by Tilda Shalof
I called for help from my own staff to move the body back to the ICU. Luckily, someone came to assist me. That was the third death of the day. If we kept this up, I was afraid we were going to set something of a strange, macabre record.
When I eventually returned to the ICU, I went to the room of the young man who had died on the operating table, to retrieve, restock, and clean the cardiac arrest cart. Meanwhile, another patient, a young woman recovering from an overdose of alcohol and Ecstasy, was showing signs of a rapid deterioration. I ran to get the other cardiac arrest cart. It was just outside the room of the lung transplant patient who had been doing so poorly that morning. I knew the nurse had left it there just in case she would need it. I looked at the cardiac monitor and noted that his heart rhythm had now stabilized. I reviewed his situation with the nurse caring for him and she informed me that indeed, her patient’s condition was improving. I felt I could take a chance and disconnect the ECG leads and move the cardiac arrest cart into the room of the overdose patient, who was now in full-blown cardiac arrest.
I saw his young, scared-looking wife glance at me with a bewildered look. To her, I realized, it looked like I was removing her husband’s life support. I rushed to reassure her that what I was doing was safe. “Your husband has stabilized now. He doesn’t need the crash cart.
I need this for another patient in the ICU who is much sicker right now.” I ran out of the room, pushing the cart ahead of me, feeling guilty at my hasty explanation.
Later, I found a moment to go back to speak with her. I wanted her to know that her husband was safe, and to understand that even in the ICU, resources are limited and we have to share them. I felt it would help her realize that although the ICU had been quite hectic that day, her husband, in contrast, was stabilized and doing very well: he had a new set of healthy lungs inside of him and his condition was looking positive.
It was late in the day and I went to check on the overdose patient who had arrested. She had been successfully resuscitated and it looked like she might make it, but it was still unknown if she had suffered any brain damage from the drugs she had taken. Her outcome was still uncertain, but for now, she was improving. I nodded at the family standing around her bed to indicate that things seemed to be going in the right direction.
Finally, my shift was done. It had been the most challenging day of my career, but I knew I had conducted the orchestra well, brought out the best in all the players, and out of chaos had made possible the best, the highest level, of patient care. Together, we had made beautiful music.
Tipping the Balance
Matt Nathan Castens, RN, BA, CCRN
STEVE HAD BEEN DOING everything right. He was an experienced motorcyclist heading to work on a sunny day. He was wearing a helmet. He also had the unfortunate timing of being out on the road when another motorist, returning home after a night of heavy drinking, crossed the median and hit oncoming traffic at full speed. Steve was the first person hit. Because he was wearing his helmet, his head was intact, but all four of his limbs and his pelvis were completely smashed and he suffered extensive abdominal and spinal injuries.
The crash occurred close to our facility. Steve was quickly stabilized by the paramedics and brought to our emergency department. The trauma team flew into action and completed the stabilization process, sending him to surgery to repair what internal injuries they could. They removed his spleen and part of his colon, and left his belly open to allow for the swelling that would occur. His spinal injuries, while unfortunate, did not need immediate attention, and orthopedic surgery would have to wait until he was more stable. Even though he’d been wearing a helmet, a CT scan of Steve’s head showed that his brain had been severely shaken inside his skull, causing bruising and swelling, but the extent of brain damage was unknown.
His mother, Ruth, waited in the ICU family lounge throughout the long surgery and was brought in to see him when he arrived in his room. She was devastated, of course, but much calmer than we would have expected. She stroked his head, whispered in his ear words of love and encouragement, and said some heartfelt prayers. She spoke the understanding refrain of love in the face of death: “He’s a strong boy. He’ll pull through.”
We believed that was unlikely, if not impossible. His internal injuries were massive and he’d lost a lot of blood. The orthopedic injuries were extensive and he lost even more blood from those. While his spinal cord was not severed, the location of the injury and resulting swelling indicated that Steve would never walk again. He was far too sedated for us to be able to evaluate brain function, but no one was optimistic. Assuming he did pull through, he would likely spend the rest of his life wheelchair-bound in a nursing home.
The following weeks were long and hard. With every slight improvement, Steve’s family and friends were elated. With every slight decline, they told us they still believed Steve would come home.
He kept getting worse. The splenectomy had initially saved his life, but now, without that powerful organ of the immune system, infection was a constant enemy. Furthermore, while his abdominal injury started healing, problems came from other areas. Even after surgeries fixed and stabilized his broken bones, the damage from the crash destroyed enough muscle tissue to leak thick proteins into his circulatory system and severely damage his kidneys. Steve now required dialysis. The surgeries also created more avenues for infection, which had to be closely monitored. Whenever the sedation was lessened in order to evaluate his neurological status, it was clear that his brain had been damaged—although it was difficult to determine to what extent. Between the dialysis, the frequent infections, and the surgeries, it was difficult to keep his blood pressure stable, and he required multiple medications to regulate it.
At about the one-week mark, the care team started discussing the need for a tracheostomy. Steve’s breathing had been supported by a mechanical ventilator. The endotracheal tube, while beneficial in the short term, was adding complicating factors: it was another route for infection, and its constant presence would, over time, damage Steve’s vocal cords and trachea. In a conference with Ruth and her family, the physician and nurse presented their plan for a tracheostomy. They explained that it was no cure or guarantee, but it was one more thing we could do to help Steve’s recovery.
Ruth said no.
Could that be right? Did she understand what the medical rationale was?
She said she understood, but “Stevie’s a proud boy. He would never want a hole in his neck—he always believed that was a sure sign of the end.”
Maybe she didn’t understand the dangers of leaving a tube in the throat for a long time? Did she realize that, if the tube were left in too long, Steve might never be able to talk again?
“I understand,” Ruth replied, “but I know my boy. He would not want this.”
As I received this information in report that evening, I shook my head. Denial had taken over and gone from being a necessary coping mechanism to being a destructive guiding force. Who would want to have an uncomfortable tube down the throat for what would likely be many more weeks, if not months? Who would want to take the risk of being rendered alive but mute? Clearly Ruth was not facing reality—it was time for the ICU nurses to start working their stuff as patient advocates.
But Ruth came from stubborn stock. At first, she very politely disagreed with the nurses. After several more conversations, she simply glared at us if we even broached the subject of a tracheostomy. Eventually, we gave up.
Things got worse. Infection erupted in Steve’s right leg at the site of surgery. The antibiotics didn’t work and the tissue became necrotic. Cultures revealed the organism was an antibiotic-resistant and highly potent infection called streptococcus A. It’s what the public knows as “flesh-eating disease.” It’s a fast-moving infection and the only “cure” is drastic: amputation of the limb well above the site of infection. Fortunately, the site was in the foot, so perhaps Steve would only lose the leg below the knee. Ruth consented to the surgery. “Anythi
ng to help my Steve come home,” she said.
Unfortunately, the operation did not help. As the infection spread, Ruth consented to more amputations—above the right knee, below the left knee, and below the left elbow. The final two most drastic surgeries she also consented to quickly: up to the right hip and up to the left shoulder. Steve was disappearing before our eyes.
As nurses, we were outraged. What were we doing to this man? A man who had been, by all accounts, a healthy, vibrant, loving son was being turned into an invalid freak by a “loving” mother who could not let go! Not only that, but her choices made sense to none of us. Her son would rather spend his life in pieces and mute than have a damn hole in his throat? No one—no one—should be forced to live like that. It was torture, pure and simple. It was time to give up and let the man die with whatever shreds of dignity he could salvage.
We started to despise Ruth. The physicians agreed with us and did their best to convince Steve’s mother that all was in vain, but they still went about their duties lopping off limbs and refusing to refuse any more interventions. We were angry at the doctors.
Each time I was assigned to care for Steve, I hated what I had to do. I had gone into nursing and trauma to save what lives. I knew that wasn’t always possible, but I also knew when it was not possible. Each time I cared for Steve, I gave him my all, stopping every once in a while to apologize in his unconscious ear for the hell I was participating in creating.
Life goes on. Eventually the infection was conquered and Steve’s kidneys took over from the dialysis. As he stared out from glassy eyes, his breathing became stronger and we were able to remove the breathing tube. It had been putting pressure on his vocal cords for six weeks, but what did that matter? There wasn’t enough brain left to carry on a conversation anyway. We transferred Steve out of intensive care and thanked our lucky stars: we would never have to deal with Ruth and her warped sense of reality again. Out of the picture, we could relegate Steve to that place in nurses’ brains that is accessed only when angrily commiserating with other nurses over a bottle of wine. Good riddance.
Seasons change. Occasionally we would get a report about Steve from a therapist or surgeon. He was starting to wake up from his vegetative state. He was making sounds—none intelligible, but sounds, nonetheless. Physical therapy and rehab were working to help him with his wheelchair—prostheses or crutches were out of the question. We would hear these reports and shake our heads. “Hurrah!” we would gloomily think, “a success,” if we could call it that.
And then Ruth came back. I could spot her from down the hall one day when working in Charge. Polite and aloof, I accepted her chocolate gift to the nurses. “Do you have a minute?” she asked, smiling. “I have someone I’d like you to meet.” With that, from around the corner, came a wheelchair.
I recognized Steve immediately. Looking good for all he had been through, I couldn’t help but be impressed that he could navigate an electric wheelchair so well with his one hand. He rolled up to me and held it out for a shake. As I took it, he looked me in the eye and said with a voice, clear and strong, “Thank you for all you did for me. And thank you from the bottom of my heart for not putting a hole in my throat. I can handle anything that life gives me, but that has always terrified me.” He patted his wheelchair. “It’s not as fast as my bike, but it’s still a fun ride. It’s good to be alive!”
It is a basic tenet of nursing to assume the role of patient advocate. It is the ethical duty of all nurses to speak for those in their care and to work hard to ensure that the patient’s wishes are followed despite influences to the contrary, be they from physicians or family members. As Steve and Ruth walked back down the hall, I couldn’t help but shake my head again. Wouldn’t you know? Sometimes, families do know best. Being a nurse means being a patient advocate, but it does not mean that we always know what the patient wants. Our mistake with Steve was to assume we knew his wishes based on what ours would be.
Critical care nurses deal with death and tragedy far more often than does the average person—and more often than the average nurse. Trauma nurses also face tragic situations that many times are the result of either poor choices or poor timing. A nurse working in a trauma intensive care unit at times gets to see the worst of both worlds—but also the best. This was one of those times.
Tennis, Anyone?
Karen Klein, RN, BScN
WHEN I GOT TO my day shift at the step-down unit, I was surprised to see Mick’s wife at his bedside. In all the time he had been my patient, I had never met a member of Mick’s family: they visited earlier in the day and were gone by the time I arrived on shift. I was happy to finally meet his spouse, a well-groomed woman in her early seventies.
“It’s our anniversary, so I decided to stay late with him tonight,” Mick’s wife explained, adding, “it would have been—” She stopped herself. “It’s fifty-one years today.”
I gave her an understanding smile. She missed him, of course. The man she’d known and loved her whole life was, in essence, gone.
Eight long months ago, Mick walked into the hospital to have triple bypass surgery for coronary artery disease. He had already had the much less invasive coronary angioplasty, but it had not been successful, and because he was a brittle diabetic, open-heart surgery would be particularly risky for him. In fact, Mick had been refused the surgery at three other facilities but had doggedly persisted, finally locating a cardiac surgeon who would perform the operation at our hospital.
Mick did well the first two days post-op, but on the third day, he suffered a massive stroke, which left him comatose. After several weeks in the surgical ICU, Mick was able to breathe independently and was off the ventilator, and was transferred to my step-down unit. A month later he developed a severe pneumonia, and though he was treated with IV antibiotics, his respiratory status worsened and he was transferred to the medical ICU to be placed back on a ventilator.
I took care of Mick many nights during his first stay in the ICU. I watched, horrified, as, due to fluid retention, he became bloated and swollen. Eventually, when the fluid was reabsorbed, he shrunk down to a cachexic shell of the man he must once have been. I could see from the pictures his family had left at his bedside that Mick had been a tall and handsome man of 72. He sported thick, distinguished white hair and carried himself proudly.
One of Mick’s biggest problems was his uncontrollable diabetes. No matter how hard we tried to regulate his blood sugars, they fluctuated wildly. We carefully monitored his liquid tube feeding intakes and monitored his blood sugars closely. This involved pricking his fingers every four hours each day, day after day. By now, months down a very hard, bumpy road through ICU-land, Mick’s fingers were a mess. Some were so calloused they yielded no blood at all, no matter how hard you pressed when sticking him. Others were so swollen, sore, or bruised that they were nearly unusable. Eventually I began to feel terrible, almost guilty, every time I had to do his finger sticks.
Mick remained comatose and did not respond in any meaningful way except the occasional grimace or a purposeless movement in response to a painful or uncomfortable stimulus. He was fed liquids specially formulated for diabetics via a tube down his nose into his stomach for the first few weeks, but eventually a small surgical opening was made in his abdomen and a feeding tube inserted directly into his stomach. This was how he now received nutrition. He breathed through a tracheostomy tube placed through a hole in his neck and he was connected to humidified oxygen tubing at all times. Because he was prone to pneumonias, every few hours we would have to remove the secretions that built up in his airway by passing a thin tube connected to suction down the trache tube into the upper trachea and suctioning out the sputum—a very distressing procedure for the patient as it takes away their air suddenly. A Foley catheter was inserted through his penis into his bladder to drain his urine passively, which caused him continual bouts of urinary tract infections. His arms were nearly covered with bruises—remnants of old IVs and blood draws. Though we tri
ed to reposition him frequently in the bed, or hoist him out to a chair, Mick was thin and the skin on his left hip began to break down. Eventually, Mick developed a bedsore, a decubitus ulcer. To relieve the pressure on that ulcer we kept him off his left hip as much as possible but then the skin on his right hip and his sacrum (backside bone) began to break down and develop decubiti as well. He was, quite literally, beginning to rot away in the bed. While caring for this patient, I often thought of Florence Nightingale’s words: “The very first requirement of a hospital is that it should do the sick no harm.” Most people think that the worst possible risk of an operation, illness, or injury is dying; nurses know otherwise. Nurses know that the options include not only living or dying, but also ending up in that limbo modern medicine has made possible: we can sometimes keep a person alive to a point where his or her condition might not be considered truly living. Ending up as a piece of rotting flesh in the bed; eating, breathing, and urinating via tubes; not interacting with your surroundings except for reflex reactions when procedures are performed on you or when you’re turned and repositioned; stuck with needles every few hours, day after day, week after week, month after month is really not living. It’s existing … painfully.
