by Tilda Shalof
By the time I climbed the last set of steps, I was pretty winded. I walked through the door and right into complete chaos. The bed was halfway out of the elevator, the elevator alarming: Alice was kneeling on the bed doing chest compressions, Rochelle was bagging and the transporter was using the elevator phone.
“I’d like to report a Code Blue coming to seven east,” the transporter said in a calm voice. “Yes sir,” he said. “We’re almost there.” He hung up the phone and turned to Alice. “I know CPR, can I help?” he asked, just like in the CPR class—good for him. “We’re good,” Alice said. “But thanks,” she smiled.
I helped the transporter extract the bed and the six IV pumps from the elevator. “You are a magnet for drama.” I told Alice.
“You can’t leave me alone for a second.” She continued compressions. Her face was flushed, her blond pony-tail swinging forward with each compression.
We rounded the corner and Drew was holding the door open; the doctors and the code team were coming through the door.
Our resident Jeremy arrived in wrinkled scrubs, running his hands through his hair. “What’s this guy’s story?”
“Sixty-seven years old,” Alice said. She nodded to the transporter and he took over compressions. “Found down at home.” I handed the CPR board in and opened a box of epinephrine. “History of coronary artery disease, had a bypass in ’90, bilateral carotid endarterectomies.” Alice climbed off the bed and on the count of three we all rolled Mr. McGovern onto the CPR board.
“Stop CPR,” Jeremy said, stepping forward and feeling for a pulse. “Okay, let’s keep going. And let’s push some epi.”
Alice pushed the epinephrine into the IV line I’d designated earlier as the “med-line” in which to push emergency drugs and opened the roller clamp to flush it in. The transporter continued compressions. He was tall and his technique looked smooth and effortless, like he was using one of those hand pumps for a camping mattress.
“We just went to head CT,” Alice said. “His heart rate went up into the one-seventies for about a minute and then he dropped into the twenties, so we started CPR.”
“Do you have a strip?” Jeremy asked
A EKG strip? We were in the elevator on a portable monitor. The transporter had called the arrest on the elevator phone. No, we didn’t have a strip! “No,” Alice answered calmly, and she grabbed another box of epinephrine. I guess I shouldn’t be so hard on people; these interns get beeped out of a sound sleep and we expect them to think clearly and bound into action. We continued CPR, no pulse, more epinephrine, listened to the breath sounds, listened again, considered a cardiac tap. Finally Jeremy called it. At that moment, I had to leave to answer another patient’s cd bell.
“Hi, Sam.” He squeezed my hand.
“How are you?” I asked and he gave me the thumbs-up.
“Drew’s busy,” I told him. “But I can help you. Do you need suctioning?” He nodded. I hooked the ambu bag up to his trache but he reached up and squeezed the bag himself.
“Hey, pretty good,” I said. He still had an arterial line in his right wrist, so he steadied the bag with that hand and pushed with the left. I suctioned him and hooked him back up to the ventilator. I spooned a few ice chips into his mouth, flipped his pillow, and turned off the light.
When I returned to Mr. McGovern’s room, the code cart and the ventilator were gone. The drips had all been taken down and the pumps delivered to the dirty utility room. Alice was sitting on a chair next to the bed, the chart on her lap.
“Are they going to do an autopsy?” I asked.
“I think so. No one can get hold of the family, though.” She picked up the chart, looked over the note, then signed her name.
I never know what to write for death notes; I usually just write what happened, what time the doctor pronounced the death, and whatever happened with the family or the patient belongings. One doctor I knew always wrote, “May he rest in peace,” at the end of his note. I tried it once but it seemed awkward. Even though I felt it, it seemed preachy.
“His CT was a mess,” Alice said.
“What?”
“Yeah, Jeremy just got the results. He had a huge stroke.” Alice pulled her ponytail forward and ran her hand along it. “So I’m not sure what to do. I guess I’ll just leave all the tubes in, in case they do an autopsy, and get him all cleaned up. I’ll have to pin two sheets together—we’ll never be able to wrap him in just one.”
Alice went to get washcloths and I filled the basin with water. Since Mr. McGovern had just come in he didn’t have any belongings in the cupboard, no cards on the wall, no pictures. I looked down at him, so big and pale. I wondered what he was thinking about right before his stroke. Maybe he was trying to read one of his newspapers. Funny that a lifetime of thoughts and memories can be cut off in a moment by a single clot of blood.
We cleaned up the body and I left the room to answer the phone. Alice followed me out and spread the sheets on an empty bed next door. I watched her bend at the waist, folding the edges of the sheets, pinning them together. Then with her thumb and forefinger she caught the top of her ponytail, and with a flick of her wrist, all her hair flew up and spread across her back. She balanced on her white clogs, folding, pinning, folding. Then, in one movement, she picked up the double sheet and twirled around.
I hung up the phone. “All set?” I asked her. And we went in to wrap Mr. McGovern and prepare his body to send to the morgue.
O, Holy Night!
Bob Hicks, RN, BScN, BHSc
IT’S 11:57 P.M., Christmas Eve, and I’m at work in the ICU. As I get ready to perform another set of hourly vital signs on my patient, I glance out the window and see that a small snow flurry has started. There’s something comforting about working in the hospital during the holiday season. Maybe it’s the break from the hustle and bustle of the malls and of trying to squeeze in every last minute with family and friends, or maybe it is just the comfort of knowing that at the end of my long shift I’ll have a nice warm bed at home waiting for me to crawl into.
My patient tonight is an elderly woman, almost 90 years old. I read in her chart that she happens to be a nun. She’s devoted her entire life to the work of God, and now I am here to watch over her life and ensure her comfort while she’s under my watch. It’s my lucky night. What could be better than caring for a nun on Christmas? She is someone who, I imagine, spent a lifetime of work to guarantee her entrance into heaven. I’ll have to ask her to remember to throw in a good word for me, I think to myself.
My patient, Bernice, was brought to the ICU after being found unconscious on the floor of her home. It was uncertain how long she had been lying there: possibly four or five days. Half of her body was covered in blackened, necrotic ulcers. She must have fallen, because she had completely fractured both her hip and her clavicle. There was also a small fracture in her skull, and she had a small cerebral bleed from which she is starting to recover. Now, finally, she is beginning to regain consciousness.
Bernice’s vital signs are stable: heart rate 82, blood pressure 134/65, and temperature normal. She’s in normal sinus rhythm with oxygen saturation 97 percent. She’d been extubated a few days earlier and is now on four liters of oxygen by nasal prongs. She is starting to wake up, but her mental status alternates between stuperous and confused. She moves her arms slightly and is unable to move her legs, possibly because they have become edematous—swollen to more than twice their size. She opens her eyes from time to time and stares blankly into space. Despite all of this, Bernice looks peaceful lying there in bed. She’s in no obvious discomfort. In fact, for her, this state of hovering between life and death is probably closer to God than she’s ever been, even though she’s devoted a lifetime to the church.
I listen to her chest with my stethoscope and hear that it is starting to sound a lot worse than before. It is even worse than it was an hour ago, when I performed my initial shift assessment. When I try to clear away secretions, by suctioning her through her no
se and at the back of her throat, I note that she has very weak gag and cough reflexes. Bernice is not nearly strong enough to protect her airway from these thick secretions. Her chest is noisy and I can hear coarse, scattered crackles throughout the lower half of her lung fields. I’m going to have to resort to more invasive measures to clear the secretions from her chest and upper airways. I absolutely hate doing this to my patients, especially ones like Bernice, who have been lucky enough to have lived 90 years and whose time to go peacefully will soon arrive. It’s invasive and undignified, but it has to be done. She can’t get proper oxygen exchange with all the thick fluid in the way, and she can’t cough it out by herself. If I don’t do this unpleasant procedure, she will likely have to be reintubated and put back onto mechanical ventilation, both of which will increase her risk of getting pneumonia. I know I have to do it.
When I was a novice nurse, new to the ICU, Karen, who was one of my preceptors and one of the strongest nurses I’ve known to date, taught me this technique. I’ve always looked up to her and modeled my nursing practice after hers. She always remained calm, always seemed to have an answer when dealing with the most difficult of situations, and, if she didn’t, she knew exactly where to find the solution.
I take the Yankauer suction catheter (a rigid plastic oral suctioning device, approximately one foot long) and begin to clear the secretions from Bernice’s mouth. I slowly inch the catheter toward the back of her throat to try to stimulate her weak gag reflex and get her to cough up the deep secretions from the bases of her lungs. No luck. Now onto the part I am reluctant to do. It is unpleasant, but I do it because I know the alternative, mechanical ventilation, carries worse risks than this brief, temporary discomfort.
At the back of Bernice’s throat, I continue onward with the suction catheter; still nothing. She doesn’t have the strength or alertness to cough. She needs to cough. I always try to think about how uncomfortable and invasive it must feel, but I don’t really think anyone can properly imagine how it feels, no matter how hard they try. I push on farther down her throat. Still no reflex. I now have my hand just about all the way into her mouth and this rigid piece of plastic must be at least six inches down her throat; then I finally hit the spot. Bernice begins to gag slightly; then she is frantically coughing, trying to clear this foreign probe from her trachea. Halfway through the coughing fit her eyes open up, and now they are focused, as they had not been (until now) during her stay in the ICU. She looks squarely at me with a menacing glare.
“You son of a bitch!”
It was as though Bernice had been following the white light and, as she reached the end of her ascent, Saint Peter himself slammed the gates shut right in her face.
There are more secretions to be cleared. I move the catheter back into her mouth and start the process again.
“You son of a bitch,” she snarls at me again, with a mixture of disgust and anger. The devout nun, now appearing to be possessed by Satan himself! She’s ready to take me along with her to the afterlife, through the firing brigade of hell, to be seated in unrest at her right side for eternity! And then, after working so hard at clearing her chest, Bernice falls asleep.
Get some rest, Saint Bernice, I think to myself with a chuckle. I’ll be with you for the rest of this night, caring for you and helping you to clear out your chest again in a few minutes. There’s no rest for the weary ICU nurse.
In the morning, when my shift is over, I make my way back home, offering a Merry Christmas to Bernice, my fellow workers, to those who celebrate Christmas, and to those who don’t.
Power and Voice
Sharon Reynolds, RN, BScN, MHsc (bioethics)
MY PATIENT HAD BEEN in the hospital many months, in and out of the ICU. We knew he was not going to get better and go home. I think, deep down, he knew this too. When I met him, his affect was flat. There was no animation in his face. When I asked him if he was comfortable I had to stand back a bit to watch for the very slight nod of his head, which one could easily miss if one wasn’t watching closely. It seemed to me that he did appreciate me speaking to him: the more questions I asked, the stronger his nod became. He seemed responsive to being informed about what we were going to do next and why. He was listening.
My patient had not been out of bed in a long, long time, which rendered him virtually immobile. He really couldn’t move his limbs. When, to assess his comprehension, I asked him to squeeze my hand, I felt a small quiver in his fingers: that was his squeeze. I knew his vision was compromised; he didn’t look directly at me unless I was right in front of him. I learned later that I was just a blur; it would be the sound of my voice he would remember and not my face. I had been told he was depressed—and with good reason, it seemed. Someone very close to him had died from the same disease he had, and at an early age. He knew his fate.
He had a tracheostomy (a breathing tube inserted at the front of the neck so that the mouth is free) and was intermittently on a ventilator—mostly at night, so as to allow him to rest—and he was unable to speak or write. Some patients are able to move their lips well enough to communicate full sentences. My patient was unable to do this. He had not spoken in a while.
The advantage of tracheostomies is that if we are able to successfully wean patients from the ventilator, and if they are strong enough, they will be able to speak when we put a cap on the end of the trache. The respiratory therapist (RT) assigned to my patient this particular day suggested this goal at the start of the day—so that became our plan: wouldn’t it be great if our patient was strong enough to speak? We told him our plan and of course he was willing to try it. I couldn’t believe it.
The moment we attached the “cork,” he spoke—and then it seemed he didn’t stop speaking. The difference between who he had appeared to be earlier and who he became once he spoke was startling. He was no longer an inanimate being in a bed whose thoughts and needs were unknown. He literally came to life. There was power and intelligence in his voice. It was really something to see. He had been liberated from a silent, locked-in world and helped to enter a place where he could assert himself and make himself known.
His initial words disturbed me, yet, somehow, they weren’t entirely surprising. He said he felt that some of the nurses were treating him as if he were already dead. They would speak about him in the room as if he were not there and could not hear them. He said he heard sounds of disgust when they looked at him (he had an open wound that required daily packing with wet gauze; some nurses found this hard to do). He said he just wanted to be treated like a human being, like everyone else. He said his mind was alive, he could feel and hear. He wasn’t stupid. He recited his social security number, his wife’s social security number, their home telephone number, his cell phone number, and her cell phone number, to prove that he had a mind that could think, remember, and process information. He seemed to feel a need to prove his intelligence, to convince us that despite his inability to speak he was a thinking, feeling, living human being who just wanted to be treated with respect.
His words were disturbing and yet humbling. I wondered whether I had treated him disrespectfully. Was I guilty, along with the others? He said he didn’t want to name names, he didn’t want to stir up trouble, he just needed to speak it and then leave it. I told him we needed to hear this kind of feedback in order to learn and grow, and not treat other patients in that dehumanizing way. He said he understood but still didn’t want to speak of it any further.
I had not thought seriously about the relationship between power and voice until that moment. It’s so obvious, really: we communicate who we are primarily through our voices. If we lose this capacity, we become almost personless, we become bodies in beds, enigmatic beings. This is one reason many nurses like for their patients to have photographs in the room. The photographs are testimonies to the humanity and personhood of the patient: she did have a life before she came here, he laughed, paddled a canoe, drank wine, rode a motorcycle, hiked in the woods…. It is strange and unfortunate,
but we can easily disregard the humanity of our patients. Their capacity to speak keeps us linked to their personhood. Their voices remind us that they are in there; they are people who command attention. Whether we like it or not, we do treat patients differently if they cannot speak. It’s awful. I cannot tell you how many times I have said to patients, “I’m sorry, but I cannot read your lips.” Then they sigh in exasperation and defeat, once again locked in with whatever it was they wished to communicate, which may have been something as simple as “Could I please have a mouth swab?” or “Could I be turned to my other side?” Sometimes, when I succeed in reading their lips, I’m astounded at how simple (or complicated) their requests can be: “What time is it?”; “Where is my wife?”; “What’s going on?”; “How am I doing?”; “Who are those people outside of my room?”; “My leg hurts, could you move it for me?”; “What is that doctor’s name?”; “Could you turn out that bright light?”; “It’s noisy in here”; “What is the weather like today?”; “Am I ever going to get out of here?”; “I feel discouraged, I want to die …”; “I miss my dog.”
There is another aspect of this communication issue that I should perhaps mention: the connection between voice and intimacy. The relationship between nurse and patient changes when communication channels are open. When patients are able to communicate their feelings, fears, and needs to us, our relationship can become more intimate—and intimacy can be hard. It makes us feel things and can trigger our own fears of death, abandonment, loss of control. It pulls us in. There is a mystery to intimacy and I must say that sometimes I do find it very hard to look into a patient’s eyes. It scares me, the intimacy scares me. I am afraid I might cry. I don’t always want to see a patient’s suffering and despair, and intimacy draws me in closer, to glimpse how hard it must be to lie in a bed all day wondering whether you are going to get better; or to lie in a bed waiting for death to come; or to lie in a bed not knowing who you really are and what is going on. I have sometimes felt tears well up and have had to look away, just not able to bear the feelings.
