MICU: no babies allowed!

We were going to admit a woman on propofol and pressors who was 27 weeks pregnant. This was not MY patient, but she was coming to my side of the unit so my hands were starting to sweat just thinking about it. I mean... little baby heartbeats that could stop any minute, emergency c-sections, placentas flying, baby coding. Just no, no, no, no, no. 

The baby may be "viable", but just the thought of participating in this made me want to run down the hall, perhaps to the safety of inpatient dialysis, where nothing (much) ever happens. Or at least, I wanted my 77-year-old, lots-of-secretions, q1 hour suctioning patient to have a HUGE code brown so I could stay in his room and do NORMAL stuff.

So there I was, being a team player and priming fentanyl and versed lines for the nurse assigned to this pregnant nightmare patient, and the L&D nurse is putting on the tocos, to monitor the baby's heartbeat, and what do I hear? NOTHING. I said to L, the assigned nurse, "oh my god please don't tell me they can't find a heartbeat." She saw that I was poised to run out the door and expel the contents of my meager lunch, and quickly reassured me that they had already found it and were just making adjustments.

Ok. Fine. But here's your fentanyl and versed and I'm outta here. Not to mention the fact that nobody likes a birth center nurse sitting around with huge clueless eyes, eating pizza, and trying to figure out if the vent alarm means that the patient is waking up or dying. Oh well... at least if a head drifts out of a vagina, someone will be around to do something about that, cause it sure as hell won't be us MICU nurses!

the demons under the surface

We think we have this built-in immunity, us ICU nurses. We watch people die, and although we may shed a tear or two, especially if we knew the patient for a while, for the most part we maintain an unflappable appearance. In fact, I usually maintain an unflappable attitude as well. It may be sad, I may feel bad for the family, I may sigh or shake my head. But at the end of the day, I'm exactly the same as I would've been if no one had died at all.

We're not cold and heartless, we're just used to it. We separate the life and death of a patient from our personal, inner worlds. This is so that we can cope, carry on, come to work and do our jobs well. We can't run a decent code or resuscitation if we're about to have a good cry over the impending death of someone's child, parent, sibling, etc.

We go into the hospital room of the deceased nonchalantly, tossing the body bag kit onto the bed. We hum or sing to ourselves while yanking out lines and catheters. We laugh and joke about our day as we turn the body from side to side and wrap it. We think nothing of it.

Or so I thought.

One night after vacation, I was home alone (with the baby) and feeling a little scared of the creaks and sounds of the darkness outside. I tried to relax, tell myself all the doors were locked, and fall asleep. Suddenly, before sleeping, my anxious mind began showing me a slideshow of all the dead people that I've either been a nurse for, or helped with post-mortem care for their bodies. I saw their jaundiced skin and eyeballs, their purple fingers, their bloated bellies and stick-thin arms. I was flooded with visions of the crusted blood around their nostrils, and the river of stomach contents that poured into the bed as they were turned.

These images frightened and surprised me. I never thought these things bothered me, but there in my moment of vulnerability, I was horrified by the monstrous images playing through my brain.

I guess I don't brush it off the way I thought. I guess it's down there somewhere afterall.

bring in the mother

It's one of those days when a patient codes repeatedly, and the other patients nearby decide to try to follow. Pressors are flying, crash carts are rolling, and alarms are going off. We've been severely understaffed, and our patients have been even sicker than usual. So sick that we've been triaging filters... who needs one the most? Take from sick to give to the sicker.

As we were coding her for the third time, her grown son came in. He held her hand, he whimpered "Mom... mom... come back... mom...." Then her mother was brought in in a wheelchair. Her face broke my heart. She kept saying, "oh my baby, my baby."

There was a moment when I felt that I, too, was back in a hospital room, the doctors telling me they could do nothing else. They took her body away, they took me away to OR, and I awoke crying out, "Oh my baby, my baby..."

They never had to tell us to stop. We couldn't get her back the fourth time. She was finally gone.

a mother

So you don't want to let him go. "Brain dead." They all file in, in groups of two or three, somber faced, long white coats. Nurses touch your shoulders in the hallway, they speak to you in low tones. Slow, measured words. Your child, your child, he is gone. In every meaningful way, gone. But his heart is still beating. Yes, mechanically pumping away, refusing to stop. A machine with no more soul.

You don't want to let go. You've held him all of his 23 years. You've bathed him, wiped his forehead, learned to decipher his mouthed words. It was your genes, wasn't it, that did this to him? You have lived your whole life in penance, your devotion to him is your self-flagellation, it is your salvation. Don't take it away, you think, because then what?

I'll tell you "then what". Then you cry, you cry for weeks, months even. You save things that were his, touch them, sleep with them, smell them. You throw yourself into his remembrance. You shop for grave stones. You spend hours at a cemetery, staring at his name on the stone, not sure how you got here, who you are, why the name is there, and not on report cards, or drivers licenses, or passports instead. You will beg, each night before sleep, beg and plead for the universe to undo it. Make it go away. You will count each minute, each hour, each day since you last touched him. You will live on, showering, dressing, wiping the kitchen table, spooning food into your own mouth. You will just keep going even when he has not, and that is terrible. Truly terrible.

Herniated. We say the words. Herniated. We equate it with death. We have already decided. But you hear a heartbeat, you want to keep listening, you want to be able to reach out and touch his warm skin. They pronounce him "brain dead". After much delicate handling, they finally tell you that they will not prolong him in this state. They will not. They bring the imam. They bring the ethics committee. They bring the patient relations representative. You call every hospital in the area. Keep my child alive, even if he's not really living, you beg.

We shake our heads, we mutter "crazy" under our breaths. Everyone is fed up, absolutely fed up, of this carrying on, this refusal to face reality.

How glad I am that I did not have to say, "yes, go ahead, withdraw". The choice was taken from me, and I'm grateful. I understand you. I want you to change your mind, but I understand you.

Peace of the universe to you, mother.

highlights of my day(s)

1) The other day one of our patient's needed an emergent ex-lap (exploratory laparotomy) for abdominal compartment syndrome, so the ICU room was turned into a temporary OR. And we all wanted to watch.
2) The GI and Surgery consulting teams spent a whole day contradicting each other and sabatoging each other's plans. The ICU team got her extubated and off pressors. Consulting teams: get along or get out!

3) The patient in the above scenario spoke Chaldean, which is a dialect of Arameic, which as you can imagine, is not a widely spoken language in these parts. In fact, it is spoken only by certain natives of Kurdistan and its diaspora. My other patient spoke Spanish. I speak neither.
4) I'm excited because my hero, friend, and favorite doctor of all-time is on the Palliative Care team, and my patient needs a palliative care consult. I know, I know, it's all about me.
5) Is anything better than a physician's permission to NOT do a sedation holiday? It's like a get-out-of-jail-free card! (Once again- all about me.)

fellow ICU blogger

Does everyone reading this follow Perspective is a Lovely Hand to Hold?c

This blogger is an ICU nurse who can really articulate the gravity of what we face in the life and death situations that make up our "mundane" work day.

This is not only my favorite nursing blog, but one of my favorite blogs period.

the maybe-ECMO patient gets lungs!

Maybe-ECMO patient is now Lung Transplant patient, after a day and a half of having ECMO (while I was off), he was called to the OR to receive his new lungs at 2am. We are following the board, watching for him to return to TICU.

Interesting facts about lung transplants:
Survival rate after 5 years: 50%
Survival rate at 10 years: 28%
Transplanted lungs typically begin to fail after 5 years, and typically fail completely at 10 years.

A single lung transplantation takes 6-8 hours, a double lung transplant can take up to 12 hours.

The single most common reason (27%) for lung transplantation is emphysema. IPF (such as what this patient has) is the reason for a transplant 16% of the time.

Patients, even vented or ECMO patients, are required to continue to do physical therapy. They cannot have received blood transfusions in the recent past, have no signs or symptoms of any kind of infection, and must be non-smoking, non-drinking, non-drug using, and willing and able to comply with medical instructions.They must fit a psychological profile, have no other chronic disorders of major organs, cannot have hepatitis or HIV, be within the required age range, and have a good social support system.

Here's to hoping Mr. Lung Transplant gets his lungs and everything goes off without a hitch!

patient funnies

Me holding up phone to confused patient's ear: "This is your son. Here you go. Say hi."

Patient, looking straight at me and ignoring the phone: "Hi!"

Me to patient: "No no... on the phone."

Patient, smiling at me: "On the phone."

*sigh*

------------------

Same patient after phone call...

Me to patient: "That was your son, he just wanted to hear your voice."
Patient: "Oh... [pause] Did he hear it?

Me: "Um, yes. He heard it."

Patient: "Good."

--------------------

Attending to patient: "Who do you live with at home sir?"

Patient: "Yes... we live together."

Attending: "Who is we? Your wife?"

Patient: "Yes... [pointing at senior, male resident] her and I!"

Heh heh.

mini-live blogging on the maybe-ECMO patient

1200: We thought we had a green light for ECMO. They changed their minds. They want us to oxygenate him with 100% FiO2, then turn the paralytics off and try again. If (when) he tanks, I'll bolus him with vec, the paralytic du jour, and restart the drip. Hopefully, he'll recover. This will prove (at least to ECMO, no one else needs convincing) that he absolutely must get cannulated for ECMO. Then that will happen tomorrow.

If he doesn't improve when I restart the paralytic?
Checkmate.

I don't like playing games like this. I am pushing buttons right now only after clear confirmation from the ICU attending and no one else. I'm not sure the resident and intern feel like this is even their patient.

1300: FiO2 is increased to 100%, will pre-oxygenate him for 30 minutes until turning off the paralytic, which will take up to 30 minutes to wear off. Group huddle with family. I encouraged his wife and daughter to walk around and stretch before the paralytic wears off.

1330: Paralytic off.

1400: Paralytic should be out of his system. Train of Four is 4:4 (four out of four).

1440: ICU Fellow tells us to continue routine care (bath, ET tube tape changes, turns, etc) per usual, if not with an extra degree of caution.

1445: Couging attack begins. I bolus versed and fentanyl. His sats drift into the 80s, he comes back up. I bolus more, repeat. His wife tells him over and over he's ok. Her mantra works. He recovers to the 90s and we don't have to start the vec. I swab the back of his throat with lidocaine and pour lidocaine down his ET tube. We got through this one somehow.

1545: Patient's heartrate suddenly increases to 138 with loss of blood pressure, appears to be afib. Rate then decreases to low 100s, irregular, EKG arrives. Patient in and out of afib/sinus/frequent PACs with intermittent need for pressors.

1645: Patient's secretions are causing him to have low tidal volumes and coughing. We take him off the vent and bag him with a PEEP valve, suctioning intermittently, to remove large amounts of tenacious secretions. Patient desats to 60s, but recovers to 90s within one minute. Victory!

1730: Patient is bathed and ET tube tapes changed without coughing or desatting.

1900: We can't believe we made it to the end of the shift without incident! I leave him with pressors off, satting well, off paralytics. I hug his wife goodbye. I know I'll spend the next few days wondering if he's still alive, and hoping that he gets his lungs.

hours of boredom, minutes of terror

The title refers to the way anesthesiologists describe their job. 

They said yes to ECMO.

It's been two days of exultant highs, white-knuckled lows. You float peacefully along the riverbed we carved out for you, like the dreamers that we are, until you catch, you snag, you tear. You break.

We patch up the hole, we sew the pieces back on. We mend you with tight lips and grim faces. Every victory snatched away from us too soon.

We bolus you over and over to stop your coughing. We watch your pulse ox saturation nose dive and sit at a breath-taking low, the seconds ticking by ever-so-slowly.

Fuck it, I say, I'm restarting paralytics. I reach for the line. Almost as if responding, your sats jump up into the 70s. My finger pauses on the button. The attending appears, and gives me the go ahead. We paralyze you. We pump up your blood pressure with pressors, trying to repair the damage we've done with our other drugs. Your head lolls, rag-doll-like. Behind us, the photos of your life (jet-skis, graduations, and sunny days) seem to call out in sudden pain.

No options, we say to the family. No options, we say to ourselves.

What will happen to you? Can you survive every odd, can you hang on through ECMO, physical therapy, waiting for lungs, and a high-risk surgery?

I want to hope, but somehow... I just don't think so.

follow-up to "Making mistakes in the ICU..."

A friend mentioned that it would be beneficial (at least to perfectionists like me) if nurses got together with management once in a while to discuss mistakes that are being made (anonymously, of course) so we could all feel a little better about ourselves when we DO make them.

I doubt this is going to happen, but I am going to email our former supervisor for some perspective. How many of us do make mistakes, what kind, and how often? Am I alone in this? Am I alone in thinking I'm alone? That much I seriously doubt.

making mistakes in the ICU

*This is a shared post with my other blog, as being an ICU nurse affects my whole self and life*

I made an error at work yesterday, a small push of a button (that I forgot to push) and everything got all screwed up for a while. The nurse following me was very kind about it, even defending me while writing a risk report… but just knowing that managers/quality indicator people/other nurses are looking at me like I’m a dummy, it bruises my ego big-time. I freely admit that I DO care about what my co-workers and superiors think of me. When I make a mistake, even one that doesn’t hurt a patient, my stomach twists into knots and I can’t eat. I am so harsh with myself that I feel I should probably leave the ICU and go somewhere where I’ll make fewer mistakes, or at least my mistakes won’t have the potential to really hurt someone. I never hear of mistakes being made by other nurses, they never talk about them, certainly, nor does anyone mention mistakes that have been made anonymously. Making an error as a nurse translates into shame, and the shame I feel each time it happens cripples me.

I am feeling the need to really look at this aspect of myself. My extreme perfectionism, which some might argue makes me the ideal ICU nurse, also works to damage my self-esteem and lead to self-loathing when I make a human mistake. Yet, I am told time and time again, that I am NOT supposed to make mistakes at work. I am supposed to do 100 tasks in an hour, anticipating needs and thinking critically at the same time, and never press the wrong button, miss a number, or forget something. If I do, I am cornered and made to feel inadequate and unworthy of working in the ICU. The environment is a pressure cooker, and I’d be lying if I didn’t say that in the mornings right before my shift, I am terrified that I will do something wrong or forget something important. At the end of the day, I drive home white knuckled, going over every detail of the day in my mind, looking for an error. I have nightmares of doing something wrong, forgetting to chart something, not wasting a narcotic, etc etc.

It’s not as intense at home, but it happens here, too. I see a diaper rash or a bit of cradle cap on the baby, and I immediately feel like a failure as a parent, and worry that she will be taken from me for it. I berate myself for not using more cream, noticing it sooner, etc. I look critically at my house, at my body, and at my own past poor decisions in relationships. But making a mistake at work is usually the trigger for my anxiety about everything else.

I want to find ways to address this anxiety, and to accept myself as human and not perfect. I want to find peace with “doing my best”. Right now, I wonder if this is possible in the environment I work in, if the expectations there are simply too high, and if I’m the only there who feels this way.

As usual, this has begun a cascade of negative emotions for me, so now I am feeling quite low about a number of things. I am going out to float in the water for a moment, and try to give my ball anxiety to the waves. Hopefully I will return with a sense of peace and contentment with things as they are, the world as it is, my self as I am.

a nurse's dreams

My dream last night:

Something had happened to the Earth's atmosphere, and some of us had swelling airways. Mine starting to swell and I was struggling to breathe. A doctor was running around, deciding who needed to be intubated. He told me I was "fine". I begged him to tube me, so he finally did. The moment the ET tube was in place, I could breathe again. It wasn't too bad going in either (but of course, what is worse than feeling that you're suffocating?). I laid there, in a bed, on a vent, signaling to a nurse that I needed a pulse ox on my finger, I wanted to see my sats.

I don't know what happened to the Earth. I don't know if I was smushed against a pillow and starting to suffocate, and then turned over and could breathe better, and this was how my nurse's brain interpreted it. I have dreamed many times that I am in VT and getting shocked, but this is my first intubation dream.

Gift of Life: the new bullies in town

When a person has a very poor prognosis, but the condition of their body is still such that they have viable organs, we have an organization called Gift of Life who handles possible or prospective organ donation. We are required to call them when the death of a patient is imminent or on the horizon, or after a quick or unexpected death.

Yesterday, the Gift of Life team was sitting on my side of the unit, keeping track of a patient who was going to be an organ donor. They did a chart review on the patient we had whose brain had herniated, and whose husband would be withdrawing support from, and decided she was a potential donor. In the meantime, the resident approached the husband and asked if he would like an autopsy to be performed following her passing (this affects the way we do postmortem care, but I still prefer to ask the family AFTER their loved one has passed). He then asked the husband if his wife had ever expressed interest in being an organ donor, or did he think that was something she would have wanted. The husband said no, neither she nor he was interested in her becoming an organ donor.

I told Gift of Life that he was not interested, and the lady immediately got up on her high horse and made a grand speech about the policy in the hospital and state being that THEY (Gift of Life reps) are the only ones qualified to approach family members about organ donation. Ok, fine, the resident broke with policy. Whatever. Either way, the husband had been asked, and had no further questions, and was firm in his decision. As the patient's nurse and advocate, and therefore her husband's advocate, I did not wish for her to continue to pester him about organ donation. She insisted that she had to be the one to ask. Why? Is it not redundant? Are you not laying it on thick at this point? And yes, I did say that to her, in those words. I told her that it is my job to protect this family, and at this point asking about organ donation AGAIN becomes a form of pressure and intimidation and I DO NOT LIKE THAT.

You know what? She went in there anyway. And the poor man was very irritated with her (and us) because he had already very clearly stated his wishes. And she (and as far as he knew, we as a hospital) was coming across like a vulture circling the body of his not-yet-deceased wife in his hour of greatest pain.

I really, really did not like that.

She left the room with a red face, and the intern told me how awful it was in the room when she was asking. He said not only did the husband repeat his wishes in a very agitated tone of voice, but the lady continued her spiel even after he spoke up. NOT ACCEPTABLE.

I will be going to my manager about this situation. Organ donation is a wonderful, beautiful thing, but it cannot and should not be pushed upon family members. It should be perfectly acceptable for a physician or nurse who already has rapport with the patient and their loved ones to inquire about interest in organ donation. If the family says they would be interested in learning about the options, we can get the Gift of Life rep in ASAP. Nothing like this should EVER happen.

I'm still so pissed.

when death follows you

I've written about being a midwife in reverse, when it comes to the dying. Sometimes it seems that death chooses one nurse in particular to do his work for a period of time, and these last three weeks, that person has been me. We often notice that one nurse or another will have a 'black cloud' that will last weeks to months, a time period where she has an unusual number of patients who either code and don't survive or are transitioned to comfort care before passing. The last three weeks, six out of 12 patients I've taken care of have died, expectedly or unexpectedly, and one co-worker on the job.

My extern is getting pretty good at post-mortem care, people.

Yesterday alone, we lost two patients in one day. The first, a man in his 60s with multiple episodes of severe bacteremia and septic shock, which came from his legs and all of the wounds they had, a result of his advanced peripheral vascular disease. For the last two days, we tried to make his distraught wife understand that he was MAXED on pressors, and the only way to stop the sepsis was to amputate both legs, which we could not do in his condition. Even maxed on pressors, his MAPs were in the 40s. She finally let him go, and he died within ten minutes of turning off pressors, and five minutes of extubation.

After we had done his postmortem care, we picked up another patient who was on innercool following a witnessed cardiac arrest, a middle-aged woman with no significant past medical history. She had just returned from a CT scan which showed severe swelling of the brain, and herniation. We had to stand by as the husband was told, by the neurology team, the resident, and finally the fellow and attending, that her chances of surviving in any way, meaningful or not, were ZERO. We watched this man cry and hold her hand and stroke her face, as we had watched the previous patient's wife do the same with her husband only hours before.

Man, it's been a tough month, and this Midwife in Reverse could use a little break from death.

when it's someone you know

I heard that you had passed out somewhere. Someone said, "everyone is running to the locker room." We opened the doors to look out into the hallway. I don't even remember how I got in there. In my mind, one minute I was looking down the hallway, the next minute I was fumbling with the crash cart, trying to get the cords that connected the defibrillator pads, grabbing an oral airway, finding the recorder sheets.

I barely look at your face. Maybe this is on purpose. At some point, though, I find myself staring at your colorful socks and clog-clag feet. Feet attired for a day of work on the unit. Your pink scrubs, the skin of your abdomen jiggling in rhythm to 100 beat per minute chest compressions. I keet remembering you telling me you were coming down with something, two days ago, during our shift together. I can still see you sitting hunched over the table back there, on your break, trying to get through a few more hours.

The first time we shock you, blood spurts out of your mouth. I watch almost detached while they drill a second IO into your other shin. I have a specific job to do, I am the recorder, and I watch the second hand go around and around the clock, repeatedly shouting out "2 minutes!" so we can stop and check for a pulse and a rhythm.

No pulse. Fine V fib. No pulse. PEA. No pulse. Asystole.

"30 seconds!" I shout. "Two minutes since the last epi!" I call out. "One more minute!" I say, over and over. I lock eyes with another nurse. She says, eyes wide, "is this really happening?" I just shake my head. You are supposed to be fine now. You are supposed to come back now, occupy one of our empty beds, let us give you VIP care. We are not supposed to keep coding you. You are supposed to come back.

Total code time, they want to know. I look back at my sheet. 45 minutes? Impossible. We haven't been coding nearly long enough. Not nearly long enough. There must be something else we can do. Epi, calcium, dextrose, I scribble furiously in a row labeled with each minute of the code. Amiodarone, bicarb, lidocaine... Time of intubation. Time of blood gas. Calcium, atropine, potassium. Vfib. PEA. Vfib.

I pull out a second recorder sheet, and then, somehow, I need to pull out a third. It feels like we just started this code. We're nowhere near giving up. I'm shocked when the doctor running the code, a SICU guy with the code pager, says, "One more round of CPR, and then we call it. Does anyone object?" No one says anything. But we all object. We don't have to say a word to object; our silence is pregnant with objection. Our eyes are alarmed. Stop? The very idea seems so absurd. You aren't back yet.

Your heart, there on the ultrasound monitor, is not moving anymore, not even the quivery motion of V fib.

Ok, he says. We'll do another round. Our fellow keeps looking at us, we keep looking at her. She keeps suggesting things. Lido drip, TPA injection, ECMO. She sees the desperation in our eyes, but slowly her look of intense focus turns to a look of pity and quiet resignation.

One more round. Last one. I am the counter, I watch the clock. Tick, tick, tick. One minute. The room has grown very quiet. That's how you know. A group of 50 doctors, nurses, and other staff in a code saying nothing, and you just know. My own voice, "30 seconds" and the soundless up and down motion of the person compressing your chest.

"15 seconds," my voice is flat, and hangs heavy in the quiet air.

"2 minutes is up."

We check a pulse. "No pulse," says someone kneeling next to you. NO PULSE I circle on the recorder sheet. "Asystole," says the doctor running the code. AYSTOLE, I write on the recorder sheet. 1818 is the time written next to it. "OK, I'm calling it," says the doctor's voice.

I slump to the floor, knees to my chest, back to you. The three code sheets in my hand, the three gas results, they slide onto the floor. I still have a duty, to get all of the names and pager numbers of everyone running the code. But I can't. I give the paper away with those final instructions. Then I stand up, and I leave. I don't look at you, but I know what you look like. Your eyes have rolled back, your skin is grey, and there are ET tube tapes tied around your head like a forlorn crown. There is watery blood on your mouth and running down your neck. It covers the floor along with the wrappers and caps and other code debris.

I cry all the way into the unit, into a back room. I cry until I feel a hand on my back. I cry until 5 more co-workers are there with me crying, too. We form a circle and hug. I walk around in a daze after that, trying to figure out what to do for the patients for whom I'm still supposed to be responsible. But the world looks different now, everything is blurred, out of focus, and not at all balanced. I want to go home and that's what I end up getting to do.

I think about the last day I had that was blurry like this, but even more so. The day they handed me my dead baby, and I thought, "You are supposed to be alive now. You are supposed to be ok." I think of skin that was the wrong color, eyes that were unseeing and rolled back, blood and more blood everywhere. I think of sad, sad doctor eyes and nurses with nothing to say. I think of death, and His presence, standing in the room. I feel His closeness again.

We think we are so comfortable with death, us ICU nurses. We think we know it, we think we can manage it. That's what we think with an air of smugness, until it comes to touch us personally, and suddenly we realize we never knew it at all. We never understood death.

And we never will.

extern on board

My student extern is now working with me. I hope that she takes away everything and more from the experience than I did when I externed in the same institution, six long years ago. She is smart and a quick learner, and I personally think she's doing very well, and in the coming weeks she will be fantastic. I'm not sure she understands this, though. I think that the 12 hours might be quite daunting to her, having never worked them before, plus the pace of our unit allows very few breaks. I can see how it would be overwhelming.

In fact, I remember that as a brand new nurse on my first orientation, at about 5pm, I felt so overwhelmed, overstimulated, and exhausted with our hectic pace that day, I had to go into a bathroom to cry.

I really hope she has not shed any tears during this first week together, but I see what can clearly be interpreted as a somewhat pained expression, hidden well with a poker face. I know our workload is brutal, and the shifts excruciatingly long for newbies, but it's going to pay off in a big way.

Grief Week

It's Grief Week in our institution. I was able to attend a small conference meeting by an author of several (ok, like 50) books on the topic of grief and loss. Most interestingly (to me) was the discussion of how North Americans/Westerners grieve as compared to the majority of other cultures. We are quiet and stoic, often stifling our tears and cries until we are completely alone. When family members from other cultures experience a loss, they may do so loudly, keening and wailing. This makes "Western" patients and family members in nearby rooms uncomfortable. It reminds them of their own mortality, and how close they are to experiencing their own loss. 

I feel we should be allowing the grievers to grieve in their own way, loudly or quietly. Everyone else just needs to accept that death is, in fact, a part of life. It's more than a part of life in our unit, it's just a part of our day. In recent times, Americans (I'll just speak for my own people since I don't want to speak for what I'm not) have not had to be around death with the frequency that they experienced just a century before. We go to the hospital not to die, but to get better. We think everything can be "fixed" with modern medicine and technology. We can't accept letting go. We aren't used to death happening around or near us, let alone to us. The one exception being, perhaps, ICU staff. We are used to it, at least in some senses. We develop techniques and strategies to cope, grieve, and mourn for the losses of our patients. 

As for me, after a patient passes I often turn on a song called "Calling All Angels" or a few other death related songs on the drive home. Sometimes I shed a few more tears for the person, but mostly I allow myself to solemnly honor their existence and their passing. 

We are a culture in denial. Our family members look at us like we're monsters when we suggest withdrawing. We look at the family members like they are monsters because they continue to allow the patient to suffer needlessly. In many ways, the culture of the ICU staff completely clashes with the culture of the ICU patients and families. We see death as a natural end to a disease progression, a profoundly sad and heartbreaking experience, but a natural and necessary one. Family members translate this into us wanting to "give up" on their loved one, or accuse us of having an apathetic attitude toward them. 

We are not apathetic when it comes to death and dying. We are advocates for a peaceful letting go, and a natural end of life, when all experts are in agreement that further treatment is not only futile, but cruel. 

So, it's grief week, and there is a panel of patients and family members sharing their experiences with grief and loss in our hospital. I wish I could go. I wish I could be on that panel. My own experience was... well, it was terrible. I was disappointed in the care I received. I understand that it's a sad and uncomfortable position to be in, as a caregiver, to guide someone through the loss of their own child. I think ICU nurses have a lot to teach other caregivers about their role in situations that present death. 

damn you JCAHO

They took away our comfortable, rolling chairs. The ones we sit in to chart. They were replaced with stackable, plastic, non-rolling chairs. They also removed the chairs from the computers that were on the outside of the nursing stations. Apparently, it is a fire hazard to have things in the corridors. Including chairs at the computers.

Fucking ridiculous, if you ask me. When will these people be satisfied? What new ridiculous rule will they come up with next?

please don't babysit me.

This is a rant. A big RANT. 

My boss came up behind me at work, behind the nurse's station, tapped me on the shoulder, and told me not to look at anything on the internet. For the record, I was reading a foster care blog. Also for the record, all of my patient care was done, my patients were both content, and none of my co-workers needed my help. This was the only time I had sat down from 0800 until 1400. 

So instead, I sat at the desk and did nothing. Then I mosied over and sat around with other nurses shooting the breeze. One nurse flipped through a magazine. So chit-chatting and magazines are ok when you have down-time, but reading online is not? If I had printed the article and read it from paper, she would have said nothing. What is it about the computer that makes older adults think you're playing? Or management, for that matter. It's like you're playing a nintendo or XBox game, but in reality, you're just reading. It's not practical to think that I will be busy every second of every day. Nor is she, I would be willing to bet. It's because of my commitment to patient care that I spend my "downtime" at the desk. I want to be available to my patient's and my co-workers should they need me.

The feeling of being babysat at work enrages me. Reading is not an inappropriate thing to do at work. My work is always caught up, always current, and I'm always ready at the drop of a hat to help someone out. Being treated like a 10-year-old is quite demoralizing. In 10 years, or maybe 20, I hope that this particular brand of management retires out, and a new group that sees the computer not as a plaything or toy, but simply as another medium for information and material, takes their place. I hope they are replaced by my own generation, people who recognize that we have the ability to multi-task and to organize our day in such a way that we get downtime while still getting our assignments done in a timely manner. 

Bottom line, I'm totally capable of reading whilst I wait for the next task that needs to be done. Staring blankly into space or chatting about the latest gossip with co-workers is NOT productive nor does it lead to an informed mind. 

the end of an era

Care plans are all the rage in nursing. At least they were. In nursing school you are forced to slave over them, re-formatting them to fit your instructor's version precisely. Like almost every other student, I thought they were ridiculous then, and like every other nurse I've ever met since, I think they're ridiculous now.

 

The premise was a good one. We needed interventions with measurable outcomes (NIC and NOC), and we needed them so that we could "prove" ourselves as a profession, the way that physicians do. From there things got a little crazy. To the point where we, as nurses, had to spend hours listing "interventions", every possible common sense thing you can think of, and daily rating on a scale of 1 to 5 if it was working. If you are a nurse, or even a college graduate of any kind, you should have the ability to recognize a problem, intervene in some way (even if it's just to keep observing), and evaluate internally whether this plan is working or not. You shouldn't have to write 10 paragraphs about it. You shouldn't have to check over 75 boxes per problem! 

To make matters worse, no one was reading these care plans, no one but the poor nurse doing them. They were irrelevant, in the end, to the patient's treatment and plan. It made me feel like a ninny. Like a L-O-S-E-R trying to be important when really that time filling in check boxes and numbers was a total waste. Just busy work. Which made me feel that my real job, that of patient care, that of actual critical thinking, was trivial and menial.

But then... everything changed. They took our care plans away!!!

Yes, care plans, at my current institutional, are a think of the past! I went home and danced naked with bells on my ankles, burning piles and piles of worthless paper, in pure joy! (Ok not really, but I thought about it.) Instead, we have a simple patient/family goal-oriented note, in which we state the patient and/or family members' goals for the shift, and for the hospitalization, and any progress that has been made toward them.

All I have to say is: Good riddance to good rubbish.

honoring death

I took care of him for 18 shifts. I had a few days of this month, but only a few. So I took this patient, and I kept getting him back. He was on a one-way train to comfort care, and I was there for the ups and downs of it all. The family planned to withdraw on Ned*, my patient, on a Wednesday. That was one of my very few days off... but I came in and worked anyway. I guess I felt like I needed to be there. I was honored that the family wanted me there, but it was more than that. I wanted to make absolutely sure that his death was given priority. That he would not suffer. That his family would have everything they needed.

I didn't know Ned, not in life. I knew him as a premonition of death. Eyes sunken into a skeleton face. Ascites and yellow-tinted skin. That gulping motion that accompanied each breath, even on a vent. All he would say to me was that he couldn't breathe. That he was in pain. That he knew he was in the hospital. During one particularly lively day he mouthed very clearly, "get me the hell out of here". I gathered from his family that he was a stubborn, cantankerous man but very loyal, inspiring fierce devotion from his close friends and family, and more than a few tears at his demise.

But I wasn't there to know about Ned's life. I wasn't there to honor it, either. That was his family's job. I was there to ease his way into death, just as 67* years ago some nurse or midwife or pair of doctor's hands eased his way into life. Just as they did not need to know the details of his life-to-be, I did not need to know the life he had. I was, in that moment, mother and sister and daughter to him, whoever he had been, wherever he was going. I was there to honor his death.

I was there to withdraw on him, and there for his last moments of consciousness. His heart continued to beat (as many stubborn hearts do) long past my shift. I placed my hand in his before I left, and said, "Godspeed Ned." Off you go, out of this world and into the mystery of the Great Beyond. The place we will all eventually find, the place my daughter already knows.

Godspeed, and it was my honor to be your pair of hands on your way out of this great human existence.

*not his real name or age

then your heart melts

When discussing making a patient comfort care, and withdrawing life support... the family said they wanted to do it when I was his nurse.

Awww.

getting an extern

I'm so excited... I'm being assigned a nurse extern this summer! A million years ago, I too was an extern. I love teaching and I'm so excited to get to be a part of such a formative experience for a young nurse.

patient update

Remember that patient I did a live blog on a few weeks ago? The one who was really, really sick?

She came back to visit us from the floor. She walked in, with a walker, as completely normal as could be! When she saw me she burst into tears. She said everything from her time here is a distorted blur, and she wanted to come back to put some normal frame of reference to it.

It was so rewarding to see her do so well, and to hear her thank us.

a girl and her filter: photos

CRRT orientation



The tools I work with

when tattling isn't tattling

I hate tattling in the nursing world. Nurses seem to get a high/boost of self-righteousness by tattling on each other to management. I have had emails from management because other nurses felt I was "using the dictionary" too much in my spare time, or didn't change my ET tube tapes that night, or let my insulin drip expire, etc etc etc. I have learned that every watchful eye is trained upon the smallest detail here. A simple reminder from the nurse would've done the trick (it's ok to be reminded that you've forgotten something), but going to management about it is going too far.

There are times, though, when it's ok to go to management. Like, if you've noticed a problem with another nurse that affects patient care, and you have already reminded that nurse or let them know face-to-face and the problem continues. Or if it's something that really, truly is not good for the patient or dangerous.

I hate tattling. I hate going to management about another nurse. Even when it's totally legit. It just feels so sneaky and underhanded.

This last stretch, a comfort care's family complained to me that their nurse never came in. They announced to me that they were going to "talk to the doctor about it". I said that was ok, but they should also talk to the charge nurse if it's a nursing concern. (The intern doesn't have any authority over nurses, he'll just go talk to charge.) So I went and just told her that the patient's family needed to talk to her. That's it. I don't want to be involved. But... that nurse NEVER went in there. I constantly fixed his pumps and beeps. I know there isn't much to do in a comfort care patient's room, which is why I always make sure to just pop in once an hour to check on the family. I always, always, always fix the beeping drips right away. I try to find a way to make them feel like the impending death of their family member is very important to me. This other nurse didn't do that, and they got mad.

Still. I don't want to be involved.

Unfortunately, my manager found me today and wanted to know what had happened. So I told her the truth. But I felt awful about it. I felt awful for that family, I feel bad for the nurse who is going to be in trouble, and I wish I wasn't involved at all.

oh my

Have you all heard of this hospital-themed restaurant in Taipei (land of the themed restaurant)? It's ri-DONK-ulous. Waitresses dressed as nurses... nurses who wear fishnet stockings with suspenders, and serve cocktails out of syringes, on tables made to look like OR gurneys. CRAZY.

I am the Filter Queen of the World

On this particular 5 day stretch, I scored a sick filter patient. For the most part it's lots of peace and quiet and monitoring, but I've had to do TWO recircs through a fistula site. Yeah, I feel pretty badass, cause I did them by MYSELF. Even a charge nurse said to me, damn, that's a pretty big deal.

Remember, at 3 years I'm still an ICU baby. But this baby is growing up, and I'm turning into the newest CRRT rockstar. Oh baby oh baby.

omg overtime

Today will be day 2 of 5 if I get all of my overtime. I'm on 12 hours of overtime right now. My eyes are bleary and heavy, but my mood is not bad. I'll get through this, and will do a big happy dance on payday.

why my co-workers are like family

1. We didn't choose each other, but we're stuck with each other.

2. We see each other at our worst, at our best, and everywhere in between.

3. We go through really extraordinary circumstances together, and no one else can really "know" what we've gone through. We just look at each other and get it. We get each other's jokes in the same way. Just a few key words are all you need, and it's instant mutual understanding.

4. No matter how much we annoy, dislike, or resent each other in normal circumstances, when something bad happens we are instantly there for each other.

5. We know each other really well. We know when someone is in a good mood or a bad one. We know what type of patient or situation we're good at or prefer. We know how to pick on one another or push each other's buttons, but we also know each other's strengths and draw from them.

Yeah, we're a family. Not all friends, not all buddies, but a family.

what happened to super sick patient?

I really enjoyed the live blog I did the other day. Such a great way to keep track of what my days are actually like, for posterity, I suppose, and my own future entertainment. I had the patient the next day, and she continued to do very well. Actually, she did better than any of the nurses and docs had ever dreamed she would. Despite being intubated, the next day she was following commands and answering yes/no questions! Hooray, mental status still intact after all that coding! Quite remarkable, really. Her kidneys were back to normal. She was off all drips except the epinephrine and the insulin. We were tube feeding her. Her fever was staying down under 38.1. Her vent settings were down to 40%, PEEP of 10. In fact, my day was a bit boring, she was so stable.

Also, the CF patient I mentioned a few days ago passed away the day after I cared for him. Other nurses told me that the next day he seemed much more accepting of the fact that he was dying. Later he pooped, and coded as he was getting cleaned up. Peace to him and his family.

Overtime is out of this world. I'm working nearly every day. I carpool in on Saturdays and Sundays, and will be spending a few nights at the houses of friends in the middle of the week. My paychecks are going to start being out of this world. Blogging here is going to pick up of course, because work is my life right now. As another nurse who does overtime nearly every day told me, it's easy once you get into the rhythm. Break the rhythm and you'll realize that you're extremely exhausted and coming back will be hell.

Live blogging on super sick patient

Background: Middle aged female, arrested during routine dental procedure. Cause unknown. Arrested twice more since admission to hospital. Lactate trending down, now at 10. pH finally normalized to 7.34 overnight. Complete heartblock resolved now to sinus tach. Mediocre urine output, creatinine of 2.3. Troponin of 20.0. Fever of 40.3 (that's 103.5 for farenheit users). Drips: Versed, Fentanyl, Insulin, Bicarb, Epinephrine, Phenylephrine (maxed), cisatracurium, heparin.

0800

Nephrology team: Intern freaks out because of fan blowing on patient under sheet "wind tunnel" for fever. "How can I assess the patient?!" he asks frantically. Step 1. Turn off fan. Step 2. Pull down sheet. Step 3. Assess patient. Wow, this is so difficult.

Nephrology team again: Snarky comment, "ok all powerful ICU nurse, we are going to put a triple lumen on one side and a double on the other". Well gee, don't work too hard on my account. As if it's my fault the patient needs that many lines!

0900

Pulmonary fellow splatters blood on my bed, and almost on me. I love my pulmonary fellow. I shout, "hey hey, you're spraying blood everywhere!" Fellow to me, "Oh shaddup." Intern staring. Fellow to intern: "We've worked together a long time."

Same fellow shouts of the room: "Can we get her a hairnet? I mean, a bonnet?" Do we call them hairnets? Or bonnets? What do we call these surgical caps anyway??? Hairnet and bonnet just sounds weird...

Coming down on Phenyl. All other drips the same. I'm about to send a gas, see what we can do with her vent settings (80%, 40/18 pressure control). Also, thinking about setting up the filter (CRRT) now. Man, I set these damn things up a lot.

Oh, and I had a red bull this morning but... is there coffee around here anywhere???

1000

Made a coffee run. Also got a stellar blood gas... 70% here we come, also weaning nitric oxide down now. Did I mention she was on that?

And to whoever put the donuts in the break room... I HATE YOU!

1100

Where is the time going?? Pulm fellow made a mess in my bed, as in blood. So we got to change her sheets and give her a bath. She didn't like bathtime... BP bottomed out, and she got extra of epi and phenyl. Boy does she need that epi. The second it beeps that it's out, I have to go running and change the bag lickety-split, or she's out of BP commission for the next several minutes.

Making more improvement in vent settings. Yay for that.

1200

Spent a lot of time talking with the family, explaining everything. I actually like that part of my job. Family is super nice. Coming down ever so slightly on phenyl. Vent settings look good. Off nitric soon?

Sidenote: I'm wearing my new glasses today. So spiffy.

1300

Dopplers, and EDMs, still give me a panicky feeling. PTSD from losing the baby.

Ta da! Renal has shown up to finally put in the sorensen. A million hours later.

This renal "fellow" frightens me when he's in the room alone with my patient. He's not the brightest bulb in the box... he totally makes me nervous in there alone.

1400

Wow this guy just had me go get him all his items. The Renal folks are usually so independent, and get their own stuff. I just hope he knows what to do with it.

1800

Just spent the last 4 hours messing with a filter. Setting a new one up, watching it work for 15 minutes, spending an hour (almost) trouble shooting very high pressures, finally giving up, tearing it down. It was a four hour exercise in futility, actually. Luckily, patient's urine output really picked up and her electrolytes are ok without dialysis. Stay the course.

Good news on vent settings: down to 50% and 36/14, nitric at 2. Much less febrile (38.4). Way down on phenyl requirements. So all in all, good work. A lot of extra work, but the patient didn't suffer for it so I guess that's all that matters.

Why can she not have a dialysis cath anywhere but her fem sites? Because NO WIRE can go into her atrium. It puts her into PEA arrest every time, due to her LBB. Interesting.

I'm tired. Haven't peed or eaten since this AM's coffee run. Need to SOAP on this patient and do her care plans. Meet my carpool rider and get my butt home.

Hope you enjoyed this lovely day in the life of an ICU nurse post!

end of life care (and growing some balls)

Lately, we have several end-of-life patients for whom we can no longer treat, that is to say, despite all of our treatments or therapies their prognosis will remain poor and their death is imminent. This particular group is frustrating to all of us working in the ICU, because each of them are being kept alive by our machines (or their dying is being prolonged, you could say), because the family members or even the patient themselves are in denial.

Case #1: This patient has cancer that has spread to many organ systems and is no longer responsive or able to tolerate chemotherapy or any other type of aggressive treatment. Her oncology prognosis is extremely poor... as in, she only has a limited time left to live. Naturally, because we are supporting her on a ventilator, she is living a little longer. But she is very weak, unable to communicate, and she's suffering. Her children insist that she would not want to be kept alive like this, but her husband is unable to let go. He looks for any little positive thing as "progress". He doesn't want to make that decision, the decision to withdraw.

I so get that. When I was in labor and complete, I did not want to be the one that pushed my daughter into the world knowing she would not survive. I knew it was the inevitable outcome, but I did not want to be the direct cause of it! This poor man does not want to make this decision... in this situation, most of our attendings or fellows step in and gently but firmly say, "we've done all we can. We have nothing more to do. It's time to make a decision".

The attending this month is just plain awful. He has let the patient continue to deteriorate while orally intubate for almost a month now. Family meetins are ongoing, but he refuses to draw a firm timeline with the family. In short, he won't let this husband off the hook. He won't make the decision for him, or help lead him to it. This poor husband feels that he is all alone in this choice, and meanwhile his wife, the patient, suffers. It's absolutely terrible to watch.

Case #2: The CFer I mentioned in the last post has been failing for weeks as well. This case is quite different in that it is the patient who is making the decision to prolong his own life. He's still mentally capable of making all of his own decisions, but he is just too afraid of death to withdraw on himself. It's hard to watch, but understandable. The worst thing, though, is how this particular attending comes in in the morning and says things that could almost be perceived (by a very scared patient) as hopeful. It's awful. In this case we are complying with his wishes, but the attending is not helping the situation. The fellow did a much nicer job, later, of explaining to him that we can keep him comfortable, or can continue aggressive vent management that may prolong his life for a short time but may make him uncomfortable. At least with that information he can make an informed decision.

Heavy stuff, always. There are just some doctors who really know how to go about end of life care with the right mix of compassion and firmness, and some who shy away from it.

from my other blog

Copying this in from my blog All My Pretty Ones:

I made a mistake that I never would’ve thought twice about before I lost my baby. I was taking care of a patient who has cancer and no hope of getting better. We are waiting for her family to make her comfort care. Her husband is at her bedside every minute, struggling with that awful choice. Meanwhile, the husband of a different patient I’d taken care of a few days ago walked by the room where I was drawing up meds for the cancer patient. He said hi enthusiastically, and I gushed to him about his wife, “oh she looks great! She’s doing SO well!”

It seems harmless, but a minute later I felt my face burn and my heart drop as I realized I’d said that right in front of the husband of my dying patient. He has NO chance of his wife getting better, or doing well. He faces loss at every turn in the coming weeks. No nurse is going to say those words to him. I realized that I had probably just made him feel very much how I feel as people gush over pregnant co-workers or new moms in front of me, and in his own wife’s room. There was nothing I could do to take it back. It wasn’t like I was “reminding” him of his loss. No one can remind us, right? It’s always there. We don’t forget it. But I was, ignorantly, rubbing his nose in it. Mr. B, I am so sorry. I am more sorry than you’ll ever know.

-----

Working so much overtime, it feels that my life is being mostly lived on the unit. Aren't we nurses truly lucky people though, to have a job that gives you the option of making so much more money, for a time, if you want to?

Anyway, I had a 25-year-old CFer that is in multi-organ failure and for whom we've done absolutely everything we can, but he's dying. His mom knows this. He's her only child... she doesn't leave his side. I told her when she was out of the room, that my heart was really hurting for her, because I lost my daughter in December. Later she brought it up to me again, and I told her that she was stillborn, so it was quite a different situation. I didn't get 25 years to spend with her, but I also never had to watch her suffer. I can't imagine how awful that truly is, but I can imagine a mother's grief. I am living it now. No matter how different the circumstances of grief might be, no matter in what manner your child dies, our grief is much more alike than it is different. I read that on By the Brooke, and it has stuck with me. Our grief is more alike than it is different.

ready... get set... overtime!

I'm in need of some hard cash, people. Aren't I lucky to have a career in nursing, where they give out overtime like candy at a parade? It's about to get real, and I'm about to pack my figurative bags and start living most of my waking days on my unit. All so that I might watch that bank account number grow.

I'm creating a memorial garden for my daughter this summer, which all in all will end up costing around $2000. And I want to travel, later in the fall, if I'm not pregnant again. But all of that can be found in every detail at my other blogs: Across the Never Sky (travel) and All My Pretty Ones (baby loss, foster care, and TTC).

I've had some pretty status quo patients lately. Does everyone know what I mean by a "feed/water/turn" patient? Basically, a patient who is out of it (as in, can't press the call light) who is being tube fed and needs turns q2 hours. And that's it. They are just sort of hanging out like that until a) they wean off the vent or get a trach, b) their mental status improves, or c) we decide what the hell else to do with them. So yeah, I had one of those, and a couple of cancer patients. We get our fair share of cancer patients either at end of life, or septic following chemo. We got a lot of BMT patients who are septic, or hypoxic, or what have you. It was actually a pleasant week of nursing, as my awake patients were very nice and not too needy, and my out of it patient was... well, out of it. And both families were quite nice as well. Awesomeness.

It might be time to take a sick single again, though. I try to take my share of doubles, and I do take patients back again even if they are doubled (unless I seriously can't stand them). People get pretty edgy if you ONLY take singles, all the time, and there are a few nurses who are notorious for that. It's considered poor form. On the other hand, sometimes it's necessary to be a bit pushy, speak up, and get a train wreck. Afterall, we live for those train wrecks!

Back in the saddle

I'm back in the saddle at work, after my medical leave. It did feel good to be back. To know how to do something, to be able to it well. The ICU is full of rules. Everything has its place. That was a comfort. You can control so much there, there's a protocol, there's an algorithm.

We had a 2 1/2 hour code... the lady's kept getting a spontaneous pulse after a few rounds of ACLS for PEA arrests. It seemed like it could go on all day, until we finally found a family member to tell us we could stop. THAT was craaaazy.

I had a few patients who were made comfort care, and passed away. I connected so well with the families. I've even shared the story of my loss with a few.

All in all, it's good to be back.

life updates

I haven't posted in a long time... mostly because I've been posting at my other blog. It was a blog about fostering and my pregnancy, but unfortunately my pregnancy came to an end after a placental abruption. I went into irreversible labor and was forced to deliver my daughter, who was not old enough to survive. I named her Avalon. My foster son was returned to his parents permanently in Mid-November, and everyone, including myself, was very happy for them.

As far as work goes, I was on my way in to work the morning I abrupted. I called literally 5 minutes before shift change, panicking as blood was gushing out of me. I've been off work since December 8th, and January 8th I go back.

My life is so different now, at least internally, that it will feel strange to go back to work. I almost wish I could start over, work somewhere new. Maybe most people would want familiarity after such a loss, but I'm feeling like I can't bear to remember how happy and pregnant I was working there before everything happened.

I had some moments as a patient I know will stay with me. There were nurses who made my day (the nurse practitioner who told me to come to triage if I was worried AT ALL, the nurse who numbed me up before inserting an 18g in my arm), and there were nurses who were major FAILS (the nurse who told me the baby would be "disposed of" when I asked what would happen to her body). The doctor who delivered me was also not impressive... when I was complete she ASKED me if I wanted to push. No, of course I didn't! She just kept saying, "you can push if you want to". And if I don't? Jeez. I needed so much more. And where was the nurse? Nowhere.

I also related very closely to those family members we always think should "withdraw" on very sick MICU patients. The patient is going to die anyway, no matter what, so we always think the choice should be simple. Just pull the damn plug already, your loved one is just going to suffer! Nothing's going to change! Well, you know what? My placenta was falling apart and my daughter was going to die, but I still didn't want to be the one who pushed her out, who ended her life with premature birth. I was in very active labor, she would come out no matter what, but I still didn't want to be the one to do it. I get that now, and I wish I didn't.