Road Trip!

Traveling with the critically ill is an art. I am a master at few things; but I will say that parallel parking, and moving the sick and intubated patient are amongst my top skills. Some of this is from instinct and most of it is from practice. I also am a perfectionist, and I try to be prepared for any situation. As I write this, I am acutely aware that the art of preparation is an exercise in both instinct and practice. Whichever came first is unimportant, as they all are intimately intertwined.

Patients need to move through the hospital for different types of procedures and scans, and the patient's nurse is usually solely responsible for their care as they are pushed through the halls.

Road trips are an exercise in preparation, focus, assertiveness, bravery, and well...exercise. These trips can take forever, and that bed is flipping heavy. You struggle to keep the IV poles together and kick visitors out of the elevator, and by the end, you are sweaty and disheveled. When you take a patient out of the ICU you are leaving the safety of staff support, an alternate oxygen supply, and unlimited resources. You are a lone wolf wandering the halls with with a sick patient, a lumbering hospital bed, a portable monitor, and your instinct to guide you. Traveling can be either a quick uneventful trip, or it can be a harrowing experience that makes you wonder if you are in the right profession.

Moving through the hospital with a sick patient is, I believe, the best way to gain confidence and experience as a new nurse. You learn how to be on your game; preparing for the worst to happen, being able to adapt to difficult circumstances, and learning who to call when all hell breaks loose. All orientees should go on as many traveling procedures that they can. This is the most basic ICU nursing, because all you have is you and the tools you bring to the table. You strip your patient to the basics, since you want to travel light. I put a few vials of emergency meds in my pocket, make sure I have an IV start, put an ambu bag on the bed, and get ready to roll. Some nurses tie themselves down with a crapload of equipment and IV poles; they are the wost kind of traveler. They are unable to adapt, freakout at every inconvenience, and they end up turning a stressful situation into a traumatic event for all involved parties. Road trips with the frantic are not fun. They are loose cannons with no focus or discipline, and if you are a patient, you are lucky to make it back unscathed.

I have learned many lessons through these patient expeditions. Always confirm IV access and patency. Nothing is worse than losing your access when your intubated patient is thrashing during a CT scan. Always bring an additional oxygen tank when your patient is on a non-rebreather mask, least the tank runs out while you are waiting for the elevator and your patient starts to turn blue. Be prepared to be a guinea pig in IR, where you are requested to disconnect your unstable patient from the vent over and over, while hiding behind a radiation blocking barrier. Know how to call anesthesia stat when your patient won't respond to sedation and is bucking while a hole is being punched and stented through his liver during a TIPS procedure(I have has to do this twice). These trips are in the extreme, but they do happen frequently. I have learned to not be optimistic, and always assume that when the shit hits the fan, it will be with me, on this particular road trip.

These experiences can be frightening, but you learn to take in your surroundings, know who your allies are, and know when you are in over your head. You also learn how to get the job done when it counts. An example is when I was traveling through the hospital with a very sick patient and making stops to CT, MRI, and to Nuclear Med for a VQ Scan to rule out a pulmonary embolism (PE). This poor man was tortured all day by me. Transferred back and forth from his bed to testing areas. He is old, in pain, and going to die any day. Who fucking cares if he had a PE? It doesn't make a difference in his treatment, seriously, I know. But, in order to provide the most thorough care we must turn over every stone, despite the discomfort of our elderly dying patients. The VQ scan looks at ventilation vs perfusion in the lungs. One has to breath in a radioactive gas, and then get transferred into a horizontal tube where they continue to breath in this toxic gas and sit until it permeates all of the lung spaces. This scan can take an hour and it sucks. It is uncomfortable, confining, and you have to keep wrapping your lips around this tube and breathing in this gas like it is the Devil's houka. I can understand how this would be unbearable. My poor old guy started to cry. Tears rolling down his cheeks. He started to scream "No more, No more!". My heart moved in my chest, I almost went to call it off, but then I thought of how I was working for three more days, and how I would have this guy again tomorrow. I didn't want this trip again. "Mr. So and So, you will finish this test. I am sweaty and tired, I look like hell, and I will not do this again. Put your mouth around this tube and breath. Breath deep and breath hard, and we will be done. I am not screwing around, and I will not take you back until we finish!" He looked at me first with fear, and then with understanding. He wrapped his lips around the tube and finished the test. We both got a resolution to get this bullshit test out of the way and be free from traveling to this hellhole again. I felt kinda bad, but I knew what needed to be done. I think he forgave me.

I like road trips for a few reasons. You are autonomous, intuitive, MacGyverish, and fluid. I get to be a better nurse for these experiences. Meeting and depending on new people, discovering my own strengths, and hopefully being able to make a difference in someones life. It is a fun break-away from the unit, and we need that sometimes. By taking ourselves out of our comfort zone, we are able to grow in ways that we could never imagine. I found that I was able to rely on gut more than monitors, and experience more than security. Most important though, I have learned to trust myself and my patients more. I was once so scared to go out of the unit by myself with my patient. I did the same thing with my daughter when she was first born. We tried to go for a walk in her jogger stroller when she was five days old. I got about fifty feet from the house, and immediately turned around and ran her home. I felt like a fool to be so scared of something so easy. It took me a while and I was finally able to move through this fear. I began to take my kid to the zoo, not unlike taking my patient to CT really. So, all and all, traveling is a necessary evil, though while uncomfortable, will ultimately be a benefit to you, and possibly to your patient.

(Plus, I haven't been to the gym in a while, and I can use the workout)

Don't Love Me Too Much

Advanced directives are a basic form that people fill out sometimes about what they would want in case they are not able to make their own medical decisions. Usually, everyone says the same thing: "I don't want to be a vegetable". Well, I am here to say no one want to be a vegetable, but that rarely helps families and medical personnel guide ones care. Everybody is different when it comes to his/her personal limit when it comes to invasive medical treatment. The goals of someone who is 50 verses 93 years old are immeasurably different. There are ways to quantify and specify the amount of medical care a person wants, and what health impairments are acceptable in defining a quality life. Unfortunately, many of these tools have come under scrutiny by the right-wing media by declaring that this is an open invitation to assisted-suicide when a persons health problems exceed the parameters that they have specified in their advanced directive. The VA Hospital has a detailed AD form that is an excellent tool, but has caused an uproar among conservative groups, and has been officially suspended by the Obama administration until flames have died down. This document spurred a backlash against progressive medical groups and the Obama administration, despite the fact that it was created and brought into use during the time Bush was President. See the example shown, and do your own exercise following the link, if you like.

http://stevebuyer.house.gov/UploadedFiles/Your_Life_Your_Choices.pdf

The point of all of this is to discuss some end of life issues that I have observed during my short career in the ICU. Please ignore any blatant political commentary that you might unearth, as my intentions are not about right and wrong, they are just feelings that have bubbled forth. Please feel free to share your own observations/feelings as appropriate.

Some themes:
The right to choose or decline medical care
The sticky issue of family in interpreting what is appropriate for their loved one
The view of medical care during end of life as a medical professional
My own Advanced Directive - which may or may not be ignored - titled: Don't Love Me Too Much

The right to plow ahead with every medical intervention possible is reoccurring theme in my work environment. This is done by both patients and families during their time of crisis. We really give them everything we have to give, but ultimately, despite our best efforts, the fight is between the patient and God. When a patient is unresponsive, or unable to participate in medical decisions, we assume that everything must be done, unless the family otherwise declines. This could be due to a terminal illness, a very poor prognosis, or the statistical indicators that this person will never return to a quality of life that is acceptable for them. These lines are very blurry, and in fact, quite subjective. As we learned from looking at the VA Life Choices pamphlet, where one person would be all right with being disabled, completely dependent, and having to spend their remaining days in a hospital; another person may find this unbearable and would want us to, in effect, pull the plug. Many times we do not know which way the chips may fall, and we can only speculate about outcomes. I have seen miracles my friends. People who should have died, being rolled out in a wheelchair for the cabulance home. That said, they seem (to me)to be a shell of what they once were. Not only do they require years of rehab, possible penile reconstructive surgery due to edema, God knows how much therapy, and the financial and emotional turmoil of the family; they will undoubtedly come back to me as a patient with some glaring infection, and we will start the process over again. I do not judge, this is what was meant to be, as it has already happened.

Some patients are scared and want everything done, even though we tell them that they will never leave the ICU. They succumb to an infection, and when they cannot communicate, a family member will assume responsibility and agree to let them go. (This has caused an ethical debate, as we knew full well what the patient wanted, and this decision would be unacceptable to them. Fortunately, we can always argue medical futility, and understand that no one wants to die, but ultimately we know everyone does.)

Some patients are stoic, and greet death as an inevitable occurrence, and these people go with grace, and the morphine drip is hung, and they are able to peacefully return to their origin. This is a rare occurrence. I had an experience where we knew this guy was going to die, but we could give him an extra week if we continues aggressive care. We could give him seven more days of torture. The pain was unbearable for him. The daily lab draws, being forced to turn every two hours, these fucking 20 year old doctors making decisions and changing their minds every day. "Screw you" the patient thinks, "I would rather die". So what do we do? Order a God-damned psych consult, cause this guy must be suicidal. Seriously, this was done. This is the dumbest crap I have ever heard. We are hypocrites for accepting a families wishes to withdraw care when someone is unable to say so, but when a patient says that it is time to stop, we gawk and feel ethically compelled to decline. This has happened to me, and I coached the family and patient on what to say in order for the doctors to allow us to stop treatment. This I felt, was my moral obligation. The patient and family were accepting, were able to say goodbyes, and the patient died the next day. I was glad for him.

Some families are not ready to let go. This is usually the case, and it is very difficult for all of us to come to terms with the mortality of both the patient, and our medical efforts. I think that it is hard for these young blossoming residents to accept defeat. They will try everything, and even try some more, though the statistical evidence is staggering that the patient will not make it. This drive from the residents, fuels the family belief that all will be well, until the inevitable moment where defeat is called and the families are blown away that all of their hope was for nothing, and their loved one should be let go. Sometimes this still does not sink in and we are forced to keep these poor bastards alive to the point of morbid horror, when either they code and have a traumatic end, or we finally convince the family that it is over, and the patient dies within a minute of removing life support.

Sometimes we are able to have a therapeutic and peaceful death, where families and medical personnel work together. This is the most gratifying part of my job.

The point of these scenarios is to demonstrate that rarely Advanced Directives are actually followed, and the fact that they are so vague with the resignation of "I don't want to be a vegetable", they are worthless without thorough thought and disclosure. The ultra-conservatives that are against in-depth death discussions want us to believe that every medical intervention should be made possible for all patients. This is a careless waste of resources, and it does not help families make educated decisions about how to manage the medical care of their loved one. Many of the interventions and ways to prolong life are not what doctors and nurses would have done for themselves. An example of this is the mundane flu shot. Doctors and nurses recommend this all the time. I myself gave over 50 flu shots in one day last year. If however, you do an informal poll like I did last week, you would find that the only nurses who get the flu shot are in management, or are kiss asses. The same goes for the doctors. It is not that we don't think the flu shot is beneficial, or that it can be lifesaving for certain individuals, we all have a deathly fear of rare complications. It is stupid, we all know, but if anyone is going to get some crazy Guillain-Barre, it will be us. We see enough weird shit, that as a superstitious measure, we protect ourselves from a 1:1,000,000 chance of drawing the short straw. The same goes for all of the other things we do. I am scared of needles. I am scared of doctors. I am scared to get my blood pressure taken. I urge all politicians to poll medical staff about how they rate quality of care before shoving it down the throat of average citizens simply because they are afraid to face their own mortality and that of the people they love. Bam.

This is a long, drawn out morbid topic I know. I will edit and condense for the book version, I assure you.

In conclusion, I will tell you my own personal advanced directive. Please do not take this as medical advice, as I am full of it, and frequently, a hoppy fermented beverage. I will also say, as another older nurse has said to me a few times before:"just wait till you get to be 83, you will feel a lot different than when you are 33" Well, thanks for the wisdom, this is my disclaimer, and I will reevaluate my goals of care through the years, and I urge you all to do the same.

I will first say that all of us nurses and doctors are scared of many things that we hope to Christ we don't get. These will act as indicators to guide my care, if I have these, I am pissed. The first is liver failure. The worst, bloody, metamorphosis a person can have. The rest in no particular order: MS, cystic fibrosis, oral cancer, severe heart failure, pancreatic cancer, severe dementia, crazy bowel problems, and renal failure. Oh, and severe COPD, leukemia, lymphoma, Tourettes...the list keeps coming. OK poor exercise. Nobody wants to get sick. Exercise more, smoke less.

If I have more that 3 organ systems failing, with less than a 30% chance of leaving the HOSPITAL, not just the ICU, please let me enjoy my time with my family and friends. Sneak me in a margarita and put it in my feeding tube. Give me lots of drugs, and play some Bonnie Raitt while I listen to the laughter of those who know me best. Let me keep my dignity, my joy for life, and don't make me haunt you. To sum up: Don't Love Me Too Much. (I promise to do the same for you)

To My Friend

We weren't together long, but I came to care for you. You came in with respiratory distress, and you got worse by the day. I helped you out the other week, and six days later, when I was your actual nurse, you remembered my name. You joked and flirted. Told me Viagra was more than just for pulmonary hypertension. You told me stories from your youth, your short career in the Air Force. How you were screwed by those good ol' boy bastards. You told me your wife of 24 years, and how she had died 14 years before. She was the love of your life. Now you had a new girlfriend 20 years your junior, but your wife was always going to be the one.
I sat on your bed with you and held your hand when I saw tears well up in your eyes, after I told you that you weren't going to get better. You looked right at me and said, "I'm dying Lisa, I am going to die." I nodded, and we cried together, our heads on each others shoulders.

I was able to be with you for three more days after that. I called every morning before work to reserve you for the day. Your eyes would brighten when I walked into the room, you would tell me that you dreampt of me the night before. "Shut up old man, you're embarrassing me!" I would say. But I grinned; this was all that you had right now. I sent a pretty nurse in to talk to you, to make you smile. She loved to be there for you.

I called Palliative care and social work for you. They came and got you signed up for hospice. You talked about going home, but we knew that wouldn't happen so you resigned to finishing out your days in a nursing home. Maybe a year you said, but we all knew your time was much shorter. I sat with you again, and held your hand.

One week ago, I was leaving for a long weekend. You had transfer orders out of the ICU. We couldn't do anything more for you. You were chipper, and asked me to come visit you. "Of course I will" I said. I kissed his cheek and hugged him for a long time.

I was giving report that night, and you were shaving. I got you set up with a hot basin of water, shaving cream, razor, and towel. I sat with the night nurse and started my update. You had visitors at the main door and I invited them in. I looked at the monitor, and your oxygen sats were very low. I went into the room and saw you. You had taken off your oxygen to shave and had passed out when it got too low. You looked peaceful. But you had visitors, and I couldn't look bad. I ran over, put your mask on, smacked your cheek and told you to wake up. You awoke with a start; confused, but easily reoriented. You had a lovely visit with your neighbors, and then I had to go home.

I kissed you one last time, walked to my car, and drove away. I thought of you over the weekend. I wondered if you were able to get out of the ICU, and sit and talk with other old dying men. Talk about dreams, and love, and share memories forgotten until then.

I looked you up this morning. You had left the ICU the next morning after I had left, and you died that night. You were found with your oxygen off, unresponsive, without a heartbeat. You had decided against resuscitation and intubation, so you were let go. I wish I could have visited you one last time. Seen the light in your eyes. Let you know that you weren't alone, and most of all, that you touched my heart.It was a peaceful death. I know that you just fell asleep, and felt no pain. That is a lovely blessing, and I am glad that you didn't have anxiety or fear.

Safe journey my friend. I hope you are in the arms of your sweet lady, and you will never have to leave her again. I will think of you with great fondness and smile when you come into my thoughts. You help me strive to be better every day, and to be present when it really matters.