two codes for the price of one

Yesterday we had two codes happen, at the same time, in beds 8 and 10. Yes, right next to each other.

We were all congregated around bed 10, who was getting a paracardiocentesis for cardiac tamponade. Exciting stuff. He was also on 100% FiO2, PEEP 20, nitric oxide, and two pressors (for non-ICU folks, just think MAX life support). Suddenly, alarms and the nurse in bed 8 yelling, "guys I need help!!!" Her patient bradied down, lost a pulse, and almost everyone (except the cards people who were doing the cardiocentesis) ran into bed 8 to code him. We did a round of epi and atropine, got a pulse back, and no sooner did we get it but we here shouting from bed 10. Everyone stampedes back over there, because he's gone into Vtach and the cards people are doing chest compressions.

We have only one crash cart for the ten beds on our south side and one for the other ten on the north side. Since we had just cracked a cart for bed 8 and he was wearing the defibrillating pads, we had to go running full speed to the other side of the unit for their crash cart. Hope no one over there codes now!

This brought a few nurses from the north side over to help us, as that side was currently coasting on easy and we were drowning. I had finished helping stabilize bed 8, so the code was in full swing in bed 10 and I asked around, "has anyone gotten the family?"

It's important to have at least one family member there to witness the code. We have someone stand with them, a nurse or social worker, to explain what is happening. We want them to see the sequence of events, so that it isn't a surprise, and so they can see how much effort we put into resuscitation.

The code was 15 minutes in, and everyone knew that this young man had a large, very involved and concerned family. I ran down the hall to the waiting rooms, asking anyone if they were here for him. I finally found someone, explained that he had gone into cardiac arrest, and asked her to come with me immediately. She got the wife, and the brothers, and we stood with them as they prayed and cried.

And he did not make it.

He had been diagnosed with AML on Sunday, at the ED, where he had driven himself for "flu-like symptoms". He had been admitted to the ICU with respiratory failure which turned into ARDS. He developed a large cardiac effusion, and then tamponaded. Seven days after his diagnosis of cancer, one week after eating dinner with his family on a normal weekend evening, and on the day of his birthday, he died after a 40 minute code. His family was hysterical. His wife looked bad, in shock, unable to cry or walk.

I carried them all home with me, last night.

(By the way, bed 8 recovered and as far as I know didn't code again that night.)

just give him some ativan, already

As someone who suffers from anxiety disorder (or suffered, I should say, since it's very well controlled now with paxil) I find myself advocating for my anxious, panic attack-laden patients.

You know how nothing is more annoying than a patient who is anxious? Because you can't fix it for them and you can't get the docs to order benzos, because oh-my-god benzos will make the patient STOP BREATHING and become a crazed addict!

Seriously, doctors, 0.5mg of PO ativan will NOT hurt your very anxious patient, the patient with physical signs of having a panic attack, nevermind his subjective reporting. If he's this worked up, a little ativan will only bring him down to normal, the same amount of ativan that had he been normal and just a drug seeker would've brought him down to a RASS of -2.

It's like stairs. A small, appropriate dose of benzos will only bring you to the next step down from whatever step you're already on!

This particular patient is homeless and a known substance abuser with chronic pain. He came in with altered mental status after OD'ing on benzos at an ECF, benzos that were not prescribed. Maybe he wouldn't have felt the need to self-medicate had the staff there been able to give him an appropriate dose that gave him relief from his panic attacks? Maybe not, but still. What's the end goal for this guy? He's old, bed bound, and lives at a facility. He's not going to go through intensive psychotherapy or life style changes. Treat his anxiety and his pain, don't just give him nothing. And if he continues to self-medicate and use, oh well. At least we tried.

Give him nothing and I guarantee that he will self-medicate again, and probably OD again. And we will be right back here where we started, with me paging YOU every time he pushes the call light, which is every 2 minutes, for more pain meds/anxiolytics. No one's having very much fun right now!

a mother says goodbye

As a baby loss mom, it was hard for me to watch. He was only 31, diagnosed with leukemia 9 months ago, an only child. We asked his mother to make the most difficult decision of her life. I turned off the pressors, respiratory decreased his FiO2 to 21%, his rate to 4 bpms.

It only took two hours. His mother was standing with her arms around me when his heartrate hit 0, his EKG rhythm a flat line. She begin to shriek, and writhe, and flail her arms and legs. I jumped back out of the way. She fell to the ground and thrashed with everything she had. It took two large guys, members of their family who were present, to get her to her feet. A few minutes later, she was covered in sweat and hyperventilating. We brought her ice water, told her to breathe in, breathe out, big deep breaths.

I said to her, "this is the worst feeling you will ever have, this is as bad as anyone anything can ever feel."

An intern said to her, "you ended his suffering, you took his pain onto yourself so that he wouldn't feel it." A perfect thing to say to a mother.

We rarely have such physical grief reactions, we are rarely witness to keening or loud displays of emotion. I guess that's just the majority of our culture. We wait until we are alone, in private, to break down and punch and kick and scream.

I'm glad she didn't wait. Her reaction was the purest, rawest form of the worst of the worst kinds of grief and loss. I wish everyone could express their emotions so accurately, and in the moment of their peak poignancy.

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.