Monday, April 28, 2008

Code Blue

On the other end of the surgical ICU, around the corner from where my patients are, Mrs. Jones is dying. I do not know about her illness, but over the past few days I have heard talk on the unit. The doctors have encouraged the family to withdraw care, but they have declined. Nurses often feel that doctors are far too hesitant to give families the bleak assessments they need to hear to prepare them for the end. Patients languish for months slowly declining while the doctors continue to throw out threads of hope for the families to cling to. One after another these threads inevitably break. Complications lead to more complications. One infection is resolved and another takes its place. When death is immanent and all that can be salvaged is the illusion of control is the time when the doctors usually encourage the family to accept the inevitable. The nurses have often known for months how the story is going to end, but they have to keep quiet. We bear the burden of maintaining the weeds false hopes that have been planted by television, watered by doctors and fertilized by incomplete information. Families visit wanting only to hear good news and we try to oblige. Inside we suppress strong urges to tell them to wake up and smell the coffee. If we could speak freely we would tell them that they are only making their loved ones suffer. All they are giving their mothers and fathers, their spouses and children is a miserable, painful death. But it is not our place to speak like this, and besides you never can tell which one out of a thousand will be an exception. Even the exceptions, though, hardly ever make it home.
So when the families are not listening to the doctors and are pushing ahead with hopeless care, as is the case with Mrs. Jones, the nurses really start to get agitated and people start to talk. In the break room I hear the fellow being asked about end of life care. She relates a story of a young man from a tight-knit Latin American family who was brain-dead. The family had brought him from another hospital for a second opinion, but the news was still the same. They begged for an experimental treatment. “Can’t you shock his brain back to life?” they had asked. The man was already dead, but the hospital maintained his body for several more days to give time for the family to digest the situation. They declined organ donation. The fellow felt at peace with her role in this and indicated that Mrs. Jones was a similar case. We were maintaining her to give the family time to adjust. She was not brain dead, but was probably still beyond much of the suffering. And there are always narcotics for pain.
In the afternoon the respiratory therapist sits at the computer next to me charting and looking up labs. “Look at this one.” she says to me, “Nothing I can do about this.” An arterial blood PH of 7.01 tells the story of rupturing cells, failing kidneys, clogged lungs and certain death. The heart will not continue to beat in such an acid environment. Normal PH is 7.35-7.45. Anything below 7.20 is critical. The charge nurse, Betty, has come to ask us for updates on our patients and Mrs. Jones’ nurse, Rachael, seeks her out to talk with her away from the family. Rachael is one of the more experience nurses on the SICU and has been given this sensitive assignment out of faith in her good judgment and sensitive bedside manner. She only has one patient today. With a sly, mischievous smile, Rachael asks the Betty quietly, “Do I bathe her?” Betty is taken by surprise and draws a quick breath. Her face shows love for Rachel and exasperation. This would be the infamous ‘death bath’ where the patient’s condition is so tenuous that she will not survive the turning of her body that is required for changing her sheets. “Well, how bad is she?” asks Betty. Rachel replies that the bed is totally soaked. Without making a decision, they begin to talk about the code we are all dreading. Another nurse joins the conversation, “With her belly open like that, her guts are going to spill out on the bed when we do chest compressions.” “What about medical futility?” I say – physicians are not required to offer treatments when they have no expectation of any positive effect. Betty replies that there would probably be a lawsuit if we did not code Mrs. Jones. “But that is not the real reason. The family needs to see it. They need to feel that everything possible was done.”
On this day one of my patients has moved out of the SICU to a step-down unit. The patient is moved in their own bed and the clean bed from the room they have gone to is brought back to the SICU and kept in the hall until the previous room has been cleaned. My room is clean now, but I chose the wrong spot to leave the bed and my bed has gone missing. With the excuse of going to get the number for Bed Supply I walk around the corner to have a look at Mrs. Jones and her family. I am almost there when I hear the warning alarms go off. I am next to one of the central monitors and with a quick glance I see Mrs. Jones’ heart beating its last. I rush back and shout around the corner, “Its time!” Rachel and Betty are already on their way. We head to the room which is by now full of busy nurses and doctors. Rachel dives in and takes up position at the head of the bed. She knows the IV lines and will push the drugs. Betty stands at the back of room, near the doctor to coordinate. The respiratory therapist is at the head of the bed. She has taken the patient off the breathing machine and is ventilating her with an ambu bag. One nurse rushes to hang IV fluids on pressure bags as Rachel dials up the meds that are already running on the IV pumps, increasing the doses. Another nurse mans the code cart, pulling out meds and handing them to Rachel to be pushed. I notice that no one has started the code documentation, so I grab the manila envelope and start. I record the meds that go in, the CPR, the fluid, the respiratory information and the heart rhythms. Nurses, techs and doctors take turns at chest compressions. The saying is that if you are not cracking ribs, your compressions are not effective. Mrs. Jones’ guts do not spill out of the 2 foot long, one foot wide incision in her belly. The surgical attending physician is in the habit of reinforcing the dressings with an OR towel and this pays off again. The brown cellophane suction bandage stays in place on Mrs. Jones’ huge swollen abdomen. Her large breast stands straight up and by its color it appears to be full of blood. The suction tube from Mrs. Jones’ stomach is full of dark red blood; her body is so full of fluid that her skin is taught all over her body and drops of yellow fluid ooze out of every pore. We continue the hopeless drama, but everyone is sincere. It is more than an exercise. We are not just drilling. The family huddles at the back of the hall and we are showing our hearts. We are doing everything we can. Meds are given every two minutes; Epinephrine, Bicarb, Atropine, Calcium, Vasopressin, over and over. We call out to each other so that we all know what has been done. “Anything else we can try? Should we give Magnesium, doctor?” “Alright, one amp of Magnesium.” Comes the reply. The defibrillator is in place, but there is no rhythm. There is nothing to shock. This is not TV and we all know there is no point in shocking asystole. We will not do it for the gratification of the family. Every few minutes we pause to check for a rhythm. After fifteen minutes, long after severe permanent brain damage is certain, we see, to our dismay, something on the monitor. How much longer will we have to put poor Mrs. Jones through all this? “Is that sinus brady?” someone calls out. “Is there a pulse?” I call out. There is no pulse, no blood pressure. I mark down PEA (pulse less electrical activity). After another minute the fellow calls the code. A young man, whose mind appears younger than his body by his affect rushes in from the hallway. “Don’t leave me Mommy! Don’t leave me!” In the hallway the other relatives begin to weep. Someone yells, “Get a gown on him!” Mrs. Jones has an antibiotic resistant bacterium we are trying to stop from spreading. The son, overwhelmed in his grief, still pauses submissively as we tie the gown on him. You can see he has appreciated our efforts. As usual, no one bothers about getting gloves on him which is really more important than the gown. We tie up loose ends and disperse.

A family’s fresh grief moves everyone in spite of the inevitability of it all. A more jaded nurse mutters “Jesus Christ!” trying to shrug it off. We all feel like being quiet. Some people pair off to talk about their feelings and how it all went down. Tomorrow it will be something else.

Sunday, April 27, 2008

First Death

Prior to working as a nurse I had never seen anyone die. I had not even seen a dead human body. When I started my orientation in the Medicine Intensive Care Unit (MICU) I was not uncomfortable with the idea of witnessing death. Instead, I was interested and curious. I had a sense that this was an area where I would find engagement for my strengths. In spite of my first experience, this has been borne out. Death is something so hidden in our society that patients and families often have little experience with it. For this reason they do not know what to expect when the time comes. They are also often unaware that the dying process is taking place. It is often seen that mourning begins when the monitors are turned off. The family may be at the patient’s side, they may have watched as breathing has stopped and seen the heart monitor go to a flat line, but when the nurse reaches up and turns off the monitor, they begin to cry and wail. This is the act that makes the situation real.
While caring for dying patients and their families I try to make sure that everyone knows what is happening. I try to answer whatever questions they may have and to keep them in touch with their doctors and other members of the care team they may want to speak with. As the patients are often unable to communicate with their families at this time, the family members usually desire to speak about concerns about what the patient would have wanted. Finding themselves in the uncomfortable role of making decisions for the patient’s end of life care, they urgently want to know what will make their loved one most comfortable.
Once I listened to a attending physician on rounds discussing end of life care with new interns. He emphasized that, once a patient has made it out of the emergency department, in greater than 95% of cases death occurs when care is withdrawn. This is a very significant fact. In our culture of TV fantasy we see that patients and families are rarely prepared to accept death as an inevitable outcome. We are so accustomed to seeing make-believe last minute heroic saves that hope for recovery often remains intact long after it has become appropriate to focus on preparing for the end. As a result, patients often receive much more intervention than is warranted. It is not unusual for patients to be maintained in medicated comas and provided with uncomfortable surgical interventions. The goal of these interventions may be simply to extend life for a few more days or hours. When this takes place, it is often because patients and especially families are not ready to let go. It is therefore particularly striking that such a great proportion of patients die when care is withdrawn. Almost all of the time patients die when families finally come to the conclusion that continued interference with the natural process of death is simply causing their loved one unnecessary pain.
As a nurse I find few things more painful and exasperating than watching patients go through unnecessary suffering at the very end of their lives. I therefore find some satisfaction in assisting in the process of coming to terms with the inevitable and thereby helping to release patient and family from hopeless and miserable situations.

A few weeks into my orientation on the MICU my preceptor selected a patient whose family was likely to withdraw care that day as our patient for the shift. This would be an important part of my orientation as the death rate for patients admitted to the MICU was around 33 percent. Caring for dying patients would certainly be part of my daily job and I would need to learn what to do and how to manage myself.
Our patient, Mr. Greene, was a man in his fifties who had worked in a fiberglass factory. His lungs had been scarred to the point where he could no longer breathe adequately on his own. Mr. Greene had been on mechanical ventilation for more than a month. When awake, Mr. Greene became agitated. He would fight against the ventilator and the restraints which kept him from pulling the breathing tube out. His agitation also drove his blood pressure dangerously high. To correct and control this, he was receiving, among other medications, high doses of morphine to make him more comfortable. While this was effective in controlling his blood pressure, he was almost never awake. His lung capacity continued to diminish and higher and higher ventilator settings were required. The time was fast approaching when it would no longer be possible to increase his ventilator settings further.
Being as new as I was, I did not question whether the use of morphine to control blood pressure was appropriate. It is even possible that I had not properly understood his medication regimen. In any case, on this day Mr. Greene’s blood pressure did not start to increase and he did not show signs of being in pain, so I did not administer the optional doses of morphine that he had been receiving for so long. This, together with a change in ventilator settings allowed Mr. Greene to awaken for the first time in several weeks.
He awoke to find perhaps fifteen members of his extended family surrounding his bed praising Jesus and praying for him. They had just had a family meeting with the physicians and had agreed to withdraw ventilator support on that day. Many of Mr. Greene’s extended family had not visited him for sometime and so they were not particularly surprised to find him awake. They happily took the opportunity to talk with him and say their goodbyes. He also appeared happy for their presence. He did not understand the decision they had made and, perhaps out of discomfort, they did not spell it out for him. Observing him I realized that after a several months of being tied down and unconscious he no longer had any use of his arms. Even his fingers did not move at all. I untied and removed his wrist restraints. He did not need them any more.
Outside of the room I told the doctor that Mr. Greene was awake. I was not sure if this would have an impact on the plan to withdraw care or not. “No way.” Said the doctor, but after coming out of Mr. Greene’s room he confirmed, to his surprise, what I had seen. The plans to withdraw care were not reevaluated.
Following instructions, I prepared a morphine drip and a 10 milligram bolus of morphine. Since Mr. Greene had been receiving so much morphine, higher than normal doses would be needed to keep him comfortable. My preceptor asked if I wanted to stay in the room for the process and I said that I did. Most of the family had left now. Only Mr. Greene’s mother and sister and another male relative remained. As my preceptor and I entered the room, the male relative decided he did not want to stay any longer and he left. I hooked up the morphine drip to the patients IV and hooked the syringe with the 10 mg bolus to the IV line. My preceptor got close to his face and explained to him, “Mr. Greene, we are going to give you some medicine now to make you comfortable and then we are going to take you off of the ventilator okay?” Mr. Green began thrashing his head back and forth. It was not okay with him. My preceptor took a few steps back. I waited for someone to say, “stop.” No one said anything. I continued to wait. Mr. Greene looked at his sister with pleading eyes and continued to shake his head. She did not engage his glance. Mr. Greene’s mother spoke up, “have you given him the medicine yet?” she asked. My preceptor looked at me with growing agitation and gestured to me that I should give the bolus. It did not seem right to me, but I deferred to my preceptor and gave the dose. It had almost no effect. I stepped away from the bed, not willing to do anything more. My preceptor quickly moved to the IV pump and began rapidly increasing the dose. The vigor gradually faded from Mr. Greene’s protests. By this time the respiratory therapist had arrived and the ventilator was removed. Mr. Greene’s eyes quickly became still and glazed over. He died quickly over the next ten minutes or so. I watched as his breathing slowed and became ineffective gasps with longer and longer pauses. His heart slowed to 60 beats a minute, then fifty, then it stopped. I reached up to turn off the monitor and the family began to weep. I seemed alone in my discomfort about how things had gone.
As I drove home that night I began to feel as if I had become an executioner. “This is not what I signed up for.” I told myself. I told my wife what had happened. It did not sound good to her. I called an older acquaintance who was a hospice nurse and told her the story. “That was totally unethical” she said, “but I am not surprised. It probably happens like that all the time in ICU’s.” (It does not). My friend encouraged me to talk to my supervisor and perhaps to contact the hospital’s ethics review board. I did so. Shortly thereafter I heard my preceptor complaining from the nurse manager’s office. “Its too late now. If he felt uncomfortable, he should have said so at the time. It is done now there is no point in talking about it.” I do not think she ever forgave me and the rest of my orientation went on with some tension. At one point I heard her tell another nurse that she could not wait to get me off of orientation. Apparently she was of the breed that embraces the philosophy of ‘never look back.’ As a highly reflective person this kind of thinking is very foreign to me. I want to know about the mistakes I have made so I can avoid repeating them.
It was particularly important for me to explore this event. Why did I acquiesce? Had I allowed myself to be intimidated? Had my curiosity and eagerness to have a new experience dampened my will to resist? What could I have done differently? The dose I had administered was not the decisive one, but I still saw that I had initiated the process. It would have been within my power to change the progression of events. What should I have done? I asked my nurse manager. No clear answer came. I was told not to do anything that made me feel uncomfortable. A nurse from the palliative care team who was also a member of the hospital’s ethics review panel came to speak with me. She also expressed the same sentiment as my nurse friend that this was probably a common affair in the MICU. At our first meeting she expressed an interest in taking the case before the review panel. A couple of days later things had changed. My preceptor had not backed my version of events. By her recollection Mr. Greene had been in a coma for more than a month. I was a new nurse and had obviously misinterpreted whatever it was I saw. There was furthermore no documentation in the chart to support my version. I had not evaluated Mr. Greene’s level of consciousness. I had not written anything about him waking up in my note on the chart. The doctor had not written anything either. No one, including myself, felt it would be a good idea to disturb the family by asking for their version.
That was pretty much the end of it all. To my preceptor’s annoyance I continued to ask other nurses what they thought. “Don’t do anything you are uncomfortable with,” was the standard answer, which I did not find particularly satisfying. After a couple of weeks my preceptor spoke with me privately. “Listen,” she said, “If we had done something the family might have taken back their decision to withdraw care. Half an hour later Mr. Greene would have been back in a coma again and he would have stayed that way for weeks until he died.” This satisfied me somewhat. I did not agree completely, but at least it made some sense. I resolved to act differently in the future. If I had it all to do again, I would have slowed things down. I would have encouraged the family to talk with him. I would have talked with him more myself. I would have tried to explain his condition to him. I would have waited that half an hour until he was back in his coma. I would have tried to save that last half hour for him.

Beyond Healing

It is mid morning and I am starting to get annoyed with the resident. He is speaking with the family of my patient. By my estimation, she does not have long to live. Instead of giving them clear answers to their questions, the resident is uncomfortable and evasive. He appears to be of the type that does not like to say that there is nothing more that can be done and death is inevitable. The family, in spite of this, seems fairly clear on the situation. They have already stipulated that there should be no further surgical interventions and are seeking information so that they can make decisions on how to manage her end of life care. The doctor keeps saying things like, “without being able to intervene surgically we do not have any way to try to change the progression of the disease process.” These statements are making me angry. I have seen her wound and know that there are no surgical solutions here. Enough has been tried already. I am feeling that it is actually very inappropriate that this doctor is trying to escape from his own discomfort by placing a burden of guilt on the family.
The patient’s husband, daughter, son-in-law, and 9 year old grandson are present. The daughter and husband are talking with the doctor while the others visit. The daughter is leading the conversation and I can tell right away that she is a nurse. She is not put off or intimidated by the doctor’s evasiveness and continues to repeat her questions over and over with different phrasing to try to corner him into giving up what he knows. She is trying to get a sense of how much time her mother has, how bad the wound is and what the different options for interventions and withdrawal of care will mean. The doctor continues to place things on the family, “We will manage her care however you decide,” he says, “If you want us to stop her care we will do that, and if you want us to continue treating her with the goal of getting her to a skilled care facility we will do that.” The daughter asks pointedly, “Do you think she is going to get better and be able to go to a skilled care facility? It has not sounded like that.” I lose patience and jump into the conversation for the first time, “It is not that she will actually make it to a nursing home, we would just manage her care with that as a goal.” “Yes, that’s it,” says the resident appearing relieved that I have found the right words to say. The daughter gathers my meaning and also appears to appreciate the clarification. I do not say anything more, but I stay nearby and wait for the conversation to wind down.
As soon as the doctor has left I turn to the daughter and say, “Are you a nurse?” She replies that she is. “Do you want to see the wound?” I ask. “Yes I do.” She replies without hesitation, “When will you change her dressing?” I explain that I have already changed the dressing for the shift, but that it is a very simple dressing and I feel it is important for her to see the wound. She agrees and we move into the room to the bedside. The patient lies in bed very much aware, but unable to speak due to being on a breathing machine which is attached to a surgically inserted tracheal airway in the middle of her neck. “The nurse is going to let us look at your wound Mom, is that okay?” says the daughter. The patient gives her consent. I gesture to the patient’s husband and son-in-law and say, “maybe they should not see it.” “No, we want to see it. We both want to see it.” comes the immediate answer. The grandson, however, is told to sit on a chair by the sink, still inside the room but on the other side of the curtain. He protests initially but quickly acquiesces.
Now it is time to see the wound. I call the daughter to my side of the bed and leave the men on the other side. I pull the patients gown down to her abdomen, exposing her chest. She has had open heart surgery a month or so prevously and the incision has become infected. A line of sutures begins from the top of her sternum and continues down to a gauze pad in the middle of her chest. At first glance it does not appear to be a mortal wound. I remove the gauze pad to expose an open area about five inches long and three inches wide which is packed with more gauze. Once this gauze is removed the entire wound is exposed. The daughter leans in to examine it. Where the sternum once was there is now a window into the patient’s chest. It is like looking into a running washing machine as fatty tissues and membranes pulse from the rapid beating of the patient’s heart and slosh up and down with her breathing. A foul odor comes up from the wound. The daughter looks at the sutures that are still intact. Beneath the skin, the tissue is brown and dry. Points of light can be seen coming through between the sutures in several places. “There is no healthy tissue there at all.” She says “the whole thing is going to open up.” From behind the curtain the grandson, overcome by curiosity, speaks up, “Is it bad Mom?” he says. “Be quiet Jeremy!” his father snaps. “I just want to know if it’s bad. Is it bad Mom?” he protests. “Jeremy, be quiet.” She says. The patient’s husband and son-in-law now come around the bed to see the wound better. They are transfixed by the wound and have forgotten the patient. I look at her. Her eyes are darting back and forth and her head moving from side to side as if she has been captured by an unseen force and is looking for some way to escape. “Are you okay?” I ask. She looks at me and mouths “I’m scared.” “Yes it is scary.” I say in a reassuring way. She becomes a little calm. I cannot tell her that everything will be alright, or that she will get better soon. I can try to connect with her, try to understand her and give her a voice. Seeing my concern she is a little soothed and becomes calmer.
I begin to feel that it may have been a mistake to show the family the wound. They continue to gawk and remain inattentive to her distress. I tell the daughter I am going to redress the wound. She helps me by getting the others away and slowly their attention shifts back to the patient. At first they seem unsure what to say, but gradually they begin talking. They turn to me and thank me for showing them. Over the next few hours they thank me numerous times for the clarity that this has brought them and I feel more at ease with my decision.
After some time the grandson leaves with his father and the patient’s husband and daughter speak with each other. They invite me to be present. Having talked with his wife the husband tells the daughter that the patient is not ready to die and that she has told him that he should pray for her. He tells us that he tried to explain to her that he was not going to be able to change her situation in this way, but that she was insistent. They begin to discuss options for her care. The daughter, being a nurse, does not want to make her mother suffer by unnecessarily prolonging her death. The husband is unsure, “she is not ready to die yet.” He says. The daughter counters him, “No one is ever ready to die Dad, but nature takes its course. Nature is taking its course here and we do not want to make her suffer for nothing.” The daughter asks me for a mirror. She wants to show her mother the wound. “I do not think she would want to see it.” I say thinking of her high level of anxiety. “But I think she needs to,” the daughter replies. I look, but there are no suitable mirrors on the unit, so the point is moot. “She asked me for a couple more days and I have to give that to her if I can,” says the husband. They are both satisfied with this plan and turn to me to ask how I expect things to go. I explain to them about IV blood pressure drips called pressors which are used to counter the drops in blood pressure which often occur as a consequence of systemic infection. I explain that, in the patient’s current condition, without pressors her blood pressure could at any time drop below life sustaining levels and she could die within a few hours from this. With aggressive use of pressors, she could possibly live for months, slowly becoming more and more ill. In the end they decide to continue to use pressors for the time being with a plan to reevaluate after a couple of days. They decline other kinds of interventions such as use of chest compressions and shocks. I work with the doctors to formalize and document their wishes.
Later in the day the patient’s daughter leaves and her husband stays. The patient falls into a deep sleep and her blood pressure drops below life sustaining levels. If nothing is done perhaps she will die in a few hours. I look at her husband and see that he is unaware of the situation. I quietly go to the IV pump and turn on the Norepinephrine which is still in place from the previous night. The husband does not enquire as to what I am doing and it feels unnecessary to mention anything. As I go to leave the room I pause for a moment near the husband and he begins to speak. I squat next to him to hear more clearly. He tells me that he had watched his mother die a similar death and that this is even more difficult. Then he says that he has studied many of the world’s religions and philosophies, “and none of it helps. The one thing that does help though is knowledge.” He thanks me again for showing them the wound. Then begins to speak about his daughter and how fortunate it is to have her assistance. “I feel sorry for people who do not have a daughter who is a nurse,” he says. She knows what questions to ask and how to ask them. She is able to help them all to understand what is happening and what it means. He tells me that she works in a neonatal intensive care unit. She has told him stories of how she has on occasion spent nights weeping for dying infants to which she had become attached and of the trauma she experiences in breaking bad news to families. I feel honored by his sharing. I feel I have gotten things right this time and I am satisfied within myself. We talk a few more minutes and then I leave the room. The rest of the shift is uneventful. I do not know what happened to them after I left.

One more piece of information

One day I paused to listen to a doctor as he spoke with the family of a dying patient. Looking at the monitor I could see the telltale wide QRS waves of a dying heart. The patient would be dead within an hour or two. The doctor explained that there was nothing more that could be done and that we were keeping the patient as comfortable as possible. After the doctor left the patient’s nurse invited the family back into the patient’s room. The patient was on isolation precautions and this would entail putting on isolation gowns again. The family declined. The nurse registered slight disapproval that the family did not want to be with the patient in her last moments and then moved on. After she left I approached the family and asked them if they understood what the doctor had told them. They said they thought they did. I said, “So you realize it is happening right now and she only has an hour or two at the most?” The husband drew a quick breath. They had not realized. They became activated and decided what to do. The rest of the relatives, including the patient’s young daughter, were brought to the room to say goodbyes. After a few minutes some of the visitors left, taking with them the young daughter, who did not understand what was happening and kept telling them that everything was going to be okay. I returned to my own patients. That patient died shortly thereafter.


What do you call a quadriplegic lying on the floor? Matt. What do you call a quadriplegic in the water? Bob. What do you call a quadriplegic leaning against the wall? Ilene. And if she is Chinese? Irene. I learned these jokes somewhere around the fourth grade. I often wonder now how anyone could find them funny. There is nothing humorous about being a “Quad”
Hear the story of Mr. Tucker. Tall and obviously once handsome in a rough way, Mr. Tucker’s face shows signs of toughness with perhaps a softer side underneath. I never heard about the circumstances surrounding his gunshot wound. That had happened ten years before I first took care of him and the story had been lost, along with the other remnants of his previous life, in his endless wandering through hospitals and long-term care facilities. Now his life is spent entirely in bed. When awake, his head nods up and down in concert with his breathing. When you get his attention, he can look at you for just an instant. He cannot respond to his name or any questions. Tears frequently run down his face. Sometimes he appears to laugh at jokes the nurses tell to each other while in his room. Perhaps he has thoughts. Perhaps he is aware of his surroundings, but it is impossible to know for sure. His right arm is folded up on his chest. If you pull it down and out about a foot, which is as far as it will go, he can pull it back up to his chest. That is the full extent of his ability to move his body. He lies in the bed, his trach forever hooked to a ventilator, a feeding pump pumping tube feeds directly into his stomach day and night. He has a large ulcer on his sacrum and smaller wounds elsewhere on his body. His belly is round like a beach ball and lies unnaturally on his middle aged frame. He comes regularly to the ICU to be treated for infections and pneumonias. Blood pressure drips, antibiotics and fluids hang on his IV pole. Who is looking after him? Why do they keep him like this? “Someone somewhere must be getting a check,” says the tech cynically. One instantly feels condemned for thinking in this way, even if there is sometimes truth in it. Is it Mr. Tucker’s mother who comes to visit him? She does not talk to anyone and sits quietly for an hour or so. When she thinks no one is listening she may say a few words to him. Who will say to her that she is keeping him alive only to suffer? It will not be me. I would not dream of it. Who then will speak for him? What would he really want?
Mr. Tucker’s care is simple. He needs to have his lungs suctioned frequently because of thick mucous buildup in his lungs, he needs to have his IV medicines administered and he needs to be bathed and to have his wound dressings changed once a shift. Wound care on this type of patient is generally done towards the end of the shift as a courtesy to the oncoming staff. If the wound care has been done early, the next shift will also be obliged to do it at the beginning of their shift. Doing it later allows the next nurse to take care of it at her convenience. The tech and I flip Mr. Tucker on to his stomach and I begin to take down his dressing. Mucous pours out of his mouth and his oxygen levels drop. He is getting sicker. I suction him again and turn the oxygen up to 100% on the ventilator. I pull out the old, foul smelling, yellow and greenish tinged gauze, apply an enzyme to dead tissue in the wound, wet a fresh piece of gauze with saline solution, wring it out and then tuck it into the wound going into the pockets between skin and flesh. An absorbent pad is placed on top and taped down. We change the sheets and bring him again to lie on his back. I suction again and wait for his oxygen levels to stabilize before turning the ventilator settings back to where they were. The tech is gone now. I look at Mr. Tucker. He looks so miserable. I say to him truthfully, “I do not think it will be much longer Mr. Tucker.” Tears stream down his face. His nodding becomes a little more pronounced. Does he hear me? Does he understand what I am telling him? I pause a moment more. I will never know the answer.

At the age of 19 John came from his home in the northwest to visit his father. He had gone one night to a party. He had had a lot to drink and could not remember the night’s events. The next day he began to feel tingling in his hands and feet. When he awoke the next day he could not move. He told his father when he came to get him up, but his father thought he was faking and went to work. He returned to find his son as he had left him and decided he would take him to the hospital – the next morning. By then it was too late to administer the anti-inflammatory medications that would, most likely, have prevented any permanent injury. John had now become known as “the new quad in room 8.” His mother had come to be with him. He could not speak as he was now dependent on a ventilator for breathing, but she could read his gestures and his lips and gave him a voice that he otherwise would not have had. His father also came frequently. He tried not to show the weight of the burden of guilt he would now carry. John’s mother did not fight with him or show any anger towards him. She made plans to bring him home. She would have to get the front porch redone to make it wheelchair accessible. She struggled with insurance companies to get them to pay for the flight he needed back to their state. She struggled to find a skilled care facility near her home that would take him in the interim. John became angry with her when she left the room.
John must have fallen badly. Someone who had been at the party must have known what had happened, but no one was talking. A man a little younger than John’s father came to visit him. He went in the room to speak with him, but John just glared at him, I wondered to myself if John thought this man knew what had happened. He came out of the room a little shaken and turned to me. “He looks like he’s really angry with me. I don’t know what’s going on,” he said. I replied that it was pretty hard for a person to be in the situation John was in. The man contemplated my words for a moment, “He’s totally fucked!” he said. Taken aback, I did not say anything more. The visitor seemed satisfied that he had done what he could and left shortly thereafter.
John stayed in our unit for a month or two before the flight was finally arranged. During that time it was arranged that his girlfriend would come to see him. As her arrival approached everyone focused on the progress he had made. John’s father shaved his face so he would look his best for her. He seemed happy at the thought of seeing her. Shortly before her entrance he became sullen. Some things are impossible. In honor of her visit John left his room for the first time since his injury. It was John in the bed being pushed down the hallway by his nurse and a tech. His girlfriend walked next to him holding his hand. His mother walked on the other side of the bed. The, respiratory therapist pushed the ventilator. Alas, what can be said about such a sight?


Leo Levy

On my first nightshift I was placed under the care of a young male nurse named Justin. Justin was quiet and mellow. He told me he liked night shifts because they give you more of a chance to get to know everything about your patients. As I was very new, Justin kindly gave me simple tasks to perform. Being emphatically not a night person, I struggled to stay awake more and more as the night progressed. Around midnight another nurse, Jessica, came to Justin to ask for help with bathing her patient – the largest on the unit weighing around 450 pounds. Justin turned to me, “Wanna help lift pannus?” he said. I nodded affirmatively. Having absolutely no idea what he was talking about I followed him into the patient’s room. There lay Mr. Ray – a large puddle of flesh in an even larger bed. Mr. Ray’s belly rolled down to his knees and sloshed out wider than his shoulders like a giant water balloon. Mr. Ray’s privacy password, something like ‘meathead,’ seemed to give some insight into his character, as did the fact that his only communication with the world around him was to raise his eyebrows in the affirmative when asked if he wanted pain medication. While Jessica used a wet cloth to wipe down his legs, Justin stationed me on one side of the bed and made his way around to the other side. There he opened up a flat sheet and began tucking one end into the skin folds between Mr. Ray’s thighs and belly. Pulling the middle portion around and under Mr. Ray’s belly fold, Justin handed me the other end and gestured that I should do as he had done. Still not comprehending, I complied. Once my task was completed, Justin grabbed his end of the sheet tightly and braced himself and indicated I should do the same. “Okay,” he said, “Heave ho.” I suddenly remembered the meaning of the word ‘pannus’ as we shifted Mr. Ray’s hanging belly fold, his pannus, up towards his chest. Jessica, a young woman, now leaned in, cursing at the foul odor, to bathe his genitals and perineal area. She did a thorough job. Afterwards we rolled Mr. Ray onto his side to change the dressing on his sacral ulcer. Being stationed on Mr. Ray’s front side I was not able to see the wound. I watched as Justin let out a breath and turned to his head away to avoid becoming nauseous, A new odor, more foul than the first, filled the room. As Jessica cleansed and then packed the wound with roll after roll of moistened gauze, she expressed frustration. “I do not know what we are supposed to do about this,” she said, “There is no way we can keep him off of it.”