Tales from a Nurse

Chad is only 25. He is gay, and has been with his partner for 15 months. 

He was last tested for HIV a year ago, and the results were negative. 

He came to my ER last Thursday with back pain - but the back pain didn’t concern the physician. The red plaques on his body did. He reported having them for 5 months or more.

These red plaques are tell tale signs of Kaposi Sarcoma, tumors that themselves are telltale signs of AIDS and a severely throttled immune system. 

Chad admitted to knowing this, but not seeking help. 

His back pain came from meningitis. He had fungus in his blood, in his spinal cord, and in his brain. He had to be placed on extreme forms of anti-fungals. We had to medicate him for the fevers, chills, and spasms the treatment caused. He had panic attacks.

And his nurses, myself included, were angry to some extent. Who would let this happen to themselves? We said in the hallways. Who grows red scales on their bodies, has every warning sign of HIV, but doesn’t seek help?

I got my answer that day. His mother came to visit as I was calming him from a panic attack. He couldn’t stand the thought of another round of amphotericin B that night. After a small dose of ativan, I plunked him in a wheelchair, and we made a point to get out of the unit for a bit. He’d been in that room for 7 days straight, growing weaker. He hadn’t seen or heard from his partner since his diagnosis. 

His mother asked me why he was so weak and he pulled me down before I could answer. “I don’t want her to know what I have,” he whispered in my ear. 

And it hit me. He is all alone. 

He is an island in the middle of nurses and doctors who are fighting hard for him, but who do not - can not - truly understand what he is going through, or why he made the choices he did in delaying treatment. 

I told his mother he has an infection in his blood and spine. I carefully avoided words that could hint at HIV; but in truth, if she had wanted to really know, less than 5 seconds googling the rash on her son’s body would have lead her to an answer. 

After she left and we returned inside, I helped him into bed. 

“Why didn’t you find help earlier?” I asked as I helped him get his weakened legs onto the mattress. 

“I didn’t think anyone would care. I thought I’d have to beg for help, and…I don’t know. I didn’t think I’d get the help. I’d be shunned.”

I was speechless for a moment. I hate that, in 2015, someone would avoid life saving treatment because of the shame society places on diseases. 

He continued “My boyfriend is the best thing that’s happened to me in years, and I knew he’d leave. My mom knows I’m gay but doesn’t ever talk about it. My dad hasn’t talked to me in years. I saw the signs and I felt like…well, my life is over. I only came in because the pain got so bad.”

I hate to think of how many more days you will spend in that room, listening to us badger you into eating hospital food, into just one more dose of amphotericin, just one more lap around the unit. I hate to think that those days may only stop because we lose the battle against the raging infection in your immunosuppressed body.

I hate to think that you may not live to see the year 2016.

You are so much more than your disease, Chad. You are more than your sexual orientation. You are more than your mother’s opinions and your fathers silence. 

When I saw my admission’s ‘reason for admit’, I groaned.

“Anemia, GI Bleed”.

I was having a shit day. Not to mean it was a crappy day (although it was that as well), but that every one of my patients was admitted for something related to their poop. Two divertics, one cdiff, one bleeding ostomy, and now this GI bleed admit. On a renal floor, of all things. An understaffed renal floor that I was floated to and subsequently swamped and left in the weeds alone. Oh, the life of a nurse.

He was young; in his 50′s. So, on the upside, he’s at least likely to be a walkie-talkie, which is great, as it hopefully means he can clean himself up. If that sounds callous, you’ve probably never handled a GI bleed. When you’re a nursing student, you hear the horror stories of cdiff smells, but let me tell you, an acute GI bleed is a much, much worse smell. 

When he gets up to the room, he hops off the cart and walks over to the bed. Internally, I do the “booyah” dance as none of the rest of my patients are self-cares today. 

I go in and start the admission process - a million mundane questions to annoy the shit out of my patients (pun intended) - partly because they’ve been asked half these questions already and our idiotic EMR doesn’t carry them over from the ER, and partly because they don’t feel good and don’t want to sit there and answer questions about if they’ve traveled to Africa recently. 

A&Ox4, lungs are CTA, belly isn’t even tender, his wife is darling, and he’s super pleasant. I won the GI Bleed lottery, guys. His only symptoms, besides you know, blood in his stool, is fatigue. I check his counts from the ER…and see a hemoglobin of 5.6. 

“Did they give you blood in the ER?” I ask.

“Yeah, but I’m not sure if it replaced how much they took out of me!” he jokes. His wife confirms he was given two units. All his radiology is pending. I set him up with all the finer things in hospital life - comb, toothbrush, cheap ass pack of off-brand tissues - help him into his gown, and toss up a bag of normal saline before I go to page the hospitalist for the rest of my orders.

Several hours later, I was hooking him up to a protonix drip after the GI doc had finally been in to see him. He’s still jovial and sweet, as is his wife. The doc catches me on my way out, and pulls me aside. “I put a consult in, please make sure it’s called quickly.” I nod. I stop by the unit secretary to ensure she calls the consult while I head back to my cdiff room to change them for the 32139th time. 

In the cdiff room, I was checking my orders when I saw the consult order on the screen. To an oncologist. Even in the big blue plastic gown in a sweltering room, I went cold.

I quickly opened the full chart and flipped to radiology. I opened the CT and read the report of an extremely large mass in his cecum.

Then I saw “multiple lesions noted” in the liver, that were “suspicious for metastasis.” My heart broke. 

I yank the gown off as my tech and I finish cleaning up, and as I exit the room, I see the oncologist walking down the hall towards his door. I’m not ready for this. I hate this part of the job. I’m selfish for feeling this way, I know. My patient is about to be diagnosed with a life altering disease, and I’m feeling pity for myself. But in just 7 hours, I feel like pals with this patient. I’ve ooh’d and aah’d at pictures of his kids, congratulated him on his youngest graduating from middle school this spring, and talked to he and his wife about their jobs and plans for the future when their nest is empty.

I was looking forward to having him reassigned to me tomorrow, to following his progress with his bleed. 

Now, I’m watching his face - his wife’s face - as they’re told he likely has Stage IV colon cancer. 

I got into this job because before I was even 16, four members of my family, including both of my grandmothers, died from lung to brain cancer. I always thought I’d go into oncology, but it turns out, I can’t deal with it. But no matter where I work, cancer sneaks its way in.

Normally, we’d do chemo first, but because his mass was causing a lot of blood loss, a fairly big colectomy was going to be the first stop. I took care of him a lot over the next week. Even post op, when he was still drowsy from the anesthesia, he’d have a smile for me whenever I walked in. He never complained about the NG tube, the foley, the wound vac, the IVs. 

He was finally discharged yesterday. He has a long road of chemotherapy ahead of him. He has a wonderful family who has rallied around him.

A lot of things get easier as a nurse. You aren’t afraid of germs. Poop -obviously - doesn’t scare me. I can tame the wildest CIWA patient, and literally have held the hands of someone dying.

But this doesn’t get easier. No matter how strong they are, it’s never easy to watch someone told they have a potentially terminal diagnosis. Cancer, MS, CJD, ALS. Among many, many others.

Last week I came into work for my third shift. Thank god. The previous two had been hellish and I was looking forward to my weekend. I just needed to survive the next twelve hours. I could do that. You can do anything for twelve hours. I picked up my assignment and, not surprisingly, it was the same four patients from the previous night. I had to freeze my smile on my face to keep myself from groaning. They had been busy and needy the previous two nights.

But I smiled. Tonight was a new night. It would be different. And it was. Save for one patient. He was here for comfort cares, meaning he was dying and there was nothing we could do except keep him comfortable. The previous night had been horrible. The doctor hadn’t switched his orders to comorft parameters yet and the night hospitalists didn’t feel comfortable doing it without the attendings approval. So I’d been limited to morphine and Ativan q4hrs. He’s been moaning and uncomfortable all night. Confused, trying to get up every thirty minutes because he ‘didn’t belong here.’ It was heartbreaking for me and torture for his wife.

Tonight was different though. I had orders for q30min on all my meds and info from day shift saying that he was comfortable as long as we gave the meds every two hours. Cool. I had my plan. I went in and said hi to the wife, she remembered me from the previous night and smiled a sad, tired smile at me. One of my goals for the night became to make sure she got some sleep. I explained my plan to her and how I’d be in every couple of hours with more medication to make him comfortable. She nodded, gave me a quick hug, and thanked me for coming back.

That’s how the night went. I did all my meds and assessments. Did all my charting. Was in every two hours on the dot to keep him comfortable. Then, around three am his respiration’s got loud and wet and it was agitating his wife. So with his next set of meds I gave him some robinul to help with his respiration’s. His wife Wales out the door with me and thanked me again. We got to chatting. She asked if I could make sure she saw a priest in the morning. He wasn’t catholic, but she was and I knew it would make her feel better so I said of course. I reminded her that we had a chapel downstairs and if she wanted to go down, I would be more than happy to show her where it was. She nodded and I saw the tears start. So I did the only thing I could think of and I reached out and pulled her in for a hug. She cried in my arms for ten minutes. All the emotions of the past months that she’s bottled up for her husbands sake, for her children’s sake, came pouring out on my shoulder and I let her. Because that’s what we do; that’s what nurses are. We are the solid rock in our patients storm, the beam of support the family members lean upon in hard times. We are the advocate for the voiceless, the strength for the weak, and the compassion for the hurting.

Her husband passed away that morning at 0602. He was sleeping and then he was gone. She had finally managed to fall asleep and dreaded having to wake her up to tel her that her husband and the father of her three children was dead. Myself and my charge confirmed and called time of death. Then I walked over and knelt beside her bed and gently touched her shoulder. She jerked awake. I looked in her eyes and saw understanding and denial. Then I said the words and she collapsed forward into my arms, weeping. She had known it was coming, known what was happening, had asked us how much longer this could go on. She had been strong and now it was her turn to be weak. I held her for a moment, asked if there was anything I could get her, and quietly left the room so she could call her kids and her family.

As I stepped out the door, I almost collapsed myself. What the wife hadn’t known was that her husband had been the first patient I’d ever lost in my care. Sure, I’d seen others pass. I’d been the second RN on the death confirmation for several people. I’d done post mortem care on my fair share of patients as a CNA. But this was different. This one was mine and it hurt. I had known he was going to pass, had spent all night preparing for it, but it still hurt. I clipped our blue butterfly onto his door, to tell the staff that someone had passed and we needed to keep our distance for a while. Then I went into the bathroom and I cried for a few minutes. I cried for all of the family members I had lost, all of the patients I had seen pass, all of the patients who would die on my watch in the future. I cried for their families and friends. I mourned for them and for my loss.

Maybe it starts slow.

Maybe it starts with way the visitor in the room asks for you to fix their coffee and you realize they see you as a servant.

Maybe it’s the way a doctor dismisses your opinion without a thought.

Maybe it’s when you continually help your peers and yet when you turn around, they never help you.

Maybe it’s when you watch the light fade yet again from someone’s eyes.

Maybe it’s when you pour your entire soul into your work and it goes unnoticed.

Maybe it’s when a families screams fill the air and you stand helpless, knowing you have done everything and it will never be enough.

Maybe it’s when you go without your lunch or a break and they still find a way to make you feel guilty about not being there every moment.

Maybe it’s when administration rounds and finds everything wrong you did when you know you have been doing everything right.

Maybe it’s when you dread the mornings you work.

Maybe…

Maybe it starts slow.   Maybe it’s one thing or maybe it’s everything.  

Just had a patient who came in as a trauma, was declared brain dead, and turned out to be a registered organ donor. With Organ Donation (and donorcycle season) coming up, I just thought I would make a post about a really interesting topic. I speak only for my state’s stuff. Each state has a different organ donation agency and different rules/regs, as does each hospital in dealing with these situations. It’s also a CMS regulation to call your respective donor agency to notify them of any deaths, so really you should be calling them at some point anyway. Firstly – how do I know if my patient is a potential donor? I know in my hospital, which has one of the busiest transplant  program in the state as well as a large donor pool, we are well versed in what are some of the criteria are for donors.

Walking into a night shift, you just never know. Most of my day shifts have a predictable rhythm to some degree, but admitting at night can be sheer madness or sleepy boredom or anything in between. 

Last night: madness. 

“Hey, glad to see you, so let me tell you about this lady in Bay 2…”

She had coded multiple times, and actually had time of death called at one point, but then regained pulses. Not brainstem reflexes, no hope of neurological recovery…but again with pulses, because modern medicine is extremely, brutally effective.

And now she was mine. Mine whose vital lies I was asked to preserve at the family’s insistence, mine to maintain on whirring machines, mine to push chemicals into, mine whose marbled veins into which I was to waste precious donated liquid flesh trying to keep her tattered heart beating that beautiful gift-blood to a brain that had already stopped functioning, to kidneys that hadn’t worked well for many years, to a liver that was oozing her own acidic blood because it had been torn open while her ribs were being broken during chest compressions…mine to “help,” mine to “save.”

And while I worked to brutalize what remained of her, the admissions kept coming. Two little old men with half-functioning brains, with different infected bits causing what little mind they each had left to flutter off, leaving me to guess at their histories as their tired families shuffled off into the night, maybe just tonight, maybe forever, maybe done. I tried to make stories from med lists. I tried to extract hopes and fears from what remained of these partial people, these small suffering remnants in front of me. I tried to be more respectful than my profession had been to them previously, but it was hard, because I was simultaneously trying to maintain the vital lies in Bay 2.

Another admission, still a whole body, most of a whole mind, but a world of pain. I am just a person and I don’t have a crystal ball but I know about crystal meth. I see the path in front of this man who can only look backwards. I was asked to fix his numbers too, just his numbers, but he is still a whole person and so he can still tell me what’s wrong, and nobody was listening because all they could hear were habits, but he was really so clear, it was like he was singing verse I already knew and his songbook was a textbook and the tired instrument of my mind which has been made to see red for so many years did what it has been programmed to do. The hammer hit my brain and the reflex was intact: I ordered a noncon head CT. 

And then back to those vital lies, but the truth set her free. The truth that she was gone, that she was done, finally trumped our chemical and electrical engineering. Three more rounds of ACLS, but nobody’s heart was in it, most of all hers. 

The CT was read as normal by a person whose only job is to be right about that, and I wanted to believe it because I had so much writing to do, because I had been working so hard all night to push giants into different orbits and I had to show my work, so that the man who parks his Tesla closest to the door can have his arithmetic work out, so that the lawyers have no empty space in which to play with our lives. But I knew it wasn’t normal, because my instrument had processed the textbook-song, he had read the script aloud to me and I knew the ending. So I doubted and I looked, and there was a smear of bright white like a comet across his frontal lobe, and I wondered for the 48th time in my brief career, “what the actual fuck do we pay radiologists for?”

I may have helped him, my only victory of the night, but only with this one small battle. We won’t win the war. I still don’t have a crystal ball, but I remember crystal meth. I may not understand what an ode is, but I understand amphetamine. I know how brutally it beats up a body just trying to survive in a world of pain. 

At some point during the night I cried in a bathroom, but my heart wasn’t in it. 

I called a daughter and told her that the terrible truth had won. 

I showed my work. 

Tonight I had a patient come in complaint of Abd pain. No big deal really routine.

More so we thought.

Doctor comes in goes through his series of questions and starts to palpate her abdomen. She has some pain/ sensitivity in her lower left quadrant. So doc decides to do a pelvic exam.

As he is explaining to this patient what’s going to happen next. She very casually states “ okay but be careful I have leaves growing out of my cooter”.

You what?

Doc at first was skeptical has her change and we come back for the exam. And holy fuck was she right. Leaves…. growing….. that’s not the weirdest part.

Upon further inspection we realize she had stuck a potato up there. Easy to remove so as Doc is going to remove it she goes “ you have to leave it there! My insides are falling out!”

She had a prolapsed uterus and had used the potato to hold it up….

This should never have happened to you.

6:30am you walked into our hospital, an ambulatory patient, NPO, ready for your laprascopic cholycystectomy. You were hopeful, just as most patients are, when your surgeon explained all the risks of the operation, hopeful that it wouldn’t be you. You were hopeful that this simple procedure would be without complication, and you would go home that afternoon.

By 9:30am, you were off the operating table, rushed to the ICU, surgery stopped midway due to the rare genetic disorder that is unfortunately only discovered with anesthetic gases, Malignant Hyperthermia.

By 10:00am, your family is updated, devastated, and shouting that we made a mistake; this should never have happened, you were only 21, no medical history to speak of, you were supposed to go home today, and now they were prepared that you may not live.

By 11am, your family had left the room, an hour of shouting at the nurse, the doctors to do something, anything to save you, an hour that involved angry calls to family members, patient relations, lawyers, an hour that we decided enough: you may not be able to advocate for yourself, to tell everyone to just keep quiet for a moment, you may not be able to speak, to state - none of that matters right now while you’re fighting internally to stay alive. You may not be able to communicate, to decide who gets to stay or who gets to go, to placate family members, so for now we will be your person and make that decision for you, and out they go.

By 12pm your heart stopped and with family screams echoing down the hall we worked on resuscitating you, our hands almost mechanical in procedure, our personal feelings about what had happened to you shoved to the side, and would have to wait.

By 12:35pm, your time of death was called, a moment of stillness in the roomful of experienced healthcare providers who were surely all thinking one thing: this should never have happened to you.

By 4:40pm, the last of your family had left the room, a hasty goodbye incomparable to the depth of grief and longing to hold on just a little longer.

By 6:00pm you were transferred to the morgue, a rather cold, stainless steel environment, certainly not where you expected to land when you walked in the brightly lit hospital entrance this morning.

People often say to nurses or doctors,

“How was your day?”

“Tell me how it is to be a nurse, how is it to be a doctor?”

Questions that perhaps give us the most pause.

Except, if you ask us, the work on the frontline feels anything but explainable, anything but extraordinary.

We wake up in the morning, we dread going to work, we hit the snooze button like any other, wishing the day wasn’t Monday, wishing the 12.5 hours stretched before us wasn’t today, wishing we could snuggle under the covers, away from the world. We surface, kick the covers off obstinately, brew our coffee/tea, curse the obnoxious commuters. We resemble any responsible adult when we go through the motions of everyday life.  

Except; the responsibility hasn’t even begun.

We punch in, walk onto the unit, surveying the waiting room as we walk in - a determinant of how the shift may be; large groups grieving, families arguing, solemn looks, crash cart lined up outside the room, empty nursing station warning trouble in one or more of the rooms, and we want to turn around and walk back off the unit.

Except, we don’t.

We take our assignment for the day, the patient who is crashing in room 12, and another supposed low maintenance patient, awaiting step down unit. We peek at the low maintenance patient on the way to the crasher, heart already feeling the guilt that we are about to neglect this patient today while we deal with the storm next door.

Except, we don’t have time for guilt - yet.

We spend the day in what could only be described as chasing our own tail; watching patients mercilessly who state “I won’t fall,” accepting blame when they do during the four seconds we turned the other way, we scurry back and forth titrating drips, sending copious labs, adjusting ventilator settings, participating in rounds, admitting, discharging, and transferring patients…and ready to begin it all over again before the room is even properly dry from being bleached clean….we spend an inordinate amount of time cleaning up after doctors, and other providers, a trail of empty gauze, sodden dressings, syringes, tape, packaging and other assorted items so they do not become trapped under patients, or invade what little personal space they have, we dedicate moments, and sometimes backbreaking hours with patients, turning and  positioning, and tucking them in snug and warmly - not just because a damn hospital policy tells us too, but because it’s the one little thing we can do to give them a little dignity, a clean environment while this room and this bed is their home. We escort families in, and tactfully shoo them out with the frequency of  cleaning escaping diarrhea around the flexi-seal tube, somewhere in the middle of this reflecting on the harsh realities and visuals of nursing that television shows will never depict.

We grapple with decisions, weighing the risks and benefits of what we’re about to do and often it occurs without anyone else in the room, the enormity of the responsibility so overwhelming, yet we cannot think and stew on it until the day is done.

Except, try as we might, we’re not sure we could articulate it well to the masses, either.

We forgo meal breaks  when a patient is decompensating; not because we desire the glory of trudging on, but because for this day, this patient is our world, our responsibility, and one hour away from them in an understaffed unit  - with a fellow nurse watching them alongside of his/her own catastrophic situation  - well, it isn’t a meal break we will enjoy peacefully, so we tell ourselves we’ll just catch up a bit more, then go. Just another 10 minutes, then 10 minutes becomes just another hour… until it becomes just two more hours to change of shift, just one more hour, just thirty minutes.

Except, on most days, we aren’t even aware of how much time has escaped and we’re catching up on all the vital signs, the hourly intake, the interruptions and time seems to stand still in the moment when the patient arrests and the room is flooded with doctors and nurses trying to save this life.

Time stands still, even though an hour has passed and the patient is successfully resuscitated, and we go about the ordinary tasks of maintaining human function that the media will never portray, we go about cleansing the grime and gore that won’t stop gushing from all orifices - a sight we endure that’s by no means extraordinary, but an ordinary function of what we do, we spend time that feels like hours scurrying after orders while patients circle the drain, when our voices have grown hoarse over days and weeks from pleading with the doctors to grow some balls and tell the families honestly their loved one isn’t coming back, and it’s time…time to stop slaughtering them with invasive treatment, time to do what’s humane, no what’s good for ego, time to to stop and let them go….even though our hearts are shattered to admit defeat too. Most days we tell ourselves ordinary has to feel “enough” as we stare at the ceiling while sleep won’t come.

We spend sacred minutes, which is more than likely scattered moments with patients who are suffering, end of life, experiencing the agony of distressing news. We are at the bedside during painful procedures, we are at the bedside when no one else is there, no families, no friends, no one to speak of, We are the comfort of the brave, the solace of the strong, the restful place of the tired, and dying. And somedays we cannot leave it all there, so the caregiver role strain, the responsibility, the extent of what we see and feel in one day cannot be captured in any articulate sentence,

So,

When someone asks us how our day was, we’ll just say, “fine”

When someone asks us what it means to be a nurse, we are likely to simply say “responsibility.”

..We punch out, the day is over.

The outside world looks for what’s extraordinary.