Please Save My Life

When I step back, when I really look at the place I work, it never ceases to amaze me. Its an intricate network of organized chaos. Its a well oiled gear set on an ever rotating cog of illness verses wellness. It seems we all have a very pivotal role, a very distinct part to play, in this theatrical production of therapeutic remedy. Often I imagine we are a cast of players in this strange episode of "Please Save My Life".

From time to time, I like to take the role of the observer (director). I like to step back, when the opportunity arises, and watch my fellow teammates function. Individually, they are amazing, each knowing the other's strengths and weaknesses. When you have a good crew, you can almost palpate the pulse of their collective heartbeat. They don't have to speak to each other, they just know by a simple nod or half sentence. "April, will you get...". "Got it right here". "Mark I need...". "Here you go, I brought two".

It seems that each person wears his or her specific role like a hand tailored suit. What fits one person well, does not fit another at all, much like the perfect role in an academy award winning film. I have learned that this works well, so long as each person can put the appropriate suit on and wear it well at the right time. It then becomes an ensemble of Armani clad players, so to speak.

As an observer, I have found one true fact which carriers across the board in any ICU setting. We (the collective entity that is an ICU team) are obsessed with labels. Not in the above mentioned name brand sense, but in the "if there is a line anywhere near me or my patient, I will label it at least three times over" sense. We have a habit of paying extreme attention to detail and then controlling that detail by placing a slick little color coded name tag on it.

I remember a specific instance when this observation played out in expert detail. It was like watching a opening night performance of a play I'd seen rehearsed for months. I remember thinking, "this must be what its like for a director when he watches his film for the first time."

Allow me to recap the performance. One night I, the director if you will, was taking care of this particularly sick patient. As the leading lady, she was sick when I started and only became sicker as the night (play) progressed. I had a great team (cast) on that night. Andrew was my leading man. He played off the patients actions with the ease and grace of a calloused veteran. My supporting cast included April, Rey, Jo, and Josh. They all put on their suits and got into their places, not missing a mark or que. April did chest compressions as if fate of the free world depended on her performance. Jo was my scribe, the one writing vitals and events in perfect penmanship. Josh played the gopher, the one sent to gather all the props we would need to successfully act out this play. Rey ran blood and fluid. He was the keeper of the keys, so to speak. Andrew, not leaving his lady's side, ran the drugs. Once my doctors (extras) showed up, it was all I could do to keep each informed, sterile, and equipped. Dr. W put in chest tubes. Dr. M, the attending, called out the emergency drugs. There were blood draws, lab checks, pulses dopplered. Each player laying it all out there, unafraid of the reviews. Each knowing exactly what they had to do and how to do it. There were applauds from the audience when we got a pulse back. There was a hush when the hematocrit came back at 8. There was a silence when asystole fell across the monitor. The production reached a crescendo when Andrew delivered his Oscar winning line. In an effort to control a situation he knew he couldn't get a hold of, we all heard his deep voice quiver as he said, "For the love of Christ, will someone please hand me a label for my Epi drip!?"

You could feel was a cumulative intake of breath; from the cast, crew, and audience of curious onlookers. It was then, at the peak of the performance, the point of no return when Dr. M called a time of death. For all our efforts, we could not save her. Each person slowly peeled off their blood covered Armani suit. Heads held low, they lined up outside the room and took an invisible bow. They exited; stage left, stage right, stage center.

After the code (show), with the curtains drawn and the seats again empty, I was left alone with the lady. She, unfortunately, was unable to leave her role behind. She, like so many others, will be one of the leading ladies we will never forget. She should have won an academy award for her performance...

45 eggs

Whatever the mind can conceive and believe, the mind can achieve.
Dr. Napoleon Hill

My patient was a 50 something year old man. A completely normal person. He is a hard working and devoted individual. He has a beautiful wife and a tremendous family. He is gleefully ordinary. Atypically ordinary. His family mirrors my own. He is just like my dad in more ways than I'd care to admit. In fact, his name was Paul too, just like my dad. Perhaps that is why I decided to take him as my patient. Perhaps it was because I felt like crying every time I hugged his wife, as I would if I were hugging my own mother. For the first time in a long time, I had an emotional response to a patients situation. I truly felt a connection with Paul and his family. He made me feel good to be a nurse. His family made me want to make a difference. I felt like I could really help him and his family. I felt like what I know, what I do, who I am could and would change their lives. I felt like me being a nurse actually would matter to this patient and his family.

He was a very sick man when he came in. He was on three pressors (medications to keep his blood pressure high enough to pump enough blood into his vital organs). He was on a lot of fluid. He was on a ventilator. His arm and leg were infected with bacteria we could not name at first. His family didn't understand what was happening. He had felt ill, like he had the flu. Two weeks later he was in our ICU fighting for his life. As the days turned into weeks, Paul lost his left arm and almost lost his right leg. The infection had seeded in his muscles. For some reason fate had picked him to host a deadly bacteria called hemolytic strep A. Its the same bug that you fight off when you have strep throat. However, for some reason this strain sometimes mutates and attacks the body in varied and unforeseen places, patterns, reasons. We can not predict who will get it, who will fight it off, or who will not. For Paul, it was a pair of aces he could not trump.

Eventually Paul fought his way back from the brink of death. He came off the pressors and fluid. He went to the OR several times over. We did painful wound care three times a day on his leg and arm. His wife never left his side. His children visited him and lifted his spirits. Finally he came off the ventilator and regained a sense of time, realizing he'd missed a month by being sedated and ventilated in the ICU. He had no idea of what he'd been through. As he woke up, he discovered his loss. As he began to recover lost details of his courageous fight, he learned how truly lucky he was.

When I think about Paul and all he'd been through, I cant help but think of what it meant to me as a nurse. I don't mean medically or professionally. From Paul and his family, I learned what it means to provide emotional and spiritual health. Usually this is often overlooked in the medical setting. Especially when you are talking about the intensity of the ICU setting. I will be the first to admit that I hardly ever consider this aspect of health and healing when I am taking care of a critically ill person. When I started taking care of Paul and his family, it was much the same. I knew their faith was strong and their support system was nothing short of amazing. I remember talking at length with his wife about his beliefs and trust in God. I recall accepting what she said and thinking that he'd need a lot more than God to get out of this. I remember telling her what to expect and what would happen next medically. I thought that if I could take the focus to the reality of how sick Paul was then she wouldn't keep talking about God. To switch off the uncomfortable subject, I remember asking her about their kids and how they were dealing with all of this. She said the older ones where a little afraid but that they understood what was going on. The youngest was more concerned with waiting for the Easter Bunny. As she talked of their children, I remember thinking that if ever there were faith to be had, here it was.

I remember the first weekend they came to visit. I knew how afraid and intimidated they would be, seeing their dad in a place like this. My focus switched from Paul's illness to his children's comfort. I had to do something to take their minds and focus off of the horror and fear of the ICU setting. At the ages of 15, 11, and 5, I knew they would be overwhelmed. I asked his wife what he would miss the most about not being at home with his family. She told me he would miss having an Easter egg hunt with the kids the most. It was a tradition in their family for Paul to hide all the eggs and the kids to find them all. She said it gave him such great joy to see his kids looking for all those eggs.

An idea struck me like a bolt of lightening. I spent a couple of hours that night cutting out Easter eggs for Paul's kids. I asked all the nurses stop for a few minutes and help me decorate them. The therapy of decorating a paper egg is completely underestimated. I haven't ever laughed so hard with my co workers as I did that night, huddled over a pile of technicolored paper Easter eggs.

I spent an hour "hiding" 45 eggs in Paul's room. I made a card with the "rules" and put it on the door. When Paul's wife came to visit Easter Sunday Morning, she smiled for the first time since he'd been admitted. She simply said, "The kids will love this". I hugged her goodbye that morning and left for a 6 day vacation.

When I came back, Paul was doing great. He was out of the ICU the following day and as he left, his wife thanked me for the Easter egg hunt. She said the kids were bummed not to have met "the nurse who made all the eggs". I told her it wasn't me, but the Easter Bunny himself. She smiled again and we hugged as Paul was taken to the floor. I asked her to bring Paul and the kids up for a visit when he was well enough to get out of bed. She assured me that they would indeed.

Looking back, I know I found a strength in Paul and his family. I found a faith I tried very hard to deny and an emotion I wanted to ignore. By embracing Paul and his family, I feel like I gave him the best care I could, simply by hiding 45 eggs...

The Jaded Dragon

Am I jaded? Have I lost my empathy? Am I a bad nurse for thinking that I may no sense of compassion for specific sects of humanity? Am I a horrible person because my empathy is directly related to one's productive contributions to society? Before you answer, let me explain...

The other day I took care of a man who is in our unit for the second time in six months. He is ill. He is addicted. He abuses himself by abusing drugs and alcohol. Not an uncommon trait for someone in our hospital. But I found myself asking the question, "why are we treating him again? Didn't he learn his lesson the last time?" I felt like a hypocrite, like a soulless, heartless, horrible person the moment the thought crossed my mind. I felt like a terrible fire breathing dragon. What kind of nurse would think such a thing? It wasn't until I heard two other nurses and two doctors ask the same exact question out loud. These are people I work with every day. These are nurses I admire and respect. These are doctors I trust and rely on. Could it be that I am a product of a jaded and indifferent generation of health care workers? At some point, without realizing it, did I cross over to the "old washout/burnout" realm?

I think not. I love my job, more than ever. I am a good nurse. I find myself looking forward to work. I catch myself praising what I do and where I work all the time. So why was my, why was our, reaction to this man so atypical?

Allow me to lay down the background here. This man is a frequent patient at my hospital. He will show up in the ER high on crack or whatever. He will fake a seizure and request pain medication. The doctors all know him by name. The nurses all know him by his award winning performances. Often he will detox from whatever he is on and leave AMA (against medical advise). He has a strict care plan in place that everyone must follow each time he is admitted to the hospital. He is not a nice person. He is not thankful for his care. He is ruthless, abusive, and mean. He has been blacklisted from all but 2 shelters in the city. This man steals drugs from other homeless people and takes them, regardless of what they are or what they do.

This is a big mistake on his part. He is allergic to a lot of different classes of drugs. He has already had a reaction so bad that all of his skin blistered and peeled off. He was in our unit for weeks. We saved him. We took exceptional care of him. We saved his life. Never a please. Never a thank you. He left AMA--again.

Now, six months later its happened all over again. He took someone else's seizure drug. A drug he is deathly allergic to. He skin has again blistered and peeled off. This time it is much worse. This time his eyes, mouth, lungs, and intestines are affected too. Its a terrible disease, extremely painful and often unsurvivable. He was lucky to have lived the last time. This time, if he survives, he will likely be blind. We are working extremely hard to keep his lungs from failing. Because he has no skin to protect him, he will likely get a horrible infection. He will probably go into kidney failure from all the hardcore antibiotics he will need to fight the infection. We are spending hundreds of thousands of dollars to treat this man...for the second time. And it would mean nothing to me except for one fact.

I am not so sure that if he survives, he wont go out and do this all over again. Meanwhile, we have to cut costs on things like organ donation because we are so far in the red. This is what I question. This is what I don't understand. This is the ethical dilemma I argue constantly in my head. I have asked others in my profession this same question and nobody has an answer. I am not sure there really is one.

I guess its not this patient I am jaded about so much as the bureaucracy of it all. The ethics of treating everyone regardless of station or circumstance used to have no boundary in my mind. Now I question where my boundaries lie. Short changing one to help another wouldn't bother me so much if the other hadn't already been given an extraordinary chance to change and prosper. I just don't see how this form of health care is justifiable. No wonder our country's health care system is failing so miserably. On the flip side of the token, how can we even begin to question the idea of not treating one person for another? It opens a whole can of ethical worms and frankly we have no right. I have no right. Yet, I cant help but think...is this natural selection trying to do its job? Are we messing where we don't belong? Is there a force much stronger than me, than the doctors, than modern medicine at work here? I don't think its a hard question to answer. It doesn't take a rocket scientist to see that its obviously...yes!

Mysteries of the Universe

Wow...its been a year since I started this blog. Its gone by so fast. I have not written nearly enough for all that's in my head, taking up space and energy. That is the point of a blog, is it not? So much has happened in the last year. Looking back, I don't know where the time really went. I guess I can stack it all up to life... Wow!!

Needless to say, I kinda checked out of blogging for a couple of months. My apologies to anyone who may read this regularly. I wish there were some great reason or rational why. I would like very much to say that I was off contemplating the mysteries of the universe with Tibetan monks. Or even that I was discovering lost species in the rain forests of south America. But I can not claim such fame. Rather I have been here, in Seattle working like crazy. It seems that there is always a good reason to pick up that extra shift or work some "Christmas spending" OT. However, the most honest answer I can truly give is this. Late last November, I had a very difficult situation at work with a pediatric patient. I took it extremely hard and didn't really know how to process it. I couldn't talk about it for weeks. I tried several times to blog it out...But every time I'd sit down and start writing, it would overwhelm me and I would loose my focus. It was too fresh and too raw. So, I checked out....Out of most everything. I stopped writing, I stopped making art, I stopped training my dogs, I stopped working out...I really checked out. I dove into work, most weeks pulling in 60-80 hours throughout the month of December. I did take 5 days off and go skiing in Canada. Otherwise, its been work, work, work.

So, here I am, a month and a half later...I am exhausted. I am sore; mentally, physically, emotionally, and spiritually. I am unbalanced. But, now I can write about it. Now its time. I think that by doing this, I will finally be in a position to realign. Its time to get healthy. Its time to process and its time to heal.

Right before Thanksgiving I was working on the PICU. We rotate between the Burn ICU and the Pediatric ICU every couple of weeks. I got report that I would be taking a sick baby. I have come to understand this to be an extremely bold but general statement. Obviously any kid admitted to our hospital and our unit is going to be sick. Otherwise they would be on the acute care floor or at the Children's Hospital across town (Children's does not take burns or trauma--hence our unit). So, knowing that these kids are coming to us is the same as knowing they will likely be pretty sick/injured. As much as I don't want to, I have come to accept this fact.

So, I pick up a 6 week old infant. My report was this: Subdural hemorrhage x2 (subdural hemorrhage= blood on the brain) and possible C1-2 fracture (C1-2 is the top joint of the spine, where the backbone meets the base of the skull). Other, possibly older, injuries by scan and film. CPS (child protective services) is involved. Right away I know this baby is ill. Kids this little don't just "break their necks"... They are extremely flexible (think about how they have been living for 9 months, all folded up and squished during pregnancy)... It takes a tremendous amount of force to break a baby's neck. I say a silent prayer. It was obvious, just from looking at his brain scan that he'd been shaken. This baby has blood in his brain in two places, in the front by the forehead and in the rear just below the crown. I think I was crying on the inside long before I ever laid eyes on him. This baby wasn't even 2 months old... and already he had been abused in such a way it would be amazing if he'd survive, let alone recover.

When I received the baby, he was lethargic and weak. He wasn't moving his left side. We had to intubate him to maintain his breathing. Even the simplest responses were lacking. He was so sick. He didn't move when we poked him for blood. He didn't respond to touch or voice. I doubt he even knew how to cry. Just the thought of that made me cry for him all the more. He had bruises on his ribs, head, and arms. Tubes and wires came and went everywhere. He was too small to put a spine collar on. They don't come that small. We had to use a rolled up pillowcase to stabilize his delicate neck. His brain scans showed he was continuing to swell. Fortunately, babies, unlike most people, have the capacity to swell in the brain. Their skulls are not solid yet, so they can expand. For this child, it was most likely the only thing keeping him alive. He continued to decompensate in the PICU. We had trouble ventilating him. His brain wasn't healing. He wasn't responding as we all wanted, and needed, him to. All he could do was stare, with big brown innocent eyes. It felt like he was screaming at me, begging me to help him, pleading with me to make his pain go away. His expression of lost innocence was almost more than I could stand as a nurse. I have never felt more helpless or more useless, than I did caring for this baby. I could do nothing but stroke his immaculate face and hold his tiny hand.

I'm not sure what made me have such an emotionally charged response. I have been trying to figure that out for nearly two months. We see the saddest of the sad circumstances every day. We've all certainly dealt with worse things. But for some reason, I took particular exception to this baby. I think the worst part, for me, is just not being able to understand how anyone, especially a parent, could ever do this to a child. It makes me angry beyond explanation. The selfishness and complete disregard for the most fragile, the most virtuous, fragment of humanity does nothing less than disgust me. I have a hard time trying to wrap my head around it, even now. On another level, all I wanted to do was protect and help this child. I couldn't even hold him and show him that he was safe. It broke my heart to know that in order to help him I had to cause him pain, above and beyond what he had already endured. On some level, I felt like a collateral hypocrite. With all the intensity of my mixed emotions, I think the most riveting one was love. Undeniable and raw love. If I could have, I would have taken that baby home with me. I am in no positon to have a child at this point in my life, but I know that as unprepared and unskilled as I may be, I could have done a better job-- 10,000 times over.

Its going to take me a long time to sort through the emotions of this case. I guess we all have that one that just gets us. In talking to my senior nurses, they all have at least one, if not several stories just like mine. We eventually had to transfer the baby to Children's Hospital. We were unable to get his swelling under control nor could we ventilate him properly. He did not have a good prognosis. His long term care was better managed at the Children's Hospital.

Unfortunately, I don't know what happened to him. I still think of him often, and wonder how he is doing. I think that's the hardest part in all of this, the not knowing. I have no closure. Nothing is for sure. All I can hope is that he did recover fully. All I can wish is that he went home with someone who will do nothing less than devour him with love...