Stay

The other day my friend sent me a link to one of the best nursing related posts I have read in a while... "Just a Nurse" written by Kateri. It is a concept I know all too well. I am often compared to physicians and nursing is ranked below the practice of medicine too often. The tasks I do on a daily basis are drastically misunderstood by the average person. I think if any one of my friends or family were to shadow me on a typical day in the ICU they would be shocked and amazed to see just what my job entailed.

I don't just pass out medicine and give bed baths... I help maintain the hemodynamic status of my patients. I take care of patients who are on multiple vasoactive drips, ventilators and highly complex machines to keep their heart, kidneys, and lungs functioning properly. I collaborate with the physicians and surgeons of all services and I have a valued opinion in the healthcare team and knowledgeable input into the lives of my patients. There are even times when I am the one teaching residents about the management of ICU patients. It's a shame that the few nursing roles people identify with are the ones on shows like Grey's Anatomy and such... and more importantly the roles for physicians on those shows are grossly exaggerated. Not saying that physicians aren't obviously vital members of the health care field but lets get real... most doctors I know aren't in the room long enough to learn how to operate the IV pump. (In my unit they aren't even allowed to touch our IV pumps!) Nurses are the ones at the bedside minute by minute.

I have been the last comforting voice to numerous patients... the last person they see as they transition out of this life. I have held so many hands through panic attacks and given CPR to coding patients who were on the brink of death. I have come home with blood and vomit and urine on my clothes. I have been kicked, hit, spit on, pinched and cussed at too many times to count. I have been apologized to for those same things but not often enough. I have had some wonderful conversations about life in the military and life on the war front. History through the eyes of a veteran is an interesting, inspiring, and heartbreaking thing to see.

I have sat through slow shifts and had the opportunity to connect with my patients on a much deeper level than just their health. I have connected with the daughter of an alcoholic who had to grow up way too fast. A man who lost his entire family to freak accidents and murders. I have had insane shifts where I was so over it at the end that I went home and had wine for breakfast.  I have been angry, frustrated, and am always exhausted at the end of the day.

I have had more than one friend and family member ask me why I stay. Why do I stay in such a difficult profession? Why do I stay in a hospital that pays the lowest salary in the area? Why do I stay in a hospital that has patients who suffer from PTSD and are combative and sometimes ungrateful.

Before I became a nurse I was planning on being a missionary in the middle east... specifically Afghanistan. Other than my family... everyone I knew thought it was incredibly noble and special. A calling so particular that despite the dangers and the difficulties of the task... it was a risk that was worth the sacrifice. A sacrifice that could have cost me my life.

But because I get paid to be a nurse I guess there is this sense that the sacrifice should not be so great? I consider this job my calling and in particular right now I consider veteran's to be the people I need to serve. I just wish people understood that just because my job is incredibly hard... doesn't mean I shouldn't be doing it. Cause seriously... if not me than who? If every singe nurse left because it was too hard or the sacrifice was too great we wouldn't have any left. Well... we might have the ones who only care about the paycheck left but what good does that do? No one really wins. This is why I chose to be a nurse and not a doctor or a missionary.

As a nurse I have this unique window into the lives of people who are incredibly vulnerable. I not only get to help save their lives by doing my job but I also get to be their comforter, healer, teacher, cheerleader, helper, advocate and voice. I love my job despite its constant sacrifice. The rewards are not always obvious but they are always great. And honestly... if you had a loved one in the hospital wouldn't you be glad to have a nurse who felt the same?

That is why I stay.

Note to Self: His mercies are new every morning...

Right now I am supposed to be reading “Ladies and Gentlemen, to the Gas Chamber” and every time I switch my browser to my school's page I just can't seem to get up the mental fortitude to go there. I keep thinking about the week that I had... four very long twelve hour shifts in a row. Lots of homework and lectures and tests and papers in between. Death. I am tired.

I have been a nurse in the ICU for four years now come this July. I still remember when I started this blog as  a new grad about three years ago. It doesn't feel like it has been that long but the weariness in me reminds that it has. 

I thought yesterday was going to be a good night. It has been a really rough week and my stress levels have been physically impacting me and I feel at my wits end. I needed it to be a good night. It started off with a perfectly wonderful conversation with my patient's family members about the perils of quitting smoking. We laughed over the crazy things we would all do during our peak addiction days just to get a cigarette. Laughing over things only an ex-smoker would be able to laugh about. It was nice to connect with the family, you could see that despite the severity of the situation... there was an ease. A trust that they felt things were moving in the right direction and knowing that their loved one was in very good hands. It was nice and despite my exhaustion I was thankful. 

Then not an hour into the shift I hear his wife yell out, "He's bleeding!" and immediately the flood gates open. Ruptured esophageal varices that eventually found its way out of his mouth and nose with force. The next four hours were a furry of attempting to get the bleeding under control with massive transfusions of blood products and a procedure to clip the bleed in his GI tract. His poor family was ushered out to the waiting room and I felt horrible. 

No, this is not a good night. Not for me... and definitely not for them. What is so difficult sometimes is knowing that despite how hard you work and all that we do to save lives... sometimes it fails.
Sometimes people die of lung cancer, probably from the 40 years of smoking a pack a day.

Sometimes people die from a GI bleed from years of binge drinking and a failing liver as a result. 

Sometimes death is peaceful and wonderfully fitting.... and sometimes it is not.

This week it was not. 

So for now, I just don't have it in me to read "Ladies and Gentlemen, to the Gas Chamber" or anything else that talks about death and sadness. Right now, I will stop and say a prayer for that family and I will spend some time here and I might also need to give these girls a call... their smiling faces and silly laughs always make the world a little better. 

Maybe tomorrow will be brighter and the world will feel a little less heavy and burdened...

Something good...

 This week... this week has just been too heavy. There has been this weight resting on my chest. Like a vice slowly closing in on my lungs. Each breath feeling tighter and tighter. I feel paralyzed by it sometimes. A hollow shell of exhaustion.

This week I helped try to resuscitate a code blue patient for nearly 6 hours. Blood products, intubation, lines.. the works. And then watched as his family stumbled into a room with trash strewn everywhere and every known machine in the unit packed into the room... and blood... so much blood streaming from this mans mouth and nose and all over the sheets... so much that 15 units of blood products didn't save him. His belly taut and distended, full of god knows what. I watched as the resident told them that their loved one was dying... and that we have nothing left to do. I watched as they sobbed and shook their heads in shock and disbelief.

I remember my first death in the ICU... it was peaceful and uneventful compared to the usual in my unit. A simple transition into another world. I went home after that death and I cried and cried and cried. I couldn't grasp that this person who was loved and cherished and had memories and a life... that this person was just now gone and I had somehow witnessed this sacred passage. 

And yet this week, I came home and felt tired and alone. Knowing that there are very few people in this world who truly understand what it is like to do what I do. I felt like I had no words for what had just transpired and so instead I said nothing. I shed no tears. I posted a short comment online hoping it would make me feel better and it didn't. Then I turned on the news and continued to be barraged with the horror that has transpired in this awful week. 

This week has been horrible and I am tired and I don't want any more news of terror or death or fear and hatred. I want hope. I want joy. I want redemption... 

So as I drove into work last night and passed our flag at half mast. I paused for a moment and thought to myself. Today I will do something good. Despite the weight on my chest, and the pit in my stomach... I will still do what I am called to do. Because today... today is a beautiful day to save lives.

Rough Day

Today is one of those days where I wish I wasn't a nurse. I dream of having a job where life and death is not on the table. Where the pressure to be perfect and always "on" isn't quite so strong. Where family members aren't skeptical of you right off the bat. Where doctors talk to you like you are a human being and not a servant. There wasn't any one thing that happened that caused this horrible day... it was busy and crazy and exhausting as always. 

Today it felt hopeless though.... I felt hopeless. As in "what's the point?" hopeless. Two patients with metastatic CA that I am poking and prodding and watching everyone freak out about when really they should be on a morphine drip in the hospice unit.

I don't know what it was about today but I felt like a failure walking out of that ICU. Like I messed it all up... and honestly I think it is because I don't agree with what I do half the time I'm at work. Forcing procedures on patients who do not want heroic measures.... it just doesn't settle right with me. Nursing today is getting harder and harder. More responsibility, more expectation.... so much pressure and stress to never make a mistake. And for what? For a patient who is going to die in a matter of months... weeks or days even. We do all of this for what? Is it for the patient or for our own peace of mind?

In the end we all have to go at some point... at the very least we can go in as little pain as possible and with a bit of dignity left. A choice in it all. I never understood why people would want to become hospice nurses but now... now I get it. I have a feeling I might end up down that path someday myself. 

Right now, all I can do is go to sleep and hope that God will give me the grace to be an ICU nurse for a little bit longer. 

The Color of Humility

“Death opens a door out of a little, dark room (that's all the life we have known before it) into a great, real place where the true sun shines and we shall meet.”
― C.S. Lewis, Till We Have Faces: A Novel of Cupid and Psyche 

 In the ICU we are all about control. Almost every ICU nurse I know would agree with that fact. In death there is no control. I guess that's part of what I love about palliative care. In a world where you can't beat the inevitable... at least I can have some control over how it ends... I can offer some solace at the very least. The chaos stops and there is only the person... no IV lines, no balloon pumps, no chest tubes, no monitors. Just pure nursing care. Today I am taking care of a dying patient and for some reason, today has not felt that way. There has been no solace here. It has felt exhausting and uncomfortable. There is an unease to everything about this night. I couldn't put my finger on it but as the hours have gone by I have felt it.
That gnawing feeling in my stomach. It wasn't until I saw my patient's family react to a simple question that I was able to pinpoint the source. A simple, "Do you want to be called before he passes away?" and the whole countenance changed... I saw that smile turn into a stern, furrowed brow and that pit in my stomach grew.
They think their loved one is going to recover and so until the very last breath they will force every invasive procedure possible in hopes of prolonging life. From that point on I realized why I wasn't settled and I don't know why it didn't hit me sooner. This is not end of life care...
In the ICU we are supposed to save lives and many times we do. We use our medical knowledge and nursing care to fix people up so they can live again as they once did before. But the reality is that most often life will never be the same. We have patients here who have been in our hospital for over a year. They have gotten sick and gotten better more times than I can count and in the end they usually end up succumbing to the inevitable. They die here... sometimes alone and often times after a long and painful hospital course... and I think to myself. What was it all for?
And if we can't save their life... at the very least we can make them comfortable in their last moments on this earth, right? But, what happens to the patients who are obviously dying and yet the family just isn't ready to let go yet?
It is that grey area that I find hard to handle and this patient was the epitome of all of that. We have to poke and prod until the very end. We have to do things we don't agree with and don't like. We have to face the fact that we cannot save every life and that medicine has its limits.... and I have no control here...

and I hate that.

I hate that grey area between death and life... where we have to wait and see...to pretend it will all be okay despite what we know will inevitably come. It is in those moments where my hands are tied and I have to be the one to carry out the invasive procedures while the family is able to get the incredible, devastating courage to let their loved one go. It is in those moments where I have no control and if the only thing I can do to provide comfort to a dying man is to pray for him as I give him a bed bath and some new sheets to pass away in... well then that is what I will give.

This is the grey area of the ICU where my faults stare glaringly back at me and I am reminded of just how insignificant I am.... of just how selfish I can be. That when a family is battling with the fact of losing their father, brother, uncle, husband... all I can think is, "I hate this" It is the grey area that reminds me of how insignificant my needs are when in comparison to those of a dying man.
It is painful and uncomfortable and in the middle of all that grey it is incredibly humbling.

In Honor of a Patriarch.

I have shared on this space many times about the wonderful family I was lucky enough to marry into. It is a very large, very loving group of people who are crazy and fun and welcoming beyond belief. From day one, I felt very comfortable slipping into the mix of people that called this clan their own.... a clan that is now mine too.

The patriarch of our family started a legacy that spreads beyond generations and has branched out all the way to people like me. A girl who came from a very broken and disconnected family... a girl who now has a place to call home... all because of the love of the two people you see in the picture above.

Today, that patriarch is no longer with us. He passed away this morning and our whole family is still in a somewhat state of shock. I have never had a very close family member pass away. I have seen death time and time again... and yet I have never really experienced it. That hole that is created... the new space in your life where something important is now nothing but an empty void.

When we went to the hospital and saw him... even I was unsure of what to expect. I see death all the time and this was no different... except that it was. You go through the motions... the details of the events are familiar to me but the aftermath was not. As I watched the emotions and reactions from everyone around me I could sense that mode of... 'this is life' settled in me. I know this... its familiar.

It wasn't until we started walking out of the hospital that it hit me. This is unchartered territory... where do we go from here? Life will no longer be the same for us... especially for grandma. I remember the first time I had a patient die in the ICU... the patient's wife stood there after saying goodbye to the man she had shared most of her life with.... she stood outside his room and looked at my preceptor and said, "Now what do I do?"

"How do I just go home without him?"

It was this moment of realization. She would not be going home with him... but she wouldn't be coming back here to see him either. She had to move on... but how? How do you just walk away from the love of your life for the last time? How do you leave the hospital with all of his belongings but without him?
This is what settled in my soul as we drove home from the hospital. That gnawing feeling of the numbness wearing off.

Grandpa, I hope you know how much you are loved... I hope you know how special you were to us... and to me. I am so grateful that I had the honor of knowing such an amazing man who created such an incredible family. I will always remember that moment, right after Chris and I said our vows to each other. You reached out to me first and said, "I have to be the first one to congratulate the new Mrs. Heggem!" I think my face said it all... I was officially now a Heggem!

Thank you for that... thank you for being you.

I know that I can take comfort in the fact that you are in peace, in heaven, celebrating with the God you served so faithfully. But for the record.... we miss you dearly, Grandpa and today we grieve the loss of our beloved patriarch.

Rest in Peace.

Blessed

Today I am tired. After a four day stretch of 12 hour shifts your emotional and physical stores are virtually non-existent. They are worn thin at best. Working in the ICU is hard. It is draining in ways that I cannot fully explain. I have learned that because of my profession my life is different than most.

 This week I had the privilege of taking care of arguably the sweetest and dearest people I have ever met. A husband who is dying and a wife who has a love for her husband unlike any other I have seen. Everyone who had contact with them instantly fell in love. I know I did.

I have sat here at my computer for an hour trying to put into words what it was like witnessing that kind of love between two people but I have failed. There was a sweetness to them… an aura of the deepest type of caring. In the way she would smile at him and kiss his forehead… the way he would reach for her hand. How she would lay her head at his bedside for days on end… supporting… hoping… caring.

In the way they both decided that now was the time. That this man had lived a life full of joy with his person at his side… the woman he knew he would marry the second he laid eyes on her. And that now it was time to let go. Time to make that transition that all of us will eventually have to make.

Every morning before I would leave work I would stop by their room to say goodbye… just in case. I would hug them both and tell them that I loved them and he would kiss me on the cheek and she would squeeze me tightly and walk me down the hall. And every morning she would burst into tears.

One morning she came down the hall… tears streaming down her cheeks.

“How will I know?” she said. “What do I look for? He isn’t really talking much.”

So we went into the room together and we talked… I told her that it wasn’t time yet.

And right then and there she fell into my arms.

 “It’s like coming to the end of a jail sentence.” She said… the fear and pain was visible on her face.

Today Bethany and I went upstairs to the hospice unit to say hello and we talked… we looked at old photos of him in the service… of their life together. It was a perfect ending to a long week.

The first night I took care of him, when we decided it was time to stop heroic measures, he told me, “This is the best night I’ve had here yet… talking to you.”

I smiled and held his wife’s hand.  And as I said goodbye that morning he grabbed my hand tightly and smiled, “ I hope you have a blessed life dear. A life full of love like I have.”

And as I walked out of the hospital that morning, exhausted and teary eyed… I knew that my life had been touched. And that I am truly, truly blessed. 

a moment

today every part of my soul feels weary. i have been walking in a sort of daze. a mix of exhaustion and sorrow and gratitude. there are moments in your life that change you. moments that give you such a clear view of your existence that you can never be the same. i made the choice to become a nurse because i knew that if i did my life would never be the same. 

it has been a long month. a busy one in our unit and it has taken a visible toll on everyone. lots of sick calls. lots of complaining. lots of very sick people who need a lot of care and not enough people to give it. emotionally we have all been drained. i am drained too. 

in the past month i have taken care of multiple patients with debilitating, chronic, fatal diseases. they teach you in nursing school how to have boundaries. how to let go and care at the same time. how to set limits with chronic patients without seeming harsh. i have never been good with that. i oscillate between the lines.

yesterday was my last night of a long stretch at work. i was tired and in pain. i had a very stable assignment. not a busy one by any ICU standard. just difficult. one patient on his 7th round of chemotherapy, suffering from a vicious cancer and a mild infection. i was thankful he slept for almost the entire 12 hour shift. thankful for the chance he got to rest and restore but thankful for myself too. thankful for the minimal interaction needed. 

my other patient, a man in his prime, suffering from the end stages of ALS (lou gehrig's disease). the only muscles left with any sort of function in his body were above his neck. he could not move, could not eat, could not speak. he couldn't even breathe without the help of a ventilator and tracheostomy that was placed. he could barely mouth enough words to ask for what he needed. his wife was there at the beginning of my shift. she wanted to make sure the night shift nurse was a "good one." that is always a bit of an anxious thing for me. the ICU is stressful and often times families of ICU patients are burdened with fear and sadness and an acute awareness of their loss of control. then here comes this 26 year old girl who will be taking care of your husband, father, brother... your son, who is on a ventilator and a plethora of medications that need titrating and managing. for them it is terrifying. which i understand. i do. but it is still hard.

it is hard to tell what they expect. what they want. do they want you to be happy and positive and cheerful? do they want you to be serious and somber and just down to business? or do they want you to be friendly with them and treat them like you have known them for years? i see some of my co-workers who are warm and friendly and smiley. hugging their patient's family members and chatting like they are bff's. i have never been good with that. i am not good at being smiley. i am genuine and hard-working and compassionate but i am not smiley. when i am at work i am serious and professional. i think some people see it as being cold and that is difficult for me. i want them to know that i am giving 100% of my attention to their loved one but it is hard when you don't know how that person receives that message. everyone is different. 

often times i am the one who relates to the few that everyone else has a hard time with. the quirky, walled up, introverted ones. the ones that take a little more time to get to know. i get that because i am that way too. maybe it is a trust thing. or maybe its just time. i find though that the ones with the hardest shells have the softest hearts. a lesson my mother taught me years ago and one that i never forgot. 

i knew this could be a difficult night. i was right. it was difficult. it was long. it took every ounce of energy left in my being to give the care i gave. it took a lot of venting sessions in the break room and hugs from my co-workers too. i am so incredibly thankful for them. they keep what little sanity i have left intact. 

i spent 90% of my evening trying to understand my patient's pleas for help. imagine what it would be like to have your mind fully functioning and completely aware of your existence but to have no way to connect that to your physical body. imagine having no way to move into a comfortable position. no way to wipe the tears from your eyes when you are sad. no way to scratch your head when it itches. or move the covers off of your body when you get hot. no way to eat or no way to communicate clearly that you've gone to the bathroom in your bed and need to be cleaned up. no way to tell someone you love them. or to say that you are in pain.

every time we had to do anything to my patient it required a 30 minute session after of discussing ways to reposition him. he would nod and attempt to mouth words but it ended up looking like the mouth of a puppet on strings. everything jumbled together and nothing was comprehensible. i resorted to head nods and one word phrases. 

Is it your head? no

Is it your arm? no

Is it your shoulder? no

Is it your hand? yes

Okay!

Is it too low? no

Is it too high? no

Is it your fingers? yes

Do you want me to spread your fingers apart? he smiles.

I fix his hands and he begins to nod his head towards his left and looks down at his hand.

Do you want me to fix your other hand too? no

Huh... try to mouth it to me.

Up? no

are you saying head? no

Im sorry but I can't understand. Try again.

I turn on the lights and walk around to the other side of the bed and begin again.

Is it your arm? no

Is it your leg? no...

I take a deep breathe in and proceed to look around for anything that looks uncomfortable.

30 minutes and 10 pillows later we have him propped up in a position that is comfortable.

an hour later the process repeats itself again.

by the end of the 12 hour shift i was translating to people what he was trying to say and dictating exactly where he wanted every limb of his body to be. down to every toe and finger... everything had its place. by the end of the 12 hour shift i had nothing left. i thought about his wife at that moment... and how she looked on the verge of tears when she left the night before. and how i thought that it was because she was sad that her husband was dying. and now i was wondering if it was also because a part of her was dying too. the life she once knew and the love she once had would never be the same. the dreams she had. the children they had. nothing would be the same. ever. and how she must feel so incredibly exhausted and drained after a year and a half long of this.

i wanted to weep for her. i wanted to tell her how sorry i was and how unfair it was and how i wished it were different. for both of them. i wished i could do more. make it easier some how.

i prayed at that moment that God would give her rest then. peace. that she would sleep well and heal too while her husband was being taken care of here. 

when i went into the room to say goodbye that morning he looked over at me and mouthed the words, "thank you. you're the best" and smiled so wide i could see the deep wrinkles form around his eyes.

i could feel the tears reach my eyelashes.
"no my friend, thank you" i squeezed his hand and smiled back.

there are moments in your life when you know that you will never be the same. and in that moment i knew that as i walked down the stairs to my car that morning, i would feel every step and inhale deeply every breath. that i would go home and tell the people in my life that i love them because i can. i also knew that this was one of those precious moments... a moment where i would surely never be the same.

7 Quick Takes Friday

1. I am a master at getting sick this year. Earlier this week I came down with food poisoning and proceeded to puke my guts up for the last hour and a half of work. I had to have Chris come pick me up from work and the poor guy had to hold my hair back as I proceeded to hurl up everything I had eaten in the past 12 hours. It was disgusting and awful on many levels. Thankfully I am better now but that was really crappy. At least I have a wonderful boyfriend who can take over the nurse role when the nurse in the house is sick.

2. I did Bay to Breakers for the first time last Sunday! B2B is a very famous race ran in San Fran. every year. Full of runners and non-runners who all come together and throw tortillas (totally random) and dress up in costume and run a 12k across the city. There is also a tradition of people running it in their birthday suits... can we say awkward? It was fun to see everyone come out and party in my favorite city. I also got a small taste of what the SF marathon is going to be like. HILLS :(

 Definitely one of my favorite costumes. A family ran together with shark fins on their heads and whenever they saw a group of people standing together they would run around them and circle them like sharks haha.

3. San Francisco is gorgeous! I love living in California... specifically norcal because it is so darn pretty. After B2B, Chris and I went out to lunch with Chris' little brother and his friend who just moved to the area. We had lunch practically on the water and it was an awesome day for it. That's Alcatraz over in the distance. :) I <3 SF.

4. In a little over two weeks I will be running my first marathon race! I am super excited too because one of my work BFF's Bethany will be coming with me.

She recently ran the Santa Cruz half marathon with me and we had a blast so I feel incredibly lucky to have her as a road trip buddy and cheerleader as I embark on one of the most crazy/exciting things I've ever done. :)

5.  A few months ago one of my very closest friends and co-workers was deployed to Iraq with the Army National Guard. I have been keeping in pretty good contact with her and I've been keeping watch over her house while she's been gone. It's been scary hearing her stories of the bombings that happen sometimes daily at the base there. Ever since Osama was killed she said it's been much worse. She dealt with her first trauma and death the other day too. Seriously, hearing her stories from a standpoint of someone so close to me.... its harrowing to say the least. I have a whole new respect for our soldiers and veterans. Especially those who have served in war zones. If you know one yourself... give them a big hug or an honest thank you. I'm sure they'd appreciate it.

6. I've really really really been wanting a puppy lately. Sadly I am allergic to dogs and cats so it probably won't ever happen... but seriously.... if this isn't one of the cutest things you've ever seen.. you have no soul.

SO CUTE!

7. I realized today that I never finished posting pictures of Lebanon and I never posted any of Ireland. Okay maybe a few but Ireland deserves a few of it's own posts. I will start working on that. Marathon training and life in general has really taken away time for picture editing and when you have 3,000+ photos to go through..... it's a little daunting. I'm not gonna lie I haven't even really started on the Ireland photos but I do have Lebanon pics to post and they will be coming soon :)

For now a sneak peek...

 Happy Friday Friends!

It never gets easier.

For some reason this year I have had quite a few patients pass away. Working in the ICU you expect to see death but surprisingly enough it isn't extremely common. A lot of our nurses will make it through an entire year without having a patient die on them.... AND yet for some reason this year I have had my fair share of comfort care experiences.

Growing up I was always terrified of death... it would keep me up sometimes at night... my mind reeling from all of the awful things that could happen to me or a loved one.... all of the things I would miss in this life if I was to die young. I think if I worked with pediatrics my perspective on death would be much different... but I don't. I work with predominantly older adults and so death is a natural part of the life process. 

This week I have seen another side of death though.... a member in Chris' family passed away a few days ago and it was incredibly sad to be on the other side of things this time. Even though I didn't know him... it was so different seeing the effect of it all. The vigil at his bedside. The smile he gave when he saw the little ones wave to him. The tears and stories and heart felt questions.... "Why now?" 
It reminded me of my first death in the ICU. I cried the entire way home listening to the Death Cab for Cutie song "What Sarah Said" ..... The lyrics "love is watching someone die" ringing in my ears... and I just couldn't get over it.... this person had a life.... a family... memories... a legacy left behind and now... well now they're gone... just like that. 

Gone.

I know that he is undoubtetdly in a better place... a place where cancer does not exist and pain has no hold. I have been praying for the H. family this week and today as they say their final goodbyes as well. I hope they feel the love that I see and feel in their family. It is a gift to have so many people surround you as you leave this world and it is so very clear that even if Uncle M. is not here anymore... his love and legacy still remain in the people he has left behind.

"Please Lord... don't let me cry"

"What Sarah Said" by Death Cab for Cutie

And it came to me then that every plan is a tiny prayer to father time
As I stared at my shoes in the ICU that reeked of piss and 409
And I rationed my breaths as I said to myself that I'd already taken too much today
As each descending peak on the LCD took you a little farther away from me
Away from me

'Cause there's no comfort in the waiting room
Just nervous pacers bracing for bad news
And then the nurse comes round and everyone will lift their heads
But I'm thinking of what Sarah said that "Love is watching someone die"

__________________________________________________________________________________________

I know that death comes with the territory of being an ICU nurse. It's simply a part of the job and in many ways it can be a wonderful part of the job. My view on death since I have become a nurse has changed drastically. It is not something I fear anymore... nor is it a negative thing by any means. 

Death in many ways is beautiful and peaceful and incredibly full of grace. 

To be present and actively involved in such a deeply personal moment with someone is truly a gift. 

This week I had a patient die (seems like its been happening to me a lot lately) and it was the most painful death I have ever witnessed. It was expected because the patient had lung cancer with mets to the brain, and bone but still... I don't think there is ever a way to be fully prepared for the death of a loved one. Just a week prior to his death the patient was playing golf with his friend when he suddenly couldn't breathe and was admitted to our ER with a pulmonary embolism. He ended up intubated, sedated, chemically paralyzed and on every medication in the book to maintain his blood pressure, prevent heart arrhythmias, prevent blood clots.... the list goes on.

When I received report from the PM shift nurse... he began desaturating to the low 70's (normal is ideally above 95%). His blood pH was 7.11.... extremely acidotic... not a survivable level by any means. He was on 100% oxygen on the ventilator with peep and pressure support settings maxed out as high as we felt comfortably going. The ICU fellow, intern and resident all crowded into my room and we began thinking of everything we could do to try and fix this.

"I can increase his tromethamine to 20gm? Maybe that will help with the acidosis?"

"ok let's do it..." next blood gas was even more acidotic at 7.10.

 hmm...

"Or what if we increase the peep to 20 and then add vasopressin to increase his pressure and counteract the decrease in cardiac output?"

"We are already on vasopressin... it's maxed out at 0.04... we could try dopamine?"

"No, he has a history of Atrial fib.... it's why he is on amiodarone."

"yikes, ok scratch that idea."

My alarms started beeping... he was now dropping his systolic blood pressure to the 70'sand his oxygen saturation was dipping into the low 60's.

I turned to the resident and reluctantly said "I think we need to bring the family in..."

"I've already sent the intern to call them"

You could hear everyone take a deep breath in and the feeling of defeat in the room instantly filled the air. This was not a battle we were going to win. By the time the family arrived we knew we had only a matter of minutes to have a plan of care discussion. The resident began explaining the situation and the decision was made to withdraw life sustaining measures and to provide comfort care only.

I encouraged the family to take a moment to say goodbye... warning them that it only would be a matter of minutes to possibly hours after I remove all of the medications.

They said they were ready and so I began...

One by one I removed 4 IV poles worth of medication.

I started by increasing the sedation and pain medication and I began with removing the paralytic.

As I wrapped up each IV bag and threw it in the waste bin all I could do was pray... the lump in my throat was growing larger by the moment and all I could think was, "Oh Lord, please be with this family."

"Lord, please give this family grace.... and Lord please.... please don't let me cry."

After all the medication was off I sat in the room with the family and just talked them through what was going to happen. We sat in silence.... the son, daughter-in-law and the patient's wife... all four of us sat in the room and watched my patient's heart rate drop down from 60... to 50... 40.... then at 36 it maintained for a little while.... he was holding on. His daughter and his grandson finally arrived and within seconds the last few beats of his heart mapped out along the monitor and faded away.... he was gone. I stood up and listened to his heart, checked his pupils and looked up at the son and nodded.

Instantly the room was filled with tears. 

"I'm so sorry for your loss. I will give you a few minutes and I'll go get the physician to confirm the time of death." The son nodded back at me and I left the room.

Luckily, my friend Dirk was my neighbor that night and I went straight over to him.... he must have seen the look on my face because he instantly gave me a hug....

"You ok?"

I nodded with a big sigh, "Yeah I'll be fine... this just sucks."

"I know." he replied.

The next few hours were filled with the logistics of dealing with a deceased patient. Setting up the family with the resources they will need. Calling the police to have them escort us to the morgue. Preparing the body, and wrapping him in that dreaded body bag. I held it together for the rest of my shift and when I made it out to my car I tried not to think about the night I had just endured.

Then... I turn on my car and the song by Death Cab for Cutie comes on....

I was instantly frozen... and sooner than I could say "Please, Lord... don't let me cry..." I hear the words

"Love is watching someone die"

Like a ton of bricks on my chest, the reality of what I had just witnessed hit me... and I felt those walls I put up crashing around me... 

and I cried ... I cried that horrible, ugly cry, the entire way home.

Life and death matters

Today, I was reunited with my old friend the ugly cry. I got off of work and I drove home in a silent reverie of emotions and wandering thoughts and by the time I arrived in my driveway I was a ball of water works. A broken down, sobbing disaster.

My patient died this week. It's been a while since a patient has died on my shift. As a matter of fact I think it's been well over a year since I've had a patient die. This time it was different too because this was a patient I had taken care of before... I had a chance to meet him when he was still very alert and talkative and full of life. I was off for a week and came back to discover he had been placed on comfort care.

The night he passed away he was doing relatively well considering the circumstances and he had family and friends from all over the country coming in to see him. They all shared such great stories about him and his life... it was truly heartwarming.

When the family came to see him in the morning they looked like zombies. They hadn't said goodbye to him the night before because we were all certain he was going to make it to the hospice unit the next day.

He didn't obviously and they were devastated.

Watching them as they came into the room where their father, grandpa, friend and brother was lying, cold to the touch, completely lifeless... it was painful.

The worst part came when one of his children came over to me... that look of shock on his face... tears streaming down his cheeks...

"What do I do from here? I mean... what.... what are we supposed to do now?"

I felt helpless... I reached out to grab his hand and all I could say was 

"I'm so sorry..."

I swallowed the lump in my throat and shook my head.

"I'm so sorry."

Week Re-cap

Monday: Stayed in bed all day because I was so sore from the half marathon that I could barely walk. Fell asleep at 7:30pm because I was so exhausted.

Tuesday: Woke up at 6:30am (yup thats 11 hours of sleep) cleaned my house and then went to work that night and found out that a patient we've had on the unit for months coded over the weekend and was now on comfort care :(

Wednesday: Went home after work and since I had been up for over 24 hours at this point slept from 10am-530pm (miracle!) and then had a paired assignment at work that night that was really busy. One stable patient + one intubated patient with respiratory failure, acute pancreatitis and was now becoming septic very quickly with an elevated lactate and a pH of 7.17, CO2 in the 70's and a paO2 in the 40's.... ended up having to go above the intern and resident (they said that the blood gas "looked fine")and paged the ICU fellow at 4am.... not my idea of fun.

Thursday: Got into an accident in the parking lot at work and then had to go home and deal with insurance etc. Didn't sleep more than 4 hours and then went back to work for my 3rd 12 hour shift in a row. Survived 4 hours of our unit's annual competency fair and then had my septic patient for the next 8 hours.... luckily we had him completely sedated, paralyzed, on a ton of drips and even though he was still sick, sick he held steady all night .... my favorite kind of patient :)

Friday: I come home from work this morning and fall asleep from 10am-11:30am and have been awake ever since.... I've desperately been trying every trick I know to get some rest... meds, hypnosis tapes, guided meditation, eye covering, ear plugs, watching tv, reading.... still. wide. awake.

Since Monday morning I have had a total of 24.5 hours of sleep = I'm averaging 4.9 hours of sleep a night = I'm not a happy camper.... plus I have been too tired to go running this week and it's just making me more grumpy.

Another thing I tried to help me fall asleep was to look at pretty pictures of fall and rainy season.... fall is my favorite season and I would be the happiest person ever if it rained 24/7... seriously I love rain.

image credit

   There is something about fall and about rain that is so comforting to me.

On an unrelated but happy note... I get to go to Colorado in a week! It'll be great to see it in the fall cause after all these years I've never been there during the fall. Plus I'll get to see these guys :D

Happy Friday Friends!

The ebb and flow of ICU nursing

Halona Sunrise

It almost frightens me to say so (especially since as I write this I have one more 12 hour shift left tomorrow) but work has been good this week. *knock on wood* Any ICU nurse knows that you don't dare jinx things by saying something like "man, it's been quiet here today!"

The next thing you will hear is "CODE BLUE" blaring over the loud speakers. Still, I'm taking a risk and just acknowledging how thankful I am to be in an upswing at work. It's been steadily busy but not crazy and we have had a lot of good people on staff this week. No issues with the on call ICU docs (miracle I tell you) and in fact this month has been good so far. Last month was great also so we've really been on a roll with our ICU team. I also think it really makes a difference when you have good nursing staff on your side. I've been working with my favorite people recently which has been nice... and sometimes that one factor will determine whether it is a good or bad day.

Waimanalo

I was able to take a training class on CVVH or continuous veno-venous hemofiltration on Tuesday and I was resource yesterday which was nice. I've been getting back into my training schedule in terms of running. Unfortunately my running injury has begun to flare up. I'm biting the bullet and looking up some sports medicine doctors in my area who might be able to help out. Very important considering I have only a few weeks left before I run my first 1/2 marathon!!

Waimanalo

This past weekend I spent time editing photos and sort of winding down from a really draining two weeks. Before I left for Hawaii I had already been feeling like I needed some good down time by myself and it wasn't until this past week that I started getting that. Being as introverted as I am its so vital for me to have time to stop and reflect and process, because when I am around people... even people I love a lot... it takes a ton of energy and I don't ever really get to stop and feel refreshed from my crazy life.

Halona Sunrise

It's been just over a year now that I've been working as an ICU nurse and even in that short time I have seen the ebb and flow of this job wash over me. There are good days and bad and sometimes they may even turn into good and bad months. I remember my preceptor last year warning me about this.

"You will go through phases of burn out in your job... that is normal and eventually things will get better. You learn to adjust and you learn how to take care of yourself properly so you can function the best way possible... even in the midst of a burn out. When you are not able to shake out of that funk and when you begin compromising patient care... that's when you know it's time to move on."
Wise words that I have taken with me and remembered in the tough moments and have been thankful for when it feels like the bad days just won't end.

Waimea Bay

Today I am taking care of a patient who was placed on comfort care this afternoon. Other than cardiac patients, these are probably my favorite patients to have. I know it sounds strange to enjoy taking care of a dying patient, but there is something incredibly peaceful about death despite the sadness. There are few things in life more impacting than being able to be present when someone passes. To be able to give them dignity in dying and to be able to make every effort for their comfort in their last moments on this Earth... it is an honor and it is in these moments that I remember... this is what nursing is all about.

Halona Sunrise

P.S. I'm totally kicking myself now because I'm at work on that last 12 hour shift I was talking about... no joke... not 5 minutes into my shift we were coding a patient and it was a little bit of a nightmare... after an emergency intubation, CPR, 2 rounds of epi., 2 rounds of bicarb and 2 shocks from the defibrillator we finally got the guy back....
hah... I really gotta stop jinxing myself.

Oh the joys of ICU  nursing.....

 

Halona Sunrise

On Letting Go

There was a great essay in The New Yorker recently about hospice care and terminal illness.
The essay was titled Letting Go, By Atul Gawande an American doctor and writer. The essay is worth reading, but in summary it followed the story of a young, soon-to-be-mother, named Sara and her vicious battle with lung cancer. Gawande recalls his many experiences dealing with patients like Sara... patients at the end of their life and he shared what he has learned and seen first hand being a surgeon. It was an incredibly informative and honest article.

I even learned something new... that atropine helps clear up secretions. I've only used it when my patient is seriously bradycardic. You learn something everyday... even in the most unexpected places. Thanks New Yorker!

Death and dying are difficult topics in health care. I think most of us would say that in one way or another we feel ill equipped to deal with end-of-life care properly. A sentiment that Gawande shares himself....

"You’d think doctors would be well equipped to navigate the shoals here, but at least two things get in the way. First, our own views may be unrealistic. A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three percent of doctors overestimated survival time. Just seventeen percent underestimated it. The average estimate was five hundred and thirty percent too high. And, the better the doctors knew their patients, the more likely they were to err.

Second, we often avoid voicing even these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than forty percent of oncologists report offering treatments that they believe are unlikely to work. In an era in which the relationship between patient and doctor is increasingly miscast in retail terms—“the customer is always right”—doctors are especially hesitant to trample on a patient’s expectations. You worry far more about being overly pessimistic than you do about being overly optimistic. And talking about dying is enormously fraught. When you have a patient like Sara Monopoli, the last thing you want to do is grapple with the truth. I know, because Marcoux wasn’t the only one avoiding that conversation with her. I was, too."

This has always been something that has frustrated me when it comes to dealing with medicine outside of my daily job. I've had multiple friends and family members that have had diagnoses of cancer or other forms of poor-outcome diseases. My own mother has recently been faced with a probable diagnosis of breast cancer...
When it comes down to the nitty gritty... the actual prognosis... I rarely find that a straight answer is given. Often times the doctors I have dealt with "beat around the bush" and do err on the side of optimism. I think partially because of liability issues... telling someone that the outlook is grim before you really, really know is not very wise... but also because no one wants to be the bearer of bad news. There is always, always hope... right?

But at what point are we actually harming rather than helping? The article talks about patient outcomes... with hospice care and without... and also with hospice care early in the game vs. right at the very end of the patient's life. The statistics were surprising... most patients lived longer while on hospice care and most patients seemed to fair better than when they decided to have every medical intervention to prolong life (vs. making life comfortable right here... right now, which is what the goal of hospice is).

"We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something."

I've seen it first hand... those families that just can't seem to let go despite a very, very poor prognosis... the ones that would rather see their loved ones slowly waste away on every medicaiton known to man... on a ventilator with lines coming out of every place possible... skin so edematous and fragile that they weep liters of fluid out daily because their body just can't take it anymore... its not pretty... it's painful to watch and to be honest I wonder if this is really what the patient wants. It's rare that we have a road map to guide us... most families don't talk about these things... and when they do... sadly, often times the wishes of the patient are ignored or at the very least the lines are blurred... and when to intervene vs. when to take a step back... well, who knows?
There were two questions in the essay that Dr. Susan Block, a palliative-care specialist posed to her father when he was faced with a surgery that could possibly leave him paralyzed or dead... I think they are two questions that all of us should ask ourselves and our loved ones...

"How much are you willing to go through to be alive? What level of being alive is tolerable for you?"

Her father replied, "Well, if I’m able to eat chocolate ice cream and watch football on TV, then I’m willing to stay alive. I’m willing to go through a lot of pain if I have a shot at that."

That answer made all the difference for Block when it came time to make some tough decisions for her father and she was sure glad she had asked him those questions the night before his surgery.

At the end of the day, here is what I have learned in my short time being an ICU nurse...

End-of-life issues are incredibly difficult to discuss and are even harder to face first hand... but if I could leave you with anything I would say: Dont wait...

 Don't wait until you or your loved ones don't have a voice... don't wait until you are faced with a crisis and you are bombarded with fear and stress and pain... don't wait until it's too late to have these discussions. It is just too important to simply put off, because really... you never know what can happen... life can change in an instant and whether you want every possible intervention done to keep you alive or you want to live the last part of your life with comfort in mind... what could be more important than having you or your loved one's final wishes being carried out in the way you know they wanted?

Please... don't wait...

For those in the US: resources on living wills and advanced directives

First week back

1st day back from vacation and even though I've only been away from this place for 12 days, it feels like I have to re-learn everything. About an hour into work I look over to my good friend and neighbor for the night, MB and I say,

"Good Lord, I forgot how stressful our job is!"

"Welcome back!" she smiles.

My patient was a triple A repair (abdominal aortic aneurysm). I won't bore you with all the clinical details but basically the night got interesting and by 0330 I was banging on the on call room door to wake up the intern after 6 unreturned pages. I was not happy to say the least. My patient had signs and symptoms of internal bleeding. To make a long story short the problem was not managed well by our ICU team and when the vascular surgeons rounded in the AM they were not happy either. Especially when they came in and found out that their patient had a hematocrit of 16 (extremely low) and no one bothered to call them.


Sad thing is that I really liked the resident on call for that night and the intern himself isn't generally a nice guy but he's good... knows his stuff. I have a feeling that everyone's lack of response had something to do with it being their last night on the rotation. Everyone seemed to have an "I-don't-care-I'm-outta-here-soon" attitude.

Not fun.

***
2nd day back at work

I have a patient that I've had before... weeks ago. Unfortunately he took a turn for the worse and has been re-intubated (for the 4th time) and has been in a fierce battle with end-stage liver disease, as a result from years of drinking. Ended up eventually with esophageal varices and now, as I have him, has a severe lower GI bleed. We haven't been able to get his family here (whom he has been estranged with for the past decade) so he is still a full code, despite a very grim prognosis.

I ended up giving a total of 10 units FFP, 4 units RBC's, 2 of Cryo, and 3 of platelets. Practically cleared the blood bank out of everything they had. Came back from break at 5am and there is the GI attending scoping him and trying to find the source of his bleed.

"This must be punishment for taking vacation." I thought to myself as I step in the room and gown up to assist.

"Only 2 and a half hours left." MB reminds me as she passes my room, seeing the desperate look on my face.

***

3rd night back

His family arrives and he is placed on comfort care. He gets extubated and is put on a fentanyl drip. Now, here I am at 3am with a patient who has an O2 sat of 76% but for all intensive purposes is hanging on quite well. Trekking along at a HR of 80 and a blood pressure of 124/50... not bad for a man that is slowly bleeding to death.

Morbid? ... maybe, but its the reality of my job.

"Welcome back to the ICU dear"... vacation is definitely over.

Good Lord, let the man die already!

Before you read this post....I must warn you. My perspective on life and death has been masterfully warped by my job. I see people die often enough to have been relatively desensitized to it. Sometimes I'm surprised with myself and it's sad, and sometimes I'm just plain surprised, "Whoa, the guy in bed 13 coded and died yesterday? Yikes."

As we speak, there is a patient on our unit who has been here for...mmm I'd say about five months. This man's history for the past couple of years is full of, "Stroke in '08, right sided paraplegia, dysphagia, aphasia, pulmonary embolism in '09 complicated by severe GI infection" etc. Seriously the list goes on and on and on.

This man is trached, vented, has a drain coming out of every orifice, (except maybe his mouth) cannot talk, cannot eat except through a PEG tube and with TPN. He has bacteria growing in his blood, urine and stool. He has contractures so severe that he cannot straighten his arms or move on his own at all. He has virtually no muscle mass left in his body and his skin is so fragile that he has hundreds of little skin tears all over his arms, legs and back. We have to change his dressings multiple times a day because his arms just weep serous fluid continuously. And even with that he still manages to soak through to his sheets, of which we have to change frequently as well.

His wife is significantly younger....a May-December romance, if you will. His son looks honestly like he is slightly younger than her (step-mother). Both of them visit every day, sitting at his bedside, talking to him and treating him as if it's any other day the family sat down to watch some TV together. They see him in the deteriorating, painful mess that he is in and for months have decided to (still) make him a FULL CODE. This means that we do anything necessary to keep this man alive. CPR, drugs etc.

Every day I go in for unit report and Bed 8 rolls a round and we all hear that familiar name. "Still a full code." reports the charge nurse.

"You've GOT to be KIDDING me?" I blurt out.

That poor man. I've had many conversations with his family and they insist that this is how he wanted it. He wanted them to fight as long as they could to keep him alive.
Ok, fair enough....maybe, just maybe (which I actually don't believe) he wanted them to do everything possible to save his life. But is this what he had in mind when he thought of living?
Slowly and painfully wasting away, soaking in your own bodily fluids, depending on a machine for your every breath and heart beat?
I doubt it. I can't help but shake my head every time I see him, and it makes me want to go home and fill out my advance directive right now.

I understand that losing someone is incredibly hard but isn't it harder to see them suffer so much? And for what? A few extra months of painfully, laying in an ICU while your disillusioned wife talks to you and sings you nursery rhymes? (Yes, she sings him nursery rhymes) That is not living....it is torture.
Unfortunately, our opinions don't matter. If that's what the family wants, then that's what happens.
At the end of the day all we can do as nurses, is give the best care we possibly can to a dying man.