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.

Monday, August 11, 2008

Did I mention...?

“If we had been doing our post-op neuro-checks like we are supposed to we might have caught it and been able to do something about it. Maybe we should look into that one day,” says the charge nurse a little wistfully and a little sadly. The next moment she is off to something else. This is my first time floating to the cardiac surgery intensive care unit (CSICU) and it is the busiest unit I have seen. My patient, Mrs. Jones, otherwise healthy for a 73 year old, has had a surgical repair of an abdominal aortic aneurism. During the operation blood flow to her spine was accidentally interrupted and Mrs. Jones is now a paraplegic, although she does not know it yet.

My other patient, Mrs. Smith, is on no less than six vasoactive drips, has a Swann (a pressure monitoring catheter that runs through the heart), is going in and out of V-tach and is already hooked up to the defibrillator in case she needs to be shocked at short notice. It is unusual to be assigned a patient in this condition on a first float to a unit, but she is awake and responsive and more or less stable. Given the level of acuity on the unit (the patients here are very sick) the assignment is appropriate. Tina, the charge nurse is very responsive, so I do not worry so much about the drips I am unfamiliar with and the Swann. I ask the questions I need to and get answers. When I arrived at this hospital, I received a four week orientation before I was allowed to take care of patients – and I had been working in the same kind of unit prior to coming here. Now I am floating, so I just have to say a little prayer and dive in.

Mrs. Jones’ daughter and son-in-law know about what has happened. They are waiting for the doctor to tell her himself before they talk about it with her. They are understandably impatient for this to happen. Mrs. Jones is lethargic, but awake, and asks occasionally why she cannot feel her feet. Her daughter responds by changing the subject. I try to find a doctor to speak with her, but the doctors on the unit all decline. They say that the doctor who did the surgery should be the one to tell her, and since he is in surgery now, he is not available. Mrs. Jones will have to wait. I explain the situation to the family.

I watch Tina following the physicians on rounds and coordinating the care on the unit. She seems twice the nurse I am. Her phone rings every five minutes with new information about patients coming to and gong from the unit etc. and she rushes all around the unit taking care of whatever needs attention. I do not have to wait more than five minutes for her to come around if I have a question. During brief pauses, Tina talks with her friend, another experienced nurse, about the stresses of being a single mother. After today’s twelve hour shift she has a PTA meeting. She wants to find a partner, but all the men are only interested in one thing etc.

Mrs. Smith’s Swann numbers and waveforms do not look right to me. Tina tells me to trouble shoot the setup, but I do not take Swanns very often, and what Tina is telling me to do does not seem to fit with what I am seeing on the monitor. I insist that Tina should come into Mrs. Smith’s room and look for herself. She does so and, after a minute or two of checking the tubing, she calls the doctor to advance the catheter. The end had been flapping around in her heart instead of being in the pulmonary artery where it belongs. No more V-tach.
Mrs. Jones’ family continues to wait in frustration. People from nutrition and physical therapy come by. Everyone wants her to know about her paraplegia, but we are all waiting for the doctor. The family begins to say that they will tell her themselves soon if the doctor does not come. I try to find out when he might be coming, but get no information.

The doctors order a blood filtration treatment for Mrs. Smith. It will be something like dialysis, but more simple. The treatment is administered by nursing. Tina wheels in a machine about the size of an average microwave oven and asks if I am ready to be trained how to use it. She leaves for a minute and returns with a plastic filtration cartridge. “Each one of these costs $3000,” she says as she rips open the sterile package. Tina begins the complicated process of inserting the cartridge into the machine. She gets confused and struggles with it for 20 minutes or so. While she is absorbed in figuring out the machine, her phone rings. A room is needed urgently for a new patient, but the only empty bed is being held for a patient who is in the OR. As she talks with the coordinator, she continues to work on the filtration machine and she forgets herself. “I wish X would just die in the OR (a hopeless case presumably) so that we would have the bed for Y.” I glance over at Mrs. Smith, but she is watching TV and not paying attention. Patients tend to tune out a lot of the discussions that go on around them as they are generally too technical to follow. Tina never did get the filtration machine set up.

A little while later I am sitting at the nurse’s station talking a little with Tina’s friend from earlier in the day. Tina comes by and I joke with her, “You know, it is usually not a good idea to wish one patient dead while in another patient’s room.” Tina turns pale and looks nauseous. “I do not think she heard you,” I add quickly. “I said that in a patient’s room?” Her friend starts to tease her about it lightly, but Tina does not see the humor in it. She is a good nurse.

Around 4:00 PM Mrs. Jones’ daughter tells me that they are ready to tell her about the situation if the doctors do not come right away. I let the doctors know and one of the fellows, not the original surgeon, comes to talk. He is obviously uncomfortable and unsure what to say. He explains that they are not really sure what has happened, but that some blood flow to her spine was disturbed. They are not sure what her final status will be. He tells her that the operation was very complicated and that she is lucky to be alive. He ends with “Just keep trying to move.” My anger rises as I listen. Why can he not tell her the truth so that she can understand it? As the fellow heads out of the room a technician from bed supply comes in. “Is this the New Para?” (as in paraplegic). This is now more than I can take. Will Mrs. Jones learn that she is paralyzed from bed supply? I ask the daughter for permission to clarify and she gives it readily. I tell Mrs. Jones that the blood supply to her spine was cut off during the operation and that the damage is irreversible. Mrs. Jones’ expression becomes so blank I become unsure if she can understand me. “Do you know what paraplegia is?” I ask. She nods once, still blank. “So, you are now paraplegic,” I say feeling how badly this is all coming out. I excuse myself as the bed tech starts to set up the specially padded bed which helps prevent bedsores from forming on immobile patients. I vent my frustration to the secretary, who alerts the nurse manager. She asks me about the situation and I tell her that I feel the fellow’s presentation was totally inadequate and ridiculous. I do not know what she did with the information, or what she thought about me or anything after that. We moved Mrs. Jones to the stepdown unit that afternoon.