The other day we let a patient die. He had been dependent on the ventilator for a couple months, and no matter what we tried, he still needed tons of extra oxygen and pressure (peep) to keep up his oxygen sats. He was always anxious and frequently requested anxiety medication. He had a trach but couldn't talk, didn't have the ability to write, and was literally trapped in his body. He was miserable, his family was torn apart, and his girlfriend was by his side all of the time with a look of heartbreak in her eyes.
He kept pulling out tubes, and over time it became clear that he did not want artificial nutrition or invasive lines. All the medical disciplines came to see him and he made it known that he wanted to be removed from the ventilator and for us to let him go. He had been fighting this for over two months, and it was clear that he would never leave his room. His family understood and accepted this, and his girlfriend was more hesitant, but ultimately, she accepted his decision, and a date was decided upon. I was charge nurse that day, and I was assisting in the comfort care process with a new-ish nurse. It is a trick to balance sedation and comfort with dying patients. You want to give them enough to sedate and comfort them, but you can't suppress breathing and actually be the death mechanism itself. (tricky). He had about eight family members and friends in the room when we started. He was given a bolus of versed and fentanyl and when he was comfortable, we disconnected him from the ventilator. We covered his trach site with some humidified oxygen, and watched him for signs of discomfort or fear. His family gathered around him, anxiously watching his face, waiting for the moment he would escape from his body. We gave him some extra sedation a couple times, but really it was a lovely passing. For his final and greatest journey, he was able to know when his time had come, all of his closest people were showering him unconditional love and support, and he was comfortable the entire time. What a blessing.
His oxygen sats slowly lowered over the next hour, his cardiac rhythm widened, and shortly after, he was in PEA. Soon had no cardiac activity. His family was told that he had passed, and it was an emotional time for them all. I was in and out of the room through the day, helping out and answering questions when I could. It was also taco day for the nurses, and I spent some time in the back getting the fiesta together while I oversaw the unit. Later, his nurse went for lunch and I stayed in the patent's room to act as family support and explain the process of what happens to his body after they leave. I stood close to his girlfriend on the side of the bed who was still holding his hand. Her eyes were red rimmed and moist, but she was calm. They had been high school sweethearts who reconnected fifteen years ago. They never married, but lived together and loved each other as life partners. She was the one who would go home to an empty house, clean out his belongings, and figure out how to carry on. His daughter began to gather up her family and say goodbyes to friends who came to be with them. I stood by the girlfriend and took in this scene of goodbye. I got weepy as they all took turns kissing the patient and waving in parting to his ladyfriend. She still sat by him holding his hand as they drifted out, the daughter was the last to leave, signaling to the partner that she would call her, her hand as the telephone to her ear, and she walked out the door into the hall. This moment was profound. This ritual of death, mourning, and goodbye. I was so there; I was both observer and participant. I found myself in the partners chair, holding his hand watching all of the others leave, and being left dreadfully alone. A flood of emotion welled up with me. My little tears turned to rivers, I began to literally heave and sob. This moment, that had been replayed over generations, centuries, since the beginning of humanity, was unfolding before my very eyes. I was hit with the full force of these very human emotions and experiences, and in that instant, I rolled in this emotional tsunami.
What a blessing.
I looked out the window and tried to pull myself together. I grabbed some tissue and dried my eyes, squeezed the girlfriend's other hand meaningfully, and walked out of the room, trying to keep these emotions in check. Then with red rimmed eyes, I went to the break room and ate a taco. My coworkers asked me if I was OK. I nodded and sat down. We all ate in silence for a while. The moment passed, I ate my tacos (delicious), dealt with the unit, wrapped up his body, and had the room cleaned. The day was done, I went home and had a beer or three. I kissed my family, read the kids books before bed, snuggled with my husband, and felt incredibly grateful. I slept without dreams.
I told my friend Jaime about this emotional experience I had, and my uncontrollable visceral reaction. She matter of factly said "Ahhh, that was the ugly cry". The spontaneous, overwhelming emotional response that possesses both body and mind. A labor pain of sentiment that strips away all personal discretion and composure, revealing the raw, pure soul within you. I was able to explain how real that moment was for me; how it symbolized humanity, mortality, unhindered love and loyalty, the true complexity and beauty of relationships. I tied it together with one encompassing word: Lovely.
It was amazing to witness such a power, such a time of incomprehensible sadness, mixed with love and hope, and to see this dance of human relationships. I was truly present for that striking moment, and it will stay with me forever.
What a blessing.
Sunday, March 28, 2010
Saturday, March 13, 2010
Jinx
You really never know who is going to do well in the hospital and who won't. You can guess fairly easily based on vital signs and labs, previous experiences, a person's feeling of well being, and your own instinct, but really all of those things have failed me more than a couple times. People can have massive MI's suddenly, and they are just - gone. Despite your best efforts to stabilize them and get a cardiac rhythm back, you fail, and they are lost to you and their loved ones in an instant. Some people you can expect this of; they have been having chest pain, they have horrible cardiac disease, they look like crap, their mentation changes. But some people give you no warning at all. They come in for shortness of breath which clears quickly with a little lasix, and you send them to the floor with a cardiology consult, never guessing that they will code that night.
In a small hospital with limited ICU beds, we are constantly trying to shuffle patients in and out. There is a lot of pressure to move patients to the floor when we think that they may be (possibly/probably) stable. Many times this is a crap shoot - the truth is, when you only have two patients, you can detect subtle changes that are missed by the floor nurse who has 10 patients. You can see when their respiratory rate goes from 20 to 35, you are there to assist them cough out huge amounts of thick, sticky sputum, you run in when they are starting to throw up and begin to aspirate bile. The floor is a different animal; where questionable patients are left to fend for themselves unless they are aware enough to use the call light, or if someone happens to come into their room at the right instant. It is a toss up, and you just pray that nothing goes wrong with them when it is your call to push them out of the ICU. When I say push, I really mean push by the way. We use gentle pressure on the residents, saying: "We have no ICU beds in the hospital. If there is a code, we have no where to put them. Who can move out? Now." We look at the patients, determine who is the least sick, and send them out, sometimes crossing our fingers. This is the nature of the beast, (and inadequate staffing) and we just hope that everything works out ok.
Through these patient transfer experiences and my own personal adventures, I have found out an amazing thing. I have a gift/curse from God. I have a horrible talent for hexing people via words of reassurance and encouragement. Oh, you good people may scoff at this, but I swear to the higher power that it is true. I incite the fates by trying to tame patient/friends fears, and I have learned that to improve the odds of survival, I must be as noncommittal and vague as I possibly can, for the sake of others. I think doctors and tattoo artists have also learned this lesson, as they will never tell you what you should actually do as a patient/client. They give you scenarios, tell you the odds, but never, ever will come out and tell you what operation you should have, or what colors would work best for the Chinese dragon you want to place on your torso. Always the same damn thing - "These are your options, I can't decide for you, this is what has worked for some other people in your situation, but I can't say it is the right choice for you". They must be jinxes too, and are taught in their schooling the nuances of ambiguity.
So, since I have learned these lessons about myself and the nature of my job, I know a few things that I will never say again in order to protect the safety of others:
"That baby will slide out like a little seal" - Translation: That baby will be born breech and you will be in heavy labor for many hours.
"It's not like you are circling the drain or anything" - Translation: Actually, this is your last night to be alive, you should call your mother.
"God, you look great, you'll probably leave in the morning" - Translation: You look good now, but wait for a couple hours after I leave - not so much.
In the hospital, we are sometimes forced into difficult choices where we have to push the patient out of the nest, to see if they fly or not. Usually this goes off fairly well, other times they come back to us in a day or two. These "repeat offenders" usually will have a hard time ever leaving the hospital, and ultimately may be treated in a palliative fashion, keeping them comfortable, and out of the ICU because we can't actually make them "better". I will not worsen their chances however, by making a generalized, overly positive statement about their condition, which, as we have learned, would mean their demise. Instead, I will take a measured, cautious approach which is noncommittal, but warm - "Hey, I hope you get to leave, but if not, I have lots of jokes and obnoxious commentary to keep you occupied for a few days while we work on it, ok with you?".
Is that better?
In a small hospital with limited ICU beds, we are constantly trying to shuffle patients in and out. There is a lot of pressure to move patients to the floor when we think that they may be (possibly/probably) stable. Many times this is a crap shoot - the truth is, when you only have two patients, you can detect subtle changes that are missed by the floor nurse who has 10 patients. You can see when their respiratory rate goes from 20 to 35, you are there to assist them cough out huge amounts of thick, sticky sputum, you run in when they are starting to throw up and begin to aspirate bile. The floor is a different animal; where questionable patients are left to fend for themselves unless they are aware enough to use the call light, or if someone happens to come into their room at the right instant. It is a toss up, and you just pray that nothing goes wrong with them when it is your call to push them out of the ICU. When I say push, I really mean push by the way. We use gentle pressure on the residents, saying: "We have no ICU beds in the hospital. If there is a code, we have no where to put them. Who can move out? Now." We look at the patients, determine who is the least sick, and send them out, sometimes crossing our fingers. This is the nature of the beast, (and inadequate staffing) and we just hope that everything works out ok.
Through these patient transfer experiences and my own personal adventures, I have found out an amazing thing. I have a gift/curse from God. I have a horrible talent for hexing people via words of reassurance and encouragement. Oh, you good people may scoff at this, but I swear to the higher power that it is true. I incite the fates by trying to tame patient/friends fears, and I have learned that to improve the odds of survival, I must be as noncommittal and vague as I possibly can, for the sake of others. I think doctors and tattoo artists have also learned this lesson, as they will never tell you what you should actually do as a patient/client. They give you scenarios, tell you the odds, but never, ever will come out and tell you what operation you should have, or what colors would work best for the Chinese dragon you want to place on your torso. Always the same damn thing - "These are your options, I can't decide for you, this is what has worked for some other people in your situation, but I can't say it is the right choice for you". They must be jinxes too, and are taught in their schooling the nuances of ambiguity.
So, since I have learned these lessons about myself and the nature of my job, I know a few things that I will never say again in order to protect the safety of others:
"That baby will slide out like a little seal" - Translation: That baby will be born breech and you will be in heavy labor for many hours.
"It's not like you are circling the drain or anything" - Translation: Actually, this is your last night to be alive, you should call your mother.
"God, you look great, you'll probably leave in the morning" - Translation: You look good now, but wait for a couple hours after I leave - not so much.
In the hospital, we are sometimes forced into difficult choices where we have to push the patient out of the nest, to see if they fly or not. Usually this goes off fairly well, other times they come back to us in a day or two. These "repeat offenders" usually will have a hard time ever leaving the hospital, and ultimately may be treated in a palliative fashion, keeping them comfortable, and out of the ICU because we can't actually make them "better". I will not worsen their chances however, by making a generalized, overly positive statement about their condition, which, as we have learned, would mean their demise. Instead, I will take a measured, cautious approach which is noncommittal, but warm - "Hey, I hope you get to leave, but if not, I have lots of jokes and obnoxious commentary to keep you occupied for a few days while we work on it, ok with you?".
Is that better?
Wednesday, March 3, 2010
patient advocacy - not as easy as you'd think
I received my first, rather horrible, critique of my nursing practice the other day from a comment on this blog. As a person who is used to praise and commendation, I was first dismissive and cold when this person presumed to judge my nursing skills, my patient devotion, and overall ability to be a fabulous nurse. When I first read this comment, I was pissed. My unedited mind said: "Fuck you. You wish you could have a nurse like me. You don't know me. How dare you put me in this little box, focusing on out of context words, and trying to chop me at the knees. Get some fucking counseling and kiss my ass." This IS a rather extreme reaction, and I held myself from responding that evening, and instead, drank some wine and slept on it. Many days later, I take a deep breath and brood on patient advocacy. Could I have done more? Should I have done more? What prevents me from acting more, on what I believe are my patient's best interests?
There are many factors involved in being completely present for your patient, and I am not perfect people! I try to be the best patient advocate that I can be, but there are a few issues in my practice that fluster these intentions. First, I am the NURSE - I take orders, not give them. Second, people say "no" all the time - this doesn't mean that they "mean" it. Third, I am fucking busy, and do not have the resources it takes to research deep issues and have many heart-to-heart discussions. These three concepts will be further explored in this essay. Angry commenter, please accept this as a rebuttal and understand that I am not an evil sadist, but a person just like you - trying to get by, and do the best that I can with my time on this Earth. Peace.
I am a nurse. Not a doctor, soothsayer, or magician. I get orders and pretty much follow them unless they are totally stupid, totally wrong, or cause more pain than they are worth. The third reason is fairly subjective and frequently, if I suggest that this might be the wrong choice during rounds, I automatically seem to sprout two heads and am stared at without comment, and the interns return to their patient plan quickly so as not to embarrass me further. Nurses during rounds are really only worth anything when the Attendings are trying to look PC, or when all other ideas have failed. So yeah, I do say what is on my mind - "This person is sick and probably going to die, have we had a family meeting recently?", "Has Palliative Care been consulted?", "Is this invasive procedure necessary, and is it going to change our plan of care?". I say this stuff, and I hope for a meaningful response - but really am only effective if I take issues up with a resident in private, and they then present the idea as their own. They proceed to get a pat on the back, and then wink at me meaningfully when they are done rounding on my patient. nice.
People shout out "No!" many times during my day. They come into the unit with a GI bleed and are tachycardic and hypotensive. I explain what I am going to do beforehand, but they are of course upset and kicking away as I push a tube into their nose to go to the stomach in order to lavage the blood out. They say "No!" when I start IVs, restrain them from pulling out tubes, or putting in a foley because they are pissing all over themselves. These same confused/sick people tend to clear up within a couple days, and are sent off waving goodbye as they leave with a thank you, and I hope to never see you again. Coming into the ICU sucks, it is not a trip to the spa. It is hell to get better sometimes, and I walk the fine line of trying to figure out if the discomfort is worth it. Sometimes no means "I hate this, I hate you, but I don't want to die like this". During these times, my patient advocacy means putting the patient's long-term interest before what they may want at that particular time.
My third reason for not being a super patient champion is because I am stretched to the max sometimes. With two patients who should actually be one-to-one, I am running my ass off all day, and can't even sit down to review their chart. Maybe this is my fault for working in a hospital that doesn't provide adequate staffing. Maybe it would be different somewhere else where I wouldn't have days where I feel like a kicked dog when I leave. Is it different anywhere else though? I don't know. My work has great benefits, awesome staff, usually a good working relationship with the doctors, and I have good potential for the future. The patients are great; very colorful, rich histories, amazing families, and usually I feel very satisfied at the end of the day. Sometimes though, I know that if I had an ICU physical therapist, respiratory therapists who actually cared about vent weaning, or even a competent nursing aide, I would be much more effective at my job.
This is a depressing post.
As a nurse in a small hospital without much nursing support, I do the best that I can with the time I can afford. There needs to be a fundamental change in the way we view patient care at the ICU level, with a holistic focus and commitment to improving patient outcomes, and accepting when we are beyond our means of making some of them better. Probably, my best way to be a better leader in patient care is to move into administration and really push for greater resources and training. But, then I would be away from where I really shine - at the bedside, with the patients whom I really do appreciate, and try to either get them better, or help them leave this world peacefully with dignity, surrounded by someone who really does care.
There are many factors involved in being completely present for your patient, and I am not perfect people! I try to be the best patient advocate that I can be, but there are a few issues in my practice that fluster these intentions. First, I am the NURSE - I take orders, not give them. Second, people say "no" all the time - this doesn't mean that they "mean" it. Third, I am fucking busy, and do not have the resources it takes to research deep issues and have many heart-to-heart discussions. These three concepts will be further explored in this essay. Angry commenter, please accept this as a rebuttal and understand that I am not an evil sadist, but a person just like you - trying to get by, and do the best that I can with my time on this Earth. Peace.
I am a nurse. Not a doctor, soothsayer, or magician. I get orders and pretty much follow them unless they are totally stupid, totally wrong, or cause more pain than they are worth. The third reason is fairly subjective and frequently, if I suggest that this might be the wrong choice during rounds, I automatically seem to sprout two heads and am stared at without comment, and the interns return to their patient plan quickly so as not to embarrass me further. Nurses during rounds are really only worth anything when the Attendings are trying to look PC, or when all other ideas have failed. So yeah, I do say what is on my mind - "This person is sick and probably going to die, have we had a family meeting recently?", "Has Palliative Care been consulted?", "Is this invasive procedure necessary, and is it going to change our plan of care?". I say this stuff, and I hope for a meaningful response - but really am only effective if I take issues up with a resident in private, and they then present the idea as their own. They proceed to get a pat on the back, and then wink at me meaningfully when they are done rounding on my patient. nice.
People shout out "No!" many times during my day. They come into the unit with a GI bleed and are tachycardic and hypotensive. I explain what I am going to do beforehand, but they are of course upset and kicking away as I push a tube into their nose to go to the stomach in order to lavage the blood out. They say "No!" when I start IVs, restrain them from pulling out tubes, or putting in a foley because they are pissing all over themselves. These same confused/sick people tend to clear up within a couple days, and are sent off waving goodbye as they leave with a thank you, and I hope to never see you again. Coming into the ICU sucks, it is not a trip to the spa. It is hell to get better sometimes, and I walk the fine line of trying to figure out if the discomfort is worth it. Sometimes no means "I hate this, I hate you, but I don't want to die like this". During these times, my patient advocacy means putting the patient's long-term interest before what they may want at that particular time.
My third reason for not being a super patient champion is because I am stretched to the max sometimes. With two patients who should actually be one-to-one, I am running my ass off all day, and can't even sit down to review their chart. Maybe this is my fault for working in a hospital that doesn't provide adequate staffing. Maybe it would be different somewhere else where I wouldn't have days where I feel like a kicked dog when I leave. Is it different anywhere else though? I don't know. My work has great benefits, awesome staff, usually a good working relationship with the doctors, and I have good potential for the future. The patients are great; very colorful, rich histories, amazing families, and usually I feel very satisfied at the end of the day. Sometimes though, I know that if I had an ICU physical therapist, respiratory therapists who actually cared about vent weaning, or even a competent nursing aide, I would be much more effective at my job.
This is a depressing post.
As a nurse in a small hospital without much nursing support, I do the best that I can with the time I can afford. There needs to be a fundamental change in the way we view patient care at the ICU level, with a holistic focus and commitment to improving patient outcomes, and accepting when we are beyond our means of making some of them better. Probably, my best way to be a better leader in patient care is to move into administration and really push for greater resources and training. But, then I would be away from where I really shine - at the bedside, with the patients whom I really do appreciate, and try to either get them better, or help them leave this world peacefully with dignity, surrounded by someone who really does care.
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