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.