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.

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!

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.

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.

Final post on Mrs. Hardy

I was off for five days and returned expecting to hear the story of Mrs. Hardy’s passing, but she was still hanging on. There had been another family meeting and she now had “do not resuscitate” (DNR) orders in place. She also had orders for no further escalation of care. Even though her systolic blood pressures were now in the mid to low eighties and her heart rate had dropped to the 50’s, her Levo drip would be left at the same dose it was at when the do not escalate orders were put in place (4 mics). I asked her nurse, Mark, for the stories from the last few days and he was glad to tell them.

Mrs. Hardy had had three dialysis treatments over the last five days to correct her critical metabolic acidosis. This had brought her back from the brink, but she continued to decline slowly and would have required continuous dialysis. “How aggressive do we want to be, considering her condition?,” someone from the renal team had asked.

Susan had gone on vacation and Debbie, a bolder, more experienced palliative care nurse, had taken over the case. She had decided to put an end to the farce. There had been a family meeting the day before. Lori was Mrs. Hardy’s nurse that day, and she made Mrs. Hardy’s children stay in the room with her for the dressing change - just before the meeting. They were shocked apparently. “This is never going to heal. Do you understand that?” Lori told them. Debbie caught the attending before the family meeting and explained things to him (she told me the story herself). She told him that the family needed to be told what care the doctor felt was appropriate, not asked what they thought was best. In the meeting, she told the family that this meeting was not going to be about their needs, like the last two had been, but was going to be about Mrs. Hardy’s needs. The son would just have to figure out where he was going to live, and what to do without that check he was getting (Debbie confirmed this as being part of the problem). The family agreed to make Mrs. Hardy a DNR without escalation. Lori had wanted to withdraw care right away, but Debbie was concerned that pushing too hard might have undone the progress they had just made. Mrs. Hardy had already had to wait three months. Another day would not be the worst outcome.

As the day passed Mrs. Hardy’s systolic pressures dropped into the seventies and her heart rate slowed to the forties. Everyone kept asking about the children. The oldest son and the daughter had said they would return, but they did not show. The younger son was going to stay away. Mrs. Hardy was dieing very slowly, all alone. I left at 7:30, expecting her to pass during the night.

The next morning, Mrs. Hardy’s systolic pressures were in the sixties and her heart rate was in the 30’s. Most people’s hearts would have given out by now. The night nurse related that Mrs. Hardy had opened her mouth to allow her oral care upon being requested to do so. Her eyes were half open with almost no movement. It was hard to tell if she could see or not. Her children had decided not to come. As I stood at the entrance to her room, pausing to watch her and the monitor, Laura came up behind me. “Did you hear what the daughter said? ‘Go ahead and pull the plug!’ If I could shoot someone right now…, but I do not have the time.” Laura was taking the charge nurse role for the first time this week. She checked on us every two hours.

Mark was taking care of Mrs. Hardy again today. The children had told him they were ready for care to be withdrawn, but they had not spoken with the physicians. The new residents were not sure if the attending needed to speak with the family, and had put it off for rounds. On rounds the attending instructed the resident to call the family for confirmation, but this was put off until after rounds. Even after rounds, the resident could not be bothered. There were a few sick patients on the unit that needed attention, and it was clearly a low priority for them. Mark had taken care of Mrs. Hardy more than any other nurse on the unit and his frustration was evident. He kept asking the doctors to call. They kept putting him off.

Debbie arrived in the afternoon. She had had other engagements in the morning. She got on the phone to call the children right away, fielding two calls at a time from the siblings. She caught the attending as he was walking by and put him on the phone with them. We would turn off the Levo and take Mrs. Hardy off of the vent. Mark thanked Debbie for her help. Debbie joked about killing patients off, showing awareness of possible other perspectives on what she was doing. “This should have been done a long time ago,” I said, not that she needed to hear it from me.

Mark started an ativan drip. Debbie grabbed Joe (the extern) and a brand new nurse who had just started orientation on the SICU to be present in the room. Even with everything off, it still took a couple of hours. About three quarters of the way through, I came around the closed curtain into the room. Mrs. Hardy, now off the vent, was taking agonal breaths. She did not seem to be in pain. The room was dark and the new nurse was standing close to her face. “Has it always been that color?” she asked. Debbie replied that she was getting a little cyanotic at this point. I did not disapprove, but thought about how different it would be if family was present. Her lifeless body was still in the room at the end of the shift. The night shift did the tagging and bagging. By morning there was another patient in the room. And do you know what? His story is not too much different from hers.

A forty ounce bottle and a two-by-four

This week Mrs. Hardy’s condition remained more or less stable. She remained on the amiodarone and levophed drips, but did not require increasing doses to maintain her blood pressure. My patients this week were her neighbors, so there was ample opportunity for me to observe.

On rounds the doctors discussed new developments: her liver function is down and her kidneys are failing. She will need dialysis soon. The resident mentions her plan to call for another family meeting to talk about whether or not to do dialysis (a very significant decision), but the attending (Dr. Pock, a different one than last week) stops her. “Didn’t you just have a family meeting a few days ago? The family said they wanted everything done, so go ahead and get a renal consult.” The residents and fellows shoot uncomfortable looks at each other. “I…I just did not know how aggressive you wanted to be…” says the resident. “Me? What do mean by that? This is not about what I want.”

I go around the unit telling some other nurses about the incident. “Oh! Dr. Pock is the worst, I hate him!” says Lori, one of the most senior nurses on the unit. “He doesn’t care about the patients. He just comes for rounds and then he goes away for the rest of the day.” Lori and another nurse talk about how they have heard that the son who is against limiting Mrs. Hardy’s care is living in her house. “Oh, now it all makes sense, now I understand everything.” The implication being that the son is benefiting financially by keeping Mrs. Hardy alive.

I ask Susan from palliative care about this, but she does not agree. She has been working closely with the family. Mrs. Hardy has been living with her youngest son, and since he has been closest to her, the other siblings are deferring to him. Susan says that he is just not very intelligent and cannot comprehend the reality of the situation. He also has another family member that is very ill and Susan thinks he is just not able to face it all yet. It is an interesting way to plan a patient’s care. The son cannot even bring himself to visit, but he cannot let her go either.

The sense of discomfort on the unit continues to heighten. Normally callous nursing assistants talk about how sad it is to do this to Mrs. Hardy. The wound care nurse, an old hand who does not usually stop to talk, asks me about whether Mrs. Hardy is still a full code and what the plans are for a family meeting.

Laura, Mrs. Hardy’s nurse today, asks me for help with a turn. Mrs. Hardy’s eyes are closed. Her complexion is now dark brown, as if she has been in the sun all summer. I touch Mrs. Hardy’s eyebrows lightly and ask Laura “Is she still there?” “Just a little,” she replies. As we turn her, Mrs. Hardy opens her eyes. She seems to be in less distress now, as if her soul’s connection with her body is loose and slackening. It would be easy to ignore her and assume she is not able to understand us. She does not even move her lips anymore. As I look into her eyes, her hand rises slightly and I take hold of it. The look I see feels like recognition and gratitude. As she stares out from the grave, I feel glad that I can still reach her, but then I start to have doubts. Her eyes hardly move. How can I know her internal state? Perhaps I have it all wrong. Perhaps she did not lift her hand at all. Maybe it was just an accident of the turn. I put her hand down, but after a minute she lifts it again, reaching out for me. I take her hand again and look into her eyes. She gazes back with sad affection. I have words to say to Mrs. Hardy, but I feel awkward saying them in front of Laura. I do not know her well, and I am not sure if I will make her uncomfortable. But there will not be another opportunity. This moment will not return. I say the only comforting words I have, “It will not be much longer now Betty.” She continues to look into my eyes. After a few moments I excuse myself and go. If I had a better heart perhaps I would stay with her longer. Perhaps I would also push my kids on their swings as long as they wanted. There are so many Mrs. Hardys. I do not have enough for any of them.

Outside of the room, Laura asks me what I think of all this. Laura is a young nurse, well seasoned on the SICU, but still bright eyed and enthusiastic. I have avoided her a little because I have not wanted to trouble her with my jaded mentality. (In nursing school some of the professors talked pointedly with me about “contagious bad attitudes,” but what did they offer us that would have prepared us for these situations? Nothing. They could not even acknowledge the existence of such cases.) I tell Laura that I think it is wrong and it makes me angry. She agrees, “I cannot Do this.” She would prefer to take care of patients she can actually help.

The renal doctors evaluated Mrs. Hardy and decided that she did not need dialysis yet. The next day on rounds the resident begins her presentation, “…status post botched hernia repair…” Dr. Pock stops her again, “I want you to try very hard not to use words like that,” he says sternly. Dr. Pock goes into the details of the case and pushes her to properly understand the disease process. This is a teaching hospital and she is here to learn. He probably does not want to waste time on things he cannot change.

I assist with another turn. Mrs. Hardy is more distant today. She stares out blankly into the room, her consciousness absorbed in the work of breathing. The flesh exposed by several large skin tears has turned the color of turmeric with a green tinge on the surface. Fluid oozes out through the many holes created for various drains as well as the huge open cavern of her abdomen. The room is filled with a foul, musty odor. Labs show her blood is becoming acidic. The end is near.

Cells produce energy by passing ions back and forth across the membranes of mitochondria. The process requires the environment inside of the mitochondria to be more acidic than the outside. When this balance is upset, the cells cannot produce energy and they die. When they die, they rupture, spilling the acid contents of their mitochondria into the blood stream, further increasing the acidity of the blood. This manifests as sepsis or septic shock. In Mrs. Hardy’s case, it will not be reversible. Her infections are too extensive and are no longer responding to antibiotics or antifungals. As the cascade gathers pace, we can turn up the pressors to buy a few more days or hours. That is all.

The fellows come by towards the end of the shift. The day fellow is handing off to the night fellow. They are have just started working together, but clearly like each other. They pause to discuss the situation. They know that she will die soon and are concerned that Mrs. Hardy is still awake. They want her to get more ativan. “You know what I’m saying? She needs a forty ounce bottle and a two-by-four.” When they are gone, I ask her nurse, Bea about it. “They want you to knock her out?” Bea is an orthodox Christian from Kenya. “Yes, but I do not understand why. She is not agitated.” I agree. The orders for ativan are PRN (as needed) and are left to the nurse’s discretion. Bea decides not to give the ativan.. The night nurse may have a different opinion.

Anonymous

I am writing anonymously for several reasons. My purpose is to talk about the way our healthcare system works on a human level. To give an accurate and honest account is to invite hard questions – “Why did you do that? Why didn’t you stand up against that?” It is difficult for people outside of the healthcare system to understand the full context and circumstances under which our decisions are made and it would be very easy to jump to condemnation. It is not my intention to expose my coworkers to this condemnation. There is great wrongness in the healthcare system and, from my perspective, I see that much harm is being perpetrated in the name of offering the highest standards of care. This is what impels me to write, even though I see that there is personal risk for me in doing so. This is what I am trying to write about. I have worked in several different hospitals and dozens of different units. While each has their own strengths and weaknesses, the situation is the same everywhere. Just because the kinds of things I am writing about are not generally discussed does not mean that the stories I am telling are exceptional. I am intentionally writing about the typical. I have not found any evil actors. The people I work with are generally caring and concerned for the patients. I may disagree with them in attitude and perspective, but I see that we are all more or less helplessly serving a system which is essentially broken and brutal. There is no real opportunity for any individual, whether he is the biggest doctor or the smallest nurse, to stand up and effect a major change. We often feel that we do not have enough love and compassion to properly perform our jobs. So much is expected and demanded of us and we are certainly lacking. In maintaining the bogus façade, we cut corners, make bad decisions and errors and we hide them most of the time because we know the outside world does not understand how bad it is. We know they do not realize how unnatural it all is, how vulnerable they are and how difficult it is to protect them on this path. Here lies the disconnect, the double life. We are so accustomed to the basic deception and take it so much for granted that we have lost the capacity to tell our patient’s stories to the people in general. The stories that do escape are generally carefully selected and highly sanitized.

Fear of death sells even better than sex. We, as a society, have agreed to be the uneducated consumers. Business men provide us with newer, more expensive products to consume- that is their livelihood. Societal values give them an open field. It is these values and our negligent ignorance which causes things to remain as they are. I am endeavoring to shed light on this world not so that the first doctor who walks by can be dragged off to judgment, but so that we can each look at ourselves and question our own participation in the system. If our eyes are open, we can make better choices. Death is ever victorious. We will not do well for ourselves if we are not able to face this truth.