavior. We hold the cloth straps tightly where they meet his wrists, “Please don’t do that Mr. Jones.” We need four people for this turn. A nurse can get in a lot of trouble for “letting” a patient pull out their breathing tube. Self extubation is an urgent emergency that requires the attention of multiple physicians and activation of the unit’s staff assist system. Suddenly, the room will be filled with 20 pumped up nurses and doctors like in a code and they will all demand “Why wasn’t this patient restrained!?” which is not to say that there is not understanding for what can happen from time to time. The patient also is at risk for brain damage from hypoxia etc. We do not give Mr. Jones any leeway. He is not going to pull that tube.

He is too weak to be dangerous to us, but he is full of Hep C and other nasty diseases, and even a scratch would be worrisome. His obviously sincere efforts hurt us do not evoke compassion. With his pale skin, drawn face and angry eyes, he fits the mold of the mean drunk. One can easily imagine him turning this violence on his lovers. My mind wanders to the moment he heard that a liver was available. He must have been so happy. All that waiting for some poor guy to drop dead was finally over. Well congratulations Mr. Jones – you got your liver.

We, his enemies, have him pulled up on his side and are wiping the liquid stool from his paper thin, yellow skin. He is full of fluid. His skin is tight and painful. Any puncture site (and he will have a few) oozes clear yellow fluid (if not blood) and does not stop. His belly is distended to perhaps 10 times its normal size. His scrotum has swollen to the size of a cantaloupe and it is raw and bleeding. He had expected to be home watching TV by now.

I am thinking about writing this. I test my thoughts, “Do you think he knew he could end up like this?” “I do not think any of them have any idea of it.,” confirms Terry, the charge nurse. Terry has been a nurse on this same unit for more than 10 years. She likes my straight talking and reciprocates with her own. Unbeknownst to me she has already put in for a transfer to another service. Many of the senior staff have already left over a conflict with the new manager. Terry was a holdout, but she is now joining the exodus.

The tech nods in agreement. The other nurse in the room is younger and less experienced. She makes a sour face and avoids eye contact. Perhaps she is thinking about the heroic transplant surgeons or the miracles of modern medicine. My perspective of the scene before us is not one she has any intention of embracing. She would rather I keep it to myself, but she is clearly in the minority so she does not say anything and keeps busy cleaning.

To be continued.

Monday, September 29, 2008

No Sanctuary for the Dying

I was in the last semester of nursing school and I was interning on the MICU where I would work after graduation. During the first or second week I observed a code. It was a patient with sepsis. Her blood was too acidic and her heart kept stopping. The team would inject bicarb (basic) and perform chest compressions and her heart would resume beating for a while. A few minutes later it would stop again. Her condition was irreversible.

Experienced nurses were running the code. “Will someone please call the family and tell them it is time to let her go to Jesus!,” one called out. Another had the job of injecting the bicarb – “Can’t….Stop…” He said as he pushed the amp into the patient during the third round. He was registering his distaste.

My preceptor had another idea. She went and got the new chest compression machine the unit was supposed to be trialing. With a little persistence, she overcame the objections of the other nurses. They complained about the interruption that would be necessary to place the machine under the patient.

After the hard board was under the patient and the 10 inch wide nylon strap was secured over her chest, the machine was turned on. On the first try, it did not engage. Then, like something out of Robocop, it came to life. First it moved the nylon strap in and out, measuring the appropriate length, then…. WHAM! WHAM! WHAM! WHAM! The strap tightened and slammed down on the patient’s chest delivering compressions. The compressions were so violent that the patient’s already swollen belly jumped a foot upwards with each contraction. Her body looked like so much bread dough in a kneading machine. It was quite horrible to watch. I asked my preceptor about it – this had to be damaging her body. My preceptor replied that studies had shown that regular chest compressions are not very effective in circulating blood throughout the body. The compressions delivered by the machine would be much more efficient. Ribs are often broken during CPR, even when it is done by hand. The machine might save lives. We had to learn how to use it and this was a good case to try it out on (because we knew she was not going to make it in any case – no harm if something goes wrong).

The other nurses seemed as unhappy as I was with the trial and I never did see the damn machine again. I made sure to give a dirty look to whoever so much as mentioned using it. No sanctuary for the dying.

Thursday, September 25, 2008

Outside Jessica's Room

Outside Jessica’s room the doctors were making morning rounds. Her liver enzymes were improving. She was stable. Her ammonia levels were down. The attending asked the intern for his recommendation. “Send her to the floor.” The attending, a mild, gentle man, did not agree. In a matter of fact way he explained his thinking. Jessica was young and unlike the rest of the patients in the unit, she could actually get better. If we sent her out now and by some chance something went wrong, how would they be able to look back and justify the rush to get her out of the ICU. She should stay one more day for observation.

I had been a nurse for less than a year, but I had already learned that most of the MICU patients did not get better. Quick deaths were simply traded for long, extended deaths (I call them MICU sunsets). Along the way the patients are tortured endlessly with knives and needles and strong drugs. For every one patient you might be able to say was helped by ICU treatment, you can be sure a hundred or more have died miserable deaths. This is how the students learn, how science advances, how the industry makes its money. I had guessed this dirty secret, but I was still surprised to hear the words come from the attending’s mouth. There was no shame, no self-consciousness, no hesitation as he spoke about how the rest of the patients were being treated just for practice and that this was the real opportunity to help someone. “How do people feel this is okay?” I wondered to myself.

It is all so complicated. Try to explain it to a patient’s family and they will hate you. They want to get everything that is available. If any treatment is withheld, they consider it neglect and abuse. The less educated the family, the worse it gets.

I have heard that more than 90% of money spent on healthcare during the average person’s life is spent during the last month of life. I have no reason to think it is otherwise based on what I have witnessed. Such a wasteful society. I tell you what; give me the million bucks now and let me die on the street when the time comes. I won’t be any worse off at the end and I promise you I will find something better to do with the money.

Inside Jessica's Room

Jessica and her mother Louise were southern ladies. Jessica, at 24, was the patient. She had suddenly developed severe liver failure and had come to the MICU to be evaluated for a liver transplant. As Jessica lay in bed moaning, her mind clouded from high ammonia levels, her mother struggled to get her mind around it all. To everyone’s relief, Jessica began to get better spontaneously. Over the course of the day her consciousness became clearer. She began to argue with her mother. “There is a toilet in the room, it is right there.” “Honey, there is no toilet in this room.” The toilet was under the sink.

The phone rang in the room. Louise answered. She became upset as she listened. The call ended quickly. “John’s dead. They found him in the house. Oh and I fussed at him last night!” John was her boyfriend. Louise yelled at Jessica as they both began to cry, “Don’t you think money is going to make you happy! Don’t you ever think money is going to make you happy!” John had been wealthy, but troubled and unhappy. He had struggled with alcohol. Louise got on the phone and called her ex-husband (I think it must have been). She told him he needed to come there, told him about John and then began to ramble. She was losing it. She handed the phone to Jessica who used what strength she had to sit up in bed and take the phone. “Momma’s all tore up.” She told whoever was on the other end of the line.

John’s body came to the hospital morgue to be autopsied since his death was unexplained. John’s doctor called the hospital to talk with Jessica’s doctors. He was concerned about foul play. Perhaps they had both been poisoned somehow. The ICU doctors dismissed it. Louise started to think about it, but Jessica had not seen John in weeks. It did not seem possible that the two illnesses could be connected.

Louise wanted to see John’s body and she asked me to help her. I made inquiries but met with resistance. What was the point? Why did she want to do this? I made phone calls and in the end arranged for the hospital Chaplin to take her to the morgue where she was met by the doctor who performed the autopsies. He presented her with a Polaroid picture of John’s body. She came back satisfied. She thanked me for understanding her need.

By the next day Jessica was well on her way to a full recovery.

Saturday, September 20, 2008


“This is an experimental hospital, so you are bound to see a lot of things that you feel are unethical. If you want to practice here, you will have to keep those feelings to yourself.”

It is my first day of orientation on a MICU in another university hospital where I will be working. My preceptor, Jim, has worked here for 15 years. It is hard to imagine that he could be so direct with all of his orientees. Perhaps he has sized me up quickly. He adds that once I have been around for a while and established my name, I will be able to intervene from time to time and say enough is enough. He does this himself and clearly feels proud of it and that it is his role. That is a good sign at least, but out the window goes any hope that this hospital is going to be different from the others I have worked in. But I knew that already, right?

“They are proud of being an experimental hospital. They just like to use the word ‘innovative.’ That means they try a lot of things on patients who have no chance of making it. If something works, they broadcast it. If something does not, they bury it.” Trial and error being what it is, I expect the latter happens much more than the former. Human experimentation anyone? These people are on the verge of death anyways, so how much harm can you really do to them. It can get to be an “anything goes” scenario if you play it right. It is always open season on the dying. They are defenseless. Even their families do not protest. Does everyone feel comfortable with this? This is where the miracles of modern medicine come from right?

Jim says that he sometimes flatly refuses to assist with experimental procedures and blocks them when he thinks things have gone too far. MICUs tend to get a lot of hopeless cases. Jim talks about how it is a good place to practice code skills. Knowing the end result will not be changed takes the stress out of it all. “We have fun with the codes. Well not fun really, but we take a few minutes at the end so that the new nurses can practice their chest compressions and stuff.” I decline the practice opportunity in advance. I do not really need it. I know what he means about codes being fun. They are exciting and they provide an opportunity to work closely with coworkers in a pleasing way. “It is a teaching hospital. This is what it means. Everyone needs to learn how to do these things. We try to stop it before it goes too far.”

I remember a story one of my nursing instructors told one day in lecture. She had gone to check on a student who had been placed in the ER for the day. She had peeked around a curtain to find her student alone, straddling a recently deceased patient, happily practicing chest compressions. Seeing her teacher, the student looked up, smiled and waved, “Oh, hi Professor Calloway.” Then she had gone back to her practicing. My instructor had stumbled away, thinking about how strange her life had become. I appreciate more and more how she shared her experiences like this with us.

Tuesday, September 16, 2008

The Good Fight

The night nurse tells me in her report that my patient for the day is in liver failure. The doctors have called for a meeting with the family to discuss code status. This means they think the patient is going to die soon. The family, however, has said that they do not want the patient, a man in his forties, to know how serious his condition is. “We’ll see about that,” I think to myself as I listen to the rest of the night nurse’s report. Apparently the doctors have gone ahead and spoken with him about his condition already anyways.

I enter his room and begin the morning assessment. I feel his pulses, listen to his lungs, “Are you in any pain?” He is not. He looks bored and nonplussed. I am suspicious. “I heard you got some bad news last night,” I say. “Yeah,” he replies in a disinterested tone. “Do you know that your liver is failing?” “Yeah, I guess.” “Do you know that you cannot live without your liver?” The doctors must have left this part out or else they spoke about it obliquely so that the patient was not able to understand. He is suddenly paying more attention to me. He begins to shake, “you mean I am going to die?” He continues to shake as I encourage him to prepare for the day’s meeting by thinking about what he would want his code status to be. I put my hand on his shoulder to calm him. Would he want everything done, or would he want to be allowed to die peacefully? Death by liver failure is one of the most agonizing deaths. The mind becomes clouded, the body fills up with fluid, and skin becomes yellow. The pain is severe and pain medicines are mostly metabolized by the liver, so the patients cannot have any medications to make them more comfortable. My patient is not a candidate for transplant. When his liver fails completely (an oversimplification of the condition), his code status could possibly save him for a week or so of agony. Past a certain point, there is no chance for recovery. The doctors would not be talking about code status if they did not think he was going to die.

“Am I going to die today?” demands the patient urgently. I try to avoid giving him a time frame, but this seems to confirm for him that he is going to die any minute. I break down and say, “More like days to weeks,” I say. We talk a little more before I leave the room.

Shortly thereafter his mother arrives with a couple of other close relatives. I did not see them go into the room. The patient points me out, “That’s the one.” He waves me into the room. His mother stands on the opposite side of the bed. I stop just inside the door. “Did you tell him he was going to die tomorrow!?” she demands indignantly. I suddenly feel like a child before an angry teacher. I feel my knees slacken and my courage deserts me. “I told him he was very sick. I explained what the doctors said.” The patient rolls his eyes. I make excuses and leave the room as quickly as possible. I tend to my other patient.

After a few minutes, I hear the mother in the hallway, “Where is the nursing supervisor!?” she demands. I hear another nurse telling her that I am right in the next room. “I don’t want Him! I want the nursing supervisor!”

“Now I understand why other nurses do not bother with this sort of thing.” I say to myself, but my courage is returning. I have not exceeded my bounds at all and I feel confident that no harm will come to me. The doctors explained it to him, but he did not understand. It is my job as his nurse to make sure he understands what he has been told. I begin to relish the thought of a fight. I search out the charge nurse and tell her my side of it first. She tells me that she has already heard about it and does not see anything wrong with what I have done. Her only question for me is about whether he had asked me for the information I gave him, or whether I had pushed it on him. This is a widely accepted unwritten code for nurses. If they do not ask, you do not tell. The basic idea is that if a patient wants to be in denial, you should not try to force them to face reality. I agree with this, but I think the principle has been taken too far. In this case, for instance, the man has no idea he is about to die even though the doctors have supposedly informed him. Would I really be a good advocate for my patient if I said nothing and watched him die? “Oh, well he did not ask me….” I did not overwhelm any denial; the patient did not have any idea how serious his condition was.

The mother talked with the charge nurse for a little and was pacified. I softened and apologized for inadvertently causing a disturbance. The doctors met with the family and backtracked on what they had said, but they did at least acknowledge that they had said it. The patient asked his sisters to stop asking the doctors questions about his illness and absorbed himself in watching sports on TV. Labs I sent showed his liver function was improving. Oh well. People should think about their own mortality from time to time anyways. The doctors continued to confirm that they had thought the situation was dire.

In the afternoon, I spoke with the patient’s sister about it all. She was a nurse, although not involved with critical care at all. She spoke of concerns that hearing a bleak assessment of his chances might depress him and cause him to give up. As if people only die because they give up. I spoke with her at some length about how horrible a death from liver failure can be. I pointed out to her that if he were to become just a little sicker than he was now; he would no longer be able to communicate with anyone. If he could say now that he wanted everything done, then the family could be peaceful that they were doing the right thing as he went through it all. If he told them that he did not want everything done, they could be confident that they had not pulled the plug on him prematurely. As I spoke, I saw light bulbs go on in the sister’s head. I could see she now saw the urgency of the situation. I could see she now understood why I had acted as I had and appreciated it. I saw she was thinking about how she could exert herself to adjust the family dynamic a bit. I am not sure how well she fared. I have no idea what happened to the patient.

Saturday, September 13, 2008

Death by Cystic Fibrosis

I had been caring for 19 year old Ms. Samson for several days now and she was not getting better. On the first day she had been able to remove the Bipap mask long enough to eat her meals. Now we removed the mask only for her to take pills and even from this short pause her blood oxygen levels would drop to the low 80’s and return to the minimally acceptable 90’s very slowly after several minutes.

Ms. Samson’s room in the medicine intensive care unit (MICU) showed signs of a family accustomed to hospital stays. Bags of clothes, half full cups of sodas, half eaten sandwiches and untouched cups of Jello (saved just in case they might be wanted), open purses and extra sheets and blankets lay about the more than usually cluttered tables, vinyl chairs and floor. The lights were dim and the TV, at low volume, was turned to a morning show. Ms. Samson’s mother lay asleep on an armchair, wrapped in a couple of white hospital blankets. She did not stir as I performed my nursing assessment and administered the medications. I left the curtains by the entrance to the room drawn and slid the glass door closed as I exited to let them rest.

When the doctors rounded and discussed Ms. Samson’s case my suspicions were confirmed. Ms Samson was on the edge of requiring intubation, (being placed on mechanical ventilation through a plastic tube which is inserted directly into the lungs). Since Ms. Samson had Cystic Fibrosis this would be a death sentence. The thick sticky mucous that coated her lungs would be pressed further and further into her airways and, although she would appear better at first, after a few weeks to a few months of gradually increasing the ventilator pressures there would be nothing more to be done and she would die. In my short nursing career I had already witnessed this a few times. The hospital where I was working specialized in treating Cystic Fibrosis and since those suffering from the genetic disorder rarely live to their twenties and almost never to their thirties, we in the MICU had the unhappy task of caring for the otherwise normal teenagers and young adults as they succumbed.

The attending physician was equivocal – if she was intubated she would never be extubated (removed from mechanical ventilation). An intern raised the possibility of a lung transplant but the attending explained that the most important predictor for success in organ transplantation is the patient’s ability to strictly adhere to a complicated medical regimen. Since Ms. Samson had a history of noncompliance with medical regimens, she was not a candidate for a lung transplant. The doctors and pharmacists discussed which antibiotics would have the best hope of working, made a plan, wrote some orders and moved on to the next patient.

After the doctors had gone I entered Ms. Samson’s room, her mother was awake now, sitting quietly in the chair staring at the wall. I squatted by her side. “Mrs. Samson,” I said gently, “do you understand how serious your daughter’s condition is right now?” “I think so, kind of,” she replied seeming glad that I was asking, “but tell me.” I told her that her daughter would soon be intubated and that the doctors did not think she would ever be able to get off the vent again. She replied, calmly, that she had not realized that. I explained to her that her daughter would die slowly over weeks or months and I told her that there was the option of deciding not to put her on a ventilator.

I know what I think I would want for myself. I have seen what these patients go through and I do not feel it is very merciful to just keep them alive in miserable conditions for as long as possible. I encouraged Mrs. Samson’s mother to think about the choice that needed to be made. What would her daughter want?

She went to her daughter’s bedside. “Do you want help with breathing?” Her daughter nodded yes, but the mother was still uncomfortable. “I do not think she realizes she would never get off of the vent. I do not think she would want to live like that.” Ms. Samson’s tattoos and piercings seemed to indicate a free spirit. Maybe it would be better just to let her go.

What must it be like to know that you will not make it to age 30? Ms. Samson had missed her 16th birthday party and her high school graduation – she had been in the hospital with pneumonia both times. She had discussed with her therapist that she was tired of being controlled by her disease and so she had delayed going to the hospital this time with hopes of being able to celebrate 19 years of life. The therapist did not visit her in the hospital. “Where is that therapist now huh?” I thought to myself, unsure if I had a right to the feelings of indignation I was experiencing.

When a mother comes to know that she is going to have to make a life and death decision about her daughter, one day is not a whole lot of time to do it in. I brought the doctors to talk with her. They confirmed the situation. I helped Mrs. Samson interview them. I introduced her to the family of another cystic fibrosis patient who was also on the unit at the time. This girl was 15 years old and had already had a lung transplant. The transplant had gone bad, and she was in the MICU on a ventilator, too sick to get another transplant, wasting away. Her parents vainly clung to the hope that she would recover enough to get the transplant. They coaxed her and prodded her to walk up and down the hallway once a day. During the journey of about 50 paces all could see her emaciation. Her knees were twice as big around as her thighs. The pride of any anorexic would be crushed. “All we are doing is rearranging deck chairs on the Titanic!,” complained one of the residents referring to her care.

Mrs. Samson looked at the girl and talked with her family. The girl seemed comfortable with her head propped up on a pillow. She looked at you when you came into the room. It was a good day for her. I worried a little that Mrs. Samson might get a too rosy impression of her life, but she came back from the room shaking her head. “They seem happy with her life, but I do not know. She is so drugged out. I do not know what kind of life that is.”

At the end of the day, Mrs. Samson was still undecided, but was leaning towards not intubating. She had talked with the doctors, and they were aware of and seemed to agree with her sentiment. I let the night nurse know where things stood and left for the night.

When I returned the next day, the room was empty. The Samsons were gone. I asked what had happened.
A blood gas had been taken at the beginning of the night shift and it came back critically acidic. The nurse had informed Mrs. Samson that the time to make the decision had come. Mrs. Samson left to think and smoke a cigarette. If it had been me, I would have told her that there was not time for that, but the night nurse apparently did not feel that was her job. While her mother was out, Ms Samson began to code. The doctors, not wanting to go against the mother’s wishes, tried to buy time by ventilating Ms. Samson by hand with an ambu bag. She vomited and was choking on her vomit when her mother returned. “What is all this! I don’t want any of this!” exclaimed Mrs. Samson. The resuscitation was promptly ended and Ms. Samson’s heart stopped almost immediately. Mrs. Samson had then broken down.

The body had stayed in the room for longer than usual. The 17 year old sister, who also had cystic fibrosis and had avoided visiting her older sister, came to offer last respects. The night nurses criticized Mrs. Samson for her smoke break. “What kind of mother with a daughter who has cystic fibrosis doesn’t talk with her about intubation and her wishes?” In younger days I would have felt outrage. Why had these nurses just stood by and watched when they should have stopped Mrs. Samson and told her what they knew? But I remained peaceful with only some sadness. One has to realize what cannot be changed.

What would Mrs. Samson say to me if I met her on the street today? Would she thank me for helping her to spare her daughter from pain and suffering? Or, would she tell me that any moment of her daughter’s life was precious and that she would have wanted to give her that time ventilator or not? I do not know. When I die, perhaps there will be someone there who can tell me whether or not I did the right thing by Ms. Samson and her family.

Missing a Lung

This is another early essay:

There is no training in nursing school that addresses how to go about giving information about a patient’s condition to a patient or their families, or about what they need to know or should know and what they should not. Neither was there, for me at least, anything in my hospital orientation that gave any guidance on the matter. For me personally, this is good because I have strong opinions about it and the absence of a defined role gives me a lot of discretion to act according to my own sentiments and intuitions. It gives me an opportunity for personal expression and allows me to help my patients and their families in a very meaningful way in spite of physical conditions that are often insoluble. I feel very strongly that patients and their families should be as aware as possible of their situations and should have all of the information necessary to make all important decisions. This becomes even more important, in my estimation, when death is imminent.

There are, however, other points of view and for whatever the reason it is often found that patients and their families are not given information promptly and in such a way that it enables them to make the big decisions with their eyes open.

The story of a not atypical workday illustrates: I arrive on the floor of the MICU at 7:00am to take report on my two patients for the day. The night nurse tells me about my first patient, he is suffering from pneumonia and has already had his entire right lung removed because of cancer. I look up from my note sheet to check the monitor and see the patent’s sats are in the mid 80’s. Without waiting to hear more I get up and go into the patient’s room to turn up the oxygen on the patient’s face mask. As I get closer to the flow meter the night nurse calls in “It’s already at 100%.” The night nurse is calm and obviously aware of the situation, so I come back out of the room to finish report. The night nurse explains that he has spent the night trying to keep the patient calm and encouraging him to take slow deep breaths. In this way he has kept the patient off of mechanical ventilation through the night, but the patient has started to slip more as the morning has come. The night nurse, who has years more experience than I, emphasizes the patient’s vulnerability due to only having the left lung (the left side is smaller because of the heart). He summarizes saying, “If he gets tubed (placed on a ventilator) he’s toast.” Then he adds that the family does not realize what is happening and expects him to be home by the end of the week.
There is not much time. I first go to the patient to try to calm him and encourage him to breathe deeply, but he is barely conscious and gasping for breath. All he can do is nod and his sats are not rising above 86%. The patient’s son is in the room. I find the fellow and ask him if the patient’s prognosis would make it appropriate to refrain from intubation and to allow the patient to expire naturally. The fellow answers in the affirmative and his tone encourages me to talk to the family. I tell the son as gently as possible that I have heard that his father has almost no chance of surviving intubation and that the time to make a decision which could spare him a lingering death with a plastic tube shoved down his throat is now. The son replies nervously that he cannot make that decision without his mother and she has just gone to the cafeteria. I encourage him to bring her. He leaves quickly.

The patient’s sats are now in the low 80’s. There is no question of calming him down now, he just cannot breathe. There is no room to delay. I find the resident and tell her about the patient’s current status. She comes directly to the room, looks at the patient and the monitor and calls for anesthesia to be paged for an intubation. I hustle to bring supplies and prepare the patient. By the time the patient’s wife returns with her son, two anesthesiologists are setting up shop, the respiratory therapist has brought the ventilator and the resident, who is standing at the bedside simply tells the patient’s wife that the patient requires help breathing and that he is going to be placed on a ventilator.

Intubation is a violent process. Families are generally asked to step out. Even if they are not asked, they always leave. A sedative is administered followed by a paralytic that leaves the patient unable to resist the impending violation. The paralytic also renders the patient entirely unable to breathe and a mask with an ambu-bag is used to give breaths until the ventilator is in place. When the patient is judged to be best able to tolerate a period without air, the mask is removed and a metal blade with a light on the end is inserted into the throat. The doctor stands behind the patient’s head and lifts up on the blade to visualize the patient’s vocal cords. When he sees them he takes the endotracheal tube (ET tube), which has a metal rod inside to make it rigid for insertion, and aims for the trachea. If all goes well (it is not uncommon for several attempts to be necessary), the tube is placed, the rod removed, the balloon at the end is inflated to make a seal, the Ambu-bag is attached directly to the tube, a carbon dioxide indicator is used to verify that the tube is in the lungs and finally the ventilator is attached and the machine begins to give breaths. The process is always somewhat intense for all involved, and when the patient’s oxygen levels are already low to begin with there are bound to be some urgent exchanges.

As I come out of the room I see that the patient’s wife and son have stayed nearby. Having heard the process going on the wife is disturbed, worried and crying. She glares at me, “He is going to be fine.” her eyes say, “why are you making us worry like this?”
I do not remember speaking with them for the rest of my twelve hour shift. I had another intensive care patient to look after also. I probably tried to say something encouraging like “I hope everything will be alright,” but I do not remember. A week later I heard the doctors explaining to the wife that there was nothing more to do. The ventilator was turned off and the patient died shortly thereafter.

Tuesday, September 9, 2008

Not for TV

I have not had time to write recently, so I am posting one of my earlier essays. I hope to get back to my regular posting in a week or so.

Not for TV

When I get to work in the morning I swipe my badge to enter the unit I am working on. I am greeted by the SNAP!...SNAP! of locks unlatching on the entrance doors. This reminds me that I work in a private place. In one sense there is no privacy for an ICU patient. There are glass doors on all of the rooms and curtains are generally kept open. The patient’s vital signs are displayed on various monitors strategically placed around the unit. The patient is meant to be under observation, or at least observable, at all times. Everything is very public in this way, but at the same time the ICU environment is emphatically not open to the general public. In three years my wife came twice to see where I was working. She would walk quickly around the unit casting a glance or two at the patient’s rooms as she passed. It is not a place where a visitor feels comfortable to sit and observe. My brother is something of a technology buff and amateur inventor. He expressed an interest in observing medical devices in action, but this is not possible. My brother is not allowed to watch me work.
There will never be any unsupervised TV cameras in an ICU. It would be a huge violation of privacy. Even regular cameras are forbidden. I have seen few things agitate nurse managers more than patient family members taking pictures of their relatives. Even talking on cell phones is against the rules and is strongly discouraged. The rationale for this is that the patient’s monitors can be affected by the phone signals, but those who know technology will tell you that this idea is false. Nurses themselves often use their own phones in empty rooms or hallways, but they are more likely to ask a family member to turn off a cell phone than to tell them to wear gloves in an isolation room. This is not limited to one hospital. As far as I am aware it is a standard policy in all hospitals. The ICU environment simply resists the outflow of information.
I am not a watcher of hospital TV shows, but I am often struck by the incongruity between the reality of the ICU environment and its public portrayal. It is not that the patient’s situations or the devices and machines are outside of the public consciousness, it is that the flow of patient care and the mood in which that care is delivered is entirely different.
An example illustrates: Shortly after I first started working in the MICU I was sitting in group report. The charge nurse from the night shift was going through the routine of giving brief updates on the patients in the unit and their conditions. She came to a particular patient and paused in the middle of the summary. She smiled slightly, relishing the moment and what was to come. “And,” she said, “A maggot crawled out of his nose.” I suddenly felt as if I were in 6th grade. Ten nurses sitting around the table let out a chorus of moans and giggles. Tongues stuck out, lips curled, everyone laughed. It was a joyful moment and not at all at the patient’s expense. Something interesting had happened on the unit and though there was no question of shrinking from it neither was there any bashfulness in feeling grossed out. It was a happy honest moment which made me feel good about my choice of workplace. It also made me aware that I was experiencing something very private. Any outside observer would have made the honesty of this moment totally impossible. I wondered how such an occurrence would have been depicted in a TV show. I imagined appall and outrage, “Oh my God! How could this have happened in Our hospital?” How far from the truth such a depiction would be!

Friday, August 22, 2008

Surprise Encounter

“Where is the documentation, Lori! We need the documentation!” says the day attending to the night attending at the beginning of the shift. Lori pours through the chart, but she can’t find the advanced directives. “I know this isn’t what she wanted. I thought the paperwork was all taken care of.” Both of these doctors are unfamiliar to me. I have seen them around, but have not worked with them. Something about the way the day attending said “Lori” makes me look at her more closely. I went to grade school with a Lori. I look at her face. There is a red splotchy birthmark. It is her. It must be. I watch as she continues to flip through the chart. Her distress at the thought of her patient’s wishes being unfulfilled raises feelings of camaraderie in me. I wait for an opportune moment to say something to her, but she gets up quickly and goes around a corner. I follow, but lose her. I go into the doctor’s work room and check her name. It is her. Either she is not married or she did not change her name. I try to find her, but cannot. I only have so much time to spare – I have to get to my patients.

During the day, I tell other nurses that I went to grade school with the night attending. Some take it simply as a happy event, but others seem to think my enthusiasm is misplaced. They look at me as if to say, “Don’t you get it, she is the attending and you are the nurse. She is the success and you are the failure.” It does not bother me. I have made my choices with eyes open and I am not unhappy with my path. I continue to share my happy news.

The next day, I meet Lori in her office (I did not realize where it was the day before which is why I could not find her.) I introduce myself and then she recognizes me. “Oh it is you. They told me a nurse was looking for me, but I could not figure out who it could be.” She has me sit opposite her. The small, windowless room with a desk, a few chairs and a computer is shared by the attending physicians. I have not previously had cause to enter it. Lori tells me that she had noticed me before and that I seemed familiar, but that she could not place me. She asks to see my badge. I go by a different first name now. “That would not have helped either.” She says.

We catch up a little. I ask her if she is married. “No, and I won’t be if I stay on night shift.” This is her first job as an attending and she took it to “get through the door.” She asks for my story and I tell her about giving up my material possessions and staying in homeless shelters for a few days before moving into a Vaisnava temple and living as a renunciate for nine years in India and elsewhere. I married six years ago and needed a livelihood. Nursing has been a pretty good fit for the last three years. Lori looks at me with a strange, disconcerted look. I do not meet people from my past very often, but when I do, they usually look at me this way when they hear my story. It takes me off guard because I am used to being around people who easily understand and appreciate the urge to jump the fence and run.

Lori asks me what I think of the MICU. “On one hand we expend a whole lot of resources on people who really are not very worthy of it, and on the other hand dogs could never be treated the way these patients are treated,” I answer without hesitation. I am referring to the drug addicts, alcoholics etc. who destroy their health and then receive unlimited treatment which they will never pay a dime for, and I am referring to the patients like Mrs. Hardy who waste away over weeks and months, helpless to defend themselves against the constant needle insertions and painful procedures which come with ICU treatment. Lori’s head drops and she turns her face away. “I know what you mean,” she says, “We flog our patients pretty hard and most of the time we do not change the final result at all.” She adds that she has worked with attendings who were very aggressive in withdrawing care and that she was not comfortable with that either.

I have a tendency to speak too directly too soon. Friends have told me this. Lori continues to avoid my gaze. I had not meant to disturb her like this. I lean forward. I want to say, “Lori, it’s me Leo! Don’t you remember? We went to school together for ten years when we were kids!” Our grade school class had only 28 students. I look at Lori and see loneliness and sadness. For me, being here is a means to support my family. I have a rich community life that has nothing to do with this place. I am a nurse second. I could never give my heart and soul to this place. But that is just what Lori has done. How hard it must be. She must have started with idealism and now she sees the emptiness of it all, but she is trapped. This is her life. There is more to it than that, of course, but I think to myself that I would not want to trade places. She can stay the attending and I will stay the nurse. (Okay, I confess, sometimes I would not mind earning a little more for my troubles).

We continue to talk. Lori is close with her father. She talks about how she does not have satisfying relationships with her patients because, in her specialty, they all die on her. (The concept of this kind of relationship with patients is foreign to me). “A holocaust survivor just came through the unit. That is interesting, but she is dead now, so I guess it does not matter.”

I tell Lori I remember her eighth grade yearbook picture. She had drawn a picture of a hippo with the words, “mighty things from small beginnings grow” over it in an arc. Lori is very short. She was tiny then. She tells me she still has her hippo collection. She remembers me more clearly from this time as well although we did got to the same highschool also. The conversation comes back to my decision to renounce and I speak generally of an existential crisis. Lori says she still has not had one. “Maybe it is time you did,” I think to myself, but I ask for news about people we went to school with. Lori is in touch with a few and knows a lot more than I do. I hear about who is married, who is a lesbian, who is gay. No one from our class has died yet.

Our whole conversation lasted about fifteen minutes. I started to feel I had been away from my patients for too long and excused myself. We saw each other occasionally for the next few months, but never spoke again. She seemed to not feel comfortable talking with me as an equal in front of others and I did not feel I could leave my patients to spend time with her in her office. Besides, our lives are so different. I could not think of anything more to say. Once she asked me about a patients’ X-ray, but as nurses we do not read them and I could not say much about it. Once she told me briefly about her frustrations with her position – new patients were mostly arriving on the nightshift when physician staffing levels are lowest and she did not have enough help to take care of everyone properly. Was that the last time I saw her? Maybe it was.