Happy Birthday

Happy Birthday Mia Rose.

You would have been 4 years old today, August 10th, but you left so suddenly and so unexpectedly.

I know it’s been 4 years and maybe I should have moved on, moved past or otherwise just moved, but some days I find it hard to do, well, anything.  I still have the snippets of images in my mind when I reflect, quick flashes of memory that can take me from normal to an emotional wreck in .25seconds.  It’s changed me.  Your life changed me.

I think of all the milestones you would have had, walking, talking, temper tantrums, special simple moments, that didn’t happen.  I wish I had reported the nurse who we think killed you, but the shock and trauma of it all had rendered us numb.  It’s like I let you down and now can’t forgive myself for it.

At least we’ll always have those small quiet moments where your Mom and I would just hold vigil in your little room.  The nurse would leave us alone in there with you, giving us some space to be a family.  It was dark in there, lit only by the blue bili lights and we would talk and dream about our future, your future.  We knew you heard us as you would calm down and seem to rest easy hearing those voices you knew so well if  only for a short time, the voices of you parents.  I treasure those moments.  When things were calm.  When things were hopeful.

All too often though I forget those special moments and remember the sheer terror of running into the NICU seeing them doing half-hearted CPR.  It was so bright in that room, thing were washed out by all the light streaming in but all I could see was your lifeless body and them looking at me.  I remember the pity on their faces, the pain they mirrored when they asked if I wanted them to continue.  I had to tell them to stop.  I let them stop.  I didn’t want to, but I knew it was far too late.  When you died, so did a little bit of me.  And I’ve had an empty hole ever since.

There’s still something missing in our lives.  Our life would have been nearly perfect with you in it, complete.  There are days where the rage is palpable, the sadness suffocating, the hopelessness immobilizing and I get into a funk so deep that all I want to do is hide in our house and bury myself into TV, praying to numb myself.  Perhaps this year is harder as I stopped the antidepressants, so I’m finally feeling the emotions again.  And while it feels good to feel again, it’s not easy.

But I’m trying to focus on the good.  You were with us for 8 days.  And what an impression you made.  Even though you were so young and so fragile, we could see your personality beginning to develop, our tiny little individual.  I’m lucky to have known you, one might say blessed (although I hate saying that I’m “blessed”…).  So I’m going to minimize the bad while remembering the good.

Happy Birthday baby girl!  We’ll never forget!

You can read Mia’s story here, here and here.

Disappearing Nurse

I looked up from my charting that night as an incessant stream of words kept drawing my attention.

“Mrs. Smith?  Mrs. Smith?  Can you hear me?  C’mon open your eyes for me!”  incessant pleading, repeating quicker, voice rising in timber and urgency.

I look over at tele, nothing ringing, nothing out of the ordinary.  As I walk across the nurses station I see two colleagues at the bedside of one of our new admissions.  Like a tag team they’re trying to get Mrs. Smith to respond.  And it isn’t working.  She is just laying there, limp, barely moving any breath into the shriveled shrunken chest.  I start to get that sinking feeling in the pit of my stomach.  Something is definitely not right.

“Hey, what’s going on?”  I ask walking into the room.  Looking around I see a manual BP cuff, fluids up and going, oxygen on, but no purposeful signs of life.

“She’s not responding to us.”  says Not-so-New-Nurse (NsNN).  She’s good, a little lacking in confidence in herself, but usually when she asks a question these days she already knows the answer, but is not yet confident to believe she has the correct answer.

“Merly was trying to get some vitals but the Dynamap isn’t reading so I came over from my patient in bed 2 to help her out.”  she continued.  “Now she’s not responding to us.”

I look around, Merly is nowhere to be found.  Not surprising.  It always seems that when her patients are going bad she finds reasons to step out.  It’s “Oh I need this”, or “I went to call RT.”  She’s been at this a long time and is a very competent nurse, she always seems to disappear at the worst times.

Outside the room another charge nurse and the house supervisor have come over.  “Do you need anything?  Want us to call the RRT?” they ask, worried looks directed my way.  They both know my reputation as a black-cloud.

“Not quite yet, let’s see what’s going on.”  I say.

I step up to the side of the bed, grab a frail limp wrist feeling for a pulse.  It’s there, thready weak, fluttering away under my fingertips.  “Mrs. Smith…”  I say squeezing on her nailbeds.  Normally I would be rubbing my knuckles along her sternum, but as I look I can count the ribs, I might snap them if I rub too hard.  Mrs. Smith is a dictionary definition of cachectic, eyes sunken, skin a wan yellow almost waxy pallor, thin stringy hair, the look of someone who has not eaten much, if not anything in a long time.  She had come in right before shift change with a diagnosis of hypokalemia and failure to thrive, or otherwise malnutrition.

As I’m thinking this through I’m inflating the manual cuff, fingers still on the radial artery.  I watch as the dial creeps lower, lower, still not feeling the tell-tale pulse, then faintly it comes.  64 palp.  Not a good thing.  As I’m feeling I’m watching her chest rise and fall.  Shallow halting breaths.

“I think it’s time, call an RRT will ya!”  I holler out the door.

Merly’s back, dragging the Code Cart.  “Tell me what’s been happening,” I say as the overhead page goes out, “Rapid Response 5NW.”

“I don’t know.  I checked her at midnight and came back to check on her fluids and she wasn’t responding to me.”  Merly says as the code team starts to fill the room.  Furniture is disappearing out of the room as we make room for the extra bodies.

Fave ICU charge nurse is first in, “Hey Wanderer”  she says.  We’ve been through this before more times than I would like to count.  I look around, Merly has disappeared once again.  “Uh, 78 year old female, found unresponsive, BP 64 palp, pulse weak and thready, resps shallow…”

“Uh Wanderer, she’s agonal…”  Fave ICU nurse says, “Call a Code!” she hollers out the room.

I look over, Mrs. Smith is surely agonal breathing.  Erratic, shallow breaths separated by pauses that are far too long.  I kick the brakes off and pull the bed away from the wall.  Someone tosses me a BVM, I pull it out and crank the O2 up.  I’m looking for RT as they are just slightly territorial, but no one’s here yet.  Head tilt, good seal on the BVM while I start to bag,  hearing the code page go out in the background.  Now people are streaming in.  It seems that with RRTs they don’t go balls out, they move fast, but not like when you call a code.  RT arrives and offers to take over the airway which I gladly let them.  I’ve seen RTs fight each other over managing an airway and I know they would just run me over so I leave it to them.

The ICU residents have arrived and not surprisingly, Merly is gone.

Once again no one steps up to talk, NsNN stands silently in the corner, fixing up IV fluids so I jump in.  “Uh, yeah, 78 year old female, admitted toady with hypokalemia, failure-to-thrive, we found her unresponsive with a BP of 64 palp.  She then began agonal breathing and we called a code.”

Mrs. Smith is just laying there, not even fighting the bagging.  We get her on the code cart’s Lifepack, and the monitor comes up showing sinus tach in the 130s.

“Let’s get some labs, draw a rainbow.  Anyone know what her K was on admit?”  the resident starts giving orders.  We’re lucky tonight, Dr. And actually wants to go into critical care and has her act together.  “You guys think we need to tube her?” she asks the RTs bagging her.

“Yeah, she’s not even fighting us nor helping a bit.” one of them says.

“How about some fluids?” says the resident.

“NS up and wide open.”  says NsNN.

“Y’all need to leave her alone!”  I hear from the other side of the curtain.  Then I realize that her neighbor has been adding her own commentary to the proceedings.  “Hey NsNN, can you talk your patient down a bit?”  I ask knowing that we’re only starting to rile up her demented roommate.  The comments she has been making would be funny in any other situation, but not tonight.

“Do you guys want to tube her or should I?”  asks Fave ED doc as he enters the room.  “Go for it.” says Dr. And.  Fave ED Doc grabs some gloves, tosses his stethoscope in the corner and starts talking to a freaked out looking guy in  a short white coat that came with him.  “Normally I would let you try, but not right now.  I’ll show what we’re going to do though.”  A visible wave of relief spreads across the poor guy’s face.  Tubing someone is one thing, tubing some one in front of an audience of hundreds is another.

“Uh,”  he says looking down, feeling the throat and jaw, “How about a #3 Mac and a 6.5 tube.  Do we have drugs?”

“Yeah, here!”  pipes up the pharmacist standing by the door, just on the edge of the chaos.

“OK, she’s what 50 kilos?”

“40, soaking wet.”  I say.

“Right, let’s do 15 of etomidae and 40 of succs.  Suction ready?”

I’m standing at the IV site, guarding it like it was the last beer in my cooler against a thirsty horde.  The pharmacist hands me the bottles of meds and a couple of syringes.

“15 of etomidate, 40 of succs, right?”  I ask, just to make sure.  “Yeah.” comes the distracted reply.  He’s face down with the scope looking into Mrs. Smith’s mouth.  I glance over at Fave ICU Nurse and quietly ask, “Etomidate first, then succs, right?”  I ask, then add, “It’s been awhile.” to qualify my question.  She nods.

“Alright, every body ready?”  Fave ED Doc asks.  “Let’s do this.”

I push the first,  “15 of etomidate in…” flush it wait a breath and push the next, “40 of succs in.”

A brief moment of action and then “Got it…someone want to listen?”

Fave ICU nurse and I, plus about 3 others start putting scopes on.  “Equal bilaterally.” is consensus.

“Let’s get her packaged and downstairs to the Unit.”  says Fave ICU nurse, “I’m going down to let them now we’re on the way.

Sometime during the preceding 5 minutes Merly showed back up, carrying a handful of supplies, fluids, tubes, IV miscellany.  But at least she’s here.   Since the start we’ve had about the same for blood pressure, in spite of the fluids .  Her roommate is still muttering at us, telling us what to do and adding her own running commentary and answering questions along the way for her obtunded roommate.

Transferring a critical patient to the ICU is a exercise in logistics.  We have an RT at the head of the bed breathing for her, trailing along is the residents, the IV pole, Merly and assorted other folks.  And naturally the elevator that comes first is the small one.  We fit.  Barely.

We pull into the pod where she’s headed.  This time I managed not to drive by feel getting the bed into the room.  Thankfully Merly is here with us.  One of the ICU nurses pulls her aside for report.  We get Mrs. Smith over to her new bed.  40 kilos was a guess, but it was pretty damn close, she’s so light.  I gather up the stuff that goes back with me upstairs and look over.  They’re about to  turn her onto her side to pull out the extra detritus under her and she pukes.  She’s on her side quicker than one would think possible.  “Suction!”  someone yells.  I get a glimpse of the vomit.  It’s brown.  It looks like poop.  Then the smell hits me.  It is poop.  Really not good.

Knowing there is nothing else I can do I crib a page from Merly and disappear myself.  NsNN and I are pushing the bed back upstairs, musing over what we just saw.  “Merly and I are going to have a talk I think.”  I say.  “This isn’t the first time we’ve RRt’d or Coded one of her patients are she isn’t around.

“You did good though,” I say to NsNN.  “It’s like I’ve been trying to tell you:  you know what to do, you know the answer, but you just have to believe in yourself.”

“Thanks, I know, but it’s so easy when you’re around…”  she says back.

Back on the floor I start relating what transpired on the way there.  “That was fun wasn’t it?”  I asked sarcastically.  Then we all went back to what we were doing before.  Because that’s how it is.  We fix them enough for them to be someone else’s problem then go back to what we had been doing.  It’s hard.  You go over it in your mind, wondering what did we miss early on, did we do everything right, are they OK?  And even though it wasn’t my patient I muse if it had been.  She was where she needed to be.

I found out a week later when I came back to work that they took Mrs. Smith to emergent surgery the night we shipped her down.  On opening her they found a belly full of poop and a perforated bowel.  Evidently Mrs. Smith had undergone a gastric bypass-type surgery in the 70’s and they think her anastomosis had finally failed.  With a belly full of poop she went into severe septic shock and came out of surgery maxed out on pressors while they searched for any family.  Mrs. Smith had lived alone, we didn’t even know if she had family.  Through some digging and a little bit of luck they were able to find some.  She held on long enough for them to say it was OK to let her go.  And then she was gone.

A Good Place to Die?

Why This Wisconsin City Is The Best Place To Die : NPR.

The result of all this attention is that nearly all adults who die in La Crosse, 96 percent of them, die with a completed advance directive. That’s by far the highest rate in the country.

Note this doesn’t say that these folks died without care, it doesn’t even mention what those advanced directives are.  It doesn’t matter, it’s that these folks have had the opportunity to explore their desires and wishes about how to proceed at the end of their lives.  And it is done before the end is nigh, giving folks enough time to thoroughly think through what they truly want.  Plus it gives them a facilitator who can answer their questions, refer them to other resources in the community to understand what they are deciding.

That’s the whole idea behind the proposal within the health care bills about end-of-life counseling.  In the case here,

But it’s expensive to spend time with patients filling out living wills. Medicare doesn’t reimburse for the time the hospital’s nurses, chaplains and social workers do this. Bud Hammes, the medical ethicist who started the program, called Respecting Choices, says it costs the hospital system millions of dollars a year. “We just build it into the overhead of the organization. We believe it’s part of good patient care. We believe that our patients deserve to have an opportunity at least to have these conversations.”

It’s not about “death panels”, it’s not about deciding how much to do at the end of life, it is about choices and the opportunity to make informed decisions about their choices.  That’s what so many people who are vehemently against the idea don’t understand.

I think it is just a good idea.

The Least of Your Worries

If you have end-stage cancer, and it’s incurable with whole body involvement, you’re in pain and don’t realistically have much time left, one would think it is time to consider hospice, palliative care or using medications like opiates to help you live out the rest of your days in some semblance of comfort.  Declining medications to quell the pain as you are worried about addiction is, in the light of everything else, seems kind of silly.  Worrying about being addicted to opiates is really the least of your worries.

Your cancer is going to kill you before you become “hooked.”  Yes, addiction is a scary thought, but I would think living out what little time I had left in excruciating agony to be a far worse fate.

But that’s just me…

Can’t Put it Into Words

We had a code the other night.  It was by far the “best” code I’ve ever been privy to.  No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient.  The resident running the code was calm, cool and collected.  As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything.  Outside of my ACLS megacode, I’ve never seen that.  But moreso, he asked the staff if there was anything that we thought he had missed.  And before he called it, he aksed if anyone else had any objections.  Truly it was a team effort.

But for some reason I can’t seem to shake it off.  I had no real connection to the patient, other than being the charge nurse.  They weren’t one of our frequent flyers.  But something reached ahold of me and won’t seem to let go.

Maybe it was the fact we found her already down in her room.  Or the fact I felt the ribs snap under my palms.  Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us.  Or that we threw everything in the code cart at her, and some things that weren’t,  but nothing seemed to help.  Our CPR was some of the best I’ve ever seen/felt.  We shocked her a total of 9 times.  She got tubed incredibly quick.  But it didn’t seem to matter.

For the last couple of nights, I’ve laid awake and thought about it.  Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl.  For some reason, this one cracked my shell.  Like the title says, I can’t put words to the feeling.

Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from.  Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago.  Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts.  More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.

I know with time this angst and malaise over it will fade.  I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.

I’m a Doctor

No, not really.

We have  to can choose to call you doctor because you have a PhD in Business Administration, not because you are a medical doctor.  You may have gone through pre-med a hundred years ago, but that does not mean you can come onto the floor, thumb through the patient’s chart and attempt to make suggestions for the patient’s care.  And to do this while feeding the spouse’s delusions that their loved one only needs a “blood transfusion tonight!” or a “gluten-free diet” or “restarting of the antibiotics” when really the spouse is “in the River©*” that their loved one is dying of metastatic cancer, is either at the very least unethical, if not totally illegal.

I can sympathize with your need to lend your advice to a family friend in their time of need, but let the professionals handle the managment of the patient and stop filling the spouse’s head with nonsense.

*in the River: referring to a family member who is in denial, i.e. “in the Nile”, a near-Cockney play on words.

When You Lose

You get used to seeing your frequent flyers, knowing their idiosyncrasies, learning their stories, sharing in their pain and struggle and once they are gone it almost leaves and empty void.  We lost one of those a couple of weeks ago, and I’m still dealing with it as it hit far too close to home.

Part of that was she was young.  My age young.  My wife’s age young.  With a family, children, hopes and dreams.  Another part was that we had brought her back once before.  The progression of her disease was insidious, things compounding into one another, each adding to the vicious cycle, adding momentum, gaining speed as she careened towards the final dance.  The heart failure brought about due to peripartum cardiomyopathy got worse.   The ray of hope that a heart transplant provided was shut out as her kidneys failed and the transplant folks never accepted her inability to lose those last 10 pounds.  I don’t think they realized that losing weight requires exercise and that it’s near impossible to exercise when your ejection fraction is 15%.

She had been on our floor for some time, then went to the ICU as she was no longer stable enough to be with us.  Dialysis at the bedside, levophed to keep her blood pressure high enough to perfuse the brain and what was left of her heart.  She told one of the aides that she wanted to come out to us, instead of our sister floor, when it was time to leave the ICU.  Her kids would come to visit, family too.  And finally it was enough.  She decided that she was done.  She was done with the fight that she had been fighting for so long.  How much of her youth had been spent dealing with this disease?  How much time away from her family had it robbed from her?  She had spent more time in the hospital this year than she spent at home.  So without telling anyone except the docs and nurses, she stopped everything and slipped away.  Selfish?  Maybe.  Maybe it was the action of someone who was just done.

I came back from time off and noticed that the location was no longer next to her name…never a good sign when someone was as sick as she was.  I asked and learned the truth.  I played with the idea of going to her service, but felt odd about it.  It didn’t feel right to intrude upon her family’s’ grieving in that fashion.  I still managed to say good-bye in my own way.

As a health-care provider, death is around us all the time.  I’ve eliucidated my views on death many times, and believe that it is a part of our journey, but when it happens to someone that you know, someone that you’ve taken care of, someone whose life you’ve saved, someone who is close in age to the wife you love, it hits far too close.  I know that she is somewhere better, freed from the shackles of her disease, resting peacefully now.