Tuesday, July 27, 2010

Sometimes I get very sad and have to drink lots because people are dumb.

Today, between snorgle-waffleonium 327 test draws (get it in that orange-topped tube that gets specially shipped from Kyurgistan! Don't rotate it counter-clockwise to mix! Don't refrigerate it! And for God's sake, don't feed it after midnight!) and helping a very nice, very old woman to the bathroom, I was reading one of those websites that I used to like but don't really any more.

I wonder why I do that. I really do.

Anyway, there was a complaint from the person in charge of this website I don't much like any more about how meeeeeaaaaannnn and anti-child and awful people in the hospital industry are, because somebody wouldn't let her special little snowflake onto a critical care floor to visit a family member. Her child is well-behaved, and attractive, and eloquent, and generally a good kid. I believe that wholeheartedly.

But I still agree with the evil hospital industry's stance on not letting your kid onto the CCU.

I dunno.....maybe it has something to do with the horror of watching two people die of a common, highly contagious, mostly harmless childhood illness because their immune systems were shot (because we'd recently transplanted new shit into 'em to replace the old shit that wasn't working no more). Maybe it has to do with the knowledge that neither death had to happen, had people simply followed the rules. Maybe it has to do with frustration at how everybody in the world--even me, yes--thinks that rules shouldn't apply to them in whatever circumstance.

I'm afraid I left a comment. In it, I described the last few days of one of my patients, who ended up hemorrhaging from a newly-transplanted organ. I talked about how the family of the person who'd died too soon and thus provided that organ were comforted by the thought that a new liver could make the difference for a stranger, then horrified beyond belief that the transplant recipient would die so soon. (Yeah, they stick around sometimes, the families, and find out things we'd rather they not know.) I wrote a little about what it's like to hold a nice, decent guy in your arms, who's bleeding out as you're doing that, and how the only clue you had to how sick he was--since his numbers looked okay early on--was that he didn't want his sheets changed.

I talked about the difference in deaths: the man who didn't want to be resuscitated, and the woman who did, and ended up being coded five times in twelve hours.

All because of a kid with the sniffles.

Your kid's inability to be inside the hospital is an inconvenience for you, yes. It means you have to drive X number of hours home and line up a baby-sitter, and may not get to see your mom this evening. But it is a matter of life and death for any number of people who come into contact with your kid, or things your kid has touched, or people who have done either.

*** *** *** *** ***

Meanwhile, back at the ranch, I had a very nice patient (female, age 95) who couldn't understand why she'd been spared to live so long, albeit with weird chronic health problems, at the same time that I had a patient who was dying far, far too young.

His kids couldn't come in and see him, which was probably best. They'd moved him up to my unit from the surgical critical-care unit primarily because his family needed more quiet and more one-to-one attention than they were getting in a unit with twenty-nine other very sick people.

He'd bled. It always starts the same way, with a horrible headache. This one progressed as it always does with the young and healthy: nausea, vomiting, the decision to stay home from work with the predictable migraine. And half an hour later, his wife had found him unresponsive, breathing agonally, and called the ambulance.

He was my age; she was a little younger. Today was all about "what's going to happen" and "is he hurting" and "what can you do for this or that minor problem", with me being as competent and calm as I could be while I looked at a patient who could've been a friend or a colleague or even an old lover.

It's hard when they're your age. It's hard when they're young, but at least then I have the luxury of fighting with God over the unfairness of it. This? Not so much. Had we been able to do something about the bleed that crushed his brain up against his skull, he would've been a vegetable, even if his organs had survived the massive doses of pressors we'd had him on for two days.

He went to sleep, and quit breathing, when she left the room to get a cup of coffee. I had warned her that that might happen; that people who looked like he looked had, in my experience, merely been waiting for their loved ones to leave the room. She came back in as I was waiting for the last rattling breath to be followed by another.

When it wasn't, I shot her a quick glance and took my stethoscope off my neck, then put the bell against his chest. She didn't break eye contact with me. I had to say, "He's dead" to a woman who already knew what was going on.

(I never say, "He's gone" or "She's passed" to a family. The person in question is not "gone"; they're still watching and waiting--as far as I know--to see what happens next. And "passed"? Passed what? The test of life?)

*** *** *** *** ***

My other patient saw the gurney leave the room opposite hers, and knew what had happened. When I came back into the room, professional expression firmly in place, she did exactly what people in books do, and stretched out one hand from her bed.

"Honey? Do you want to talk?"

We sat for about an hour and a half, just talking about why life seems so unfair, and how it seems less so as you get older. I'm trusting her nearly-hundred-years of perspective over mine. As she put it, "The people who die too young are the ones who miss all the inconveniences of getting old. My husband had the chance, twenty years ago, to say 'C'est la guerre' and let me go, but he didn't. Now that I'm past ninety, it doesn't seem so unjust that I would've died at seventy-three."

She's funny. She's sharp as a damn tack, and aside from needing the occasional tune-up at the geriatrician's office, she's in pretty good shape. She'll probably go on, with her Kindle and her iPhone and her water aerobics class, for another five years.

I'm not sure if I want the peace that her perspective would give me. I talk about death a lot here, because midwifing a death is an honorable, amazing, incredible thing to be a part of. Once I know more and have more experience, I might go into hospice. I feel the same way about my dying patients--protective and gentle and more human--that I once did about my very poor, very scared teenaged patients.

But at the same time....being able to look back over a life that spans all but a bit of a century might not be such a good thing. I'm not sure I'm capable of the peace she's managed to achieve. I think I might keep fighting and cussing and being pissed off into my nineties.

24 comments:

messymimi said...

Fussing about not being able to take a germ magnet kid (I have 4, I know where their hands have been!) into a place with people who could die of a sneeze? Get over it already. I remember, as a kid, when no one under 12 was allowed beyond the lobby unless being admitted as a patient!

Midwifing death is a noble thing. Once you get tired of Manglement ruining your new NICU, or you get it running so well in spite of them that it gets boring, you might consider it.

Please keep being pissed off and fighting into your nineties. You will continue to do great work.

me said...

Amen to Messymimi's last paragraph ~ I miss that fight!!

Tonjia said...

it never gets easy does it? Sometimes I really wonder why we do what we do. Our hospital is strictly enforcing the "no child under 12" poliicy. We started it when we had an H1N1 epidemic and have continued.

Judy said...

I worked as a Hospice social worker for many years. It's a wonderful profession. As a nurse you get to work independently which is great. You still have to call the doctors to get orders, but most of them are on board with the end of life issues. There are negatives, like any job. When I left a couple of years ago, the patients were getting younger and you had more patients with drug and alcohol problems. When I started 20 years ago, most of my patients were as lovely as your 90 year old lady. I learned so much from the older people. It is a tough job but so is yours. You would be a great hospice nurse.

Molly said...

Maybe I'm a terrible person, but I do hope the people who brought their germ factories in to infect and kill those people know exactly what happened, and feel really shitty about it. The rules are there for a reason and they DO APPLY TO YOU. I turned purple with rage when the Duggar family (I'm addicted to that stupid show) herded all seventeen of their children, including the runny-nosed 5-and-under crowd into the NICU to see their barely-alive new baby sister. NO child is so freaking "special" that they don't carry germs.

AtYourCervix said...

Midwifing death - very interesting wording. I like it.

You're an awesome nurse!

(I seriously wish visitors would at least TRY to understand the reasons why children are not allowed in certain units. So frustrating to try to explain it, over and over, and over.)

Geosomin said...

I'm glad to hear your compassion in what you do every day. It's a hard thing. My mum was a palliative nurse and I know she found it very draining at times.

I was very grateful for the kindness and honesty of the nurses and doctors who cared for my Mum during her last few days. They genuinely cared, but were honest and decent and took the time to talk to us and answer our questions. Hospice care from kind considerate people makes final days so much more peaceful.
Just wanted to tell you that it makes the world of difference, it really does :)

pita said...

Sorry about the boneheads you are having to deal with.
Nothing wrong with still kicking and screaming when you are in your nineties. My grandmother like that till the end and my grandfather is still like that. :)

Anonymous said...

Two points:

Our local hospital was a joy to take my clinical students to last winter, when H1N1 fears led to a "no visitors under 18" policy. It was a special joy during OB, as the hoards of slutty girlfriends and gang-banger boyfriends could no longer crowd the room while their equally slutty and clueless 16 year old friend gave birth.

You seem to have a hospice heart. I adored my time in hospice and was board certified, and I can assure you that it is much less technical than what you are doing now. You get OJT and am sure would be a gift to any hospice patient and family. If you want to deal with death the way it is SUPPOSED to be, seriously think about hospice. And check out the small but touching book "A Mid-Wife for Souls".

Pattie, RN

Anonymous said...

I love your description of midwifing death. I hope you o into hospice care, but also that you know how important your work is now.

Halie said...

Great post. Well said, as usual.

Penny said...

My Mother waited until I had left, after literal days of being at her bedside. I finally snapped and ran home for a much needed shower and about an hour of sleep. She died about ten minutes before I returned. I KNOW it was her way of saying, "I'm still your Mother and I'll still make the big decisions and you still have to put up with them, you little shit." It helps to know that, and yet, it sometimes still really bothers me that I wasn't there.

Laura said...

Could someone explain the no kids thing to me? While I understand kids can be little germ-bombs, I would think I could just as easily carry something in with me if I visited a critically ill patient before realizing I was coming down with something. If the patient is ill enough that a cold/flu could kill them, I assume some sort of hand-washing, mask, or other preventative measure needs to be take for the adult visitors. Couldn't the kids be expected to do the same? Also, is the "no under 18" part just a convenience or is there a reason? A 17 year old's cleanliness habits are a bit different from a 7 year old's.

(I don't have a vested interest in kids or no kids in particular hospital units, I'm just trying to understand the logic.)

Jo said...

Laura:

Adults do need to take precautions, like reverse-isolating themselves (gown, gloves, and mask) before visiting an immunocompromised patient. It's not just that kids are germ carriers; it's the sorts of germs they carry.

Kids can have chicken pox (which caused a bone marrow transplant unit in this area to close) or RSV, which can be devastating. Adults are less likely to carry those (and other) infections. Likewise, an adult's immune system is more developed, so they're more likely to look sick and thus stay (or be kept) away than a little guy.

The under-sixteen rule in our facilities is there because there've been outbreaks of things like whooping cough, H1N1, and measles around here lately. It doesn't keep everything out of the isolation areas, but it helps. A lot of the kids getting sick are older elementary-school age or middle-school aged kids.

It's kind of like trying to bail the ocean with a colander, frankly, but you plug up what holes you can. I have an equal amount of concern about some of our doctors (shudder) as I do about a five-year-old with a runny nose.

Anonymous said...

Have you ever listening to Danion Brinkley? I think you would find him fascinating: http://www.coasttocoastam.com/guest/brinkley-dannion/5744

Thank you for this post. Keep up the great writing and doing what you do, I believe you have a real talent. You never know who you might need to lead outside to the roof and into Light. ;)

Lisa said...

What do you do for children whose parents or siblings are dying? Do you allow them to visit? Do you take the patient someplace they can visit with them? Or do they die without saying goodbye?

Jo said...

Lisa: If they're dying, then we move them to a place on one of the floors where kids are allowed, so that everybody can say goodbye. In the case of my last patient who died, they'd said their goodbyes earlier.

The rule isn't inflexible in extreme cases. Like I said, it's like trying to empty the ocean with a leaky sieve. Sometimes you have to make exceptions for the good of the family (ie, transferring the patient to a bed on a less-acute unit).

woolywoman said...

OK, here's a good reason to keep your kid out of the ICU: it's horrifying. Tubes, machines, monitors, pee, blood, restraints, ventilator, suction, trach care, did I mention blood? How at least once in one's carreer in the ICU it will get quiet, and you hear this Zen like dripping sound, like water on a stone, and HOLY SHIT HES BLEEDING CALL CODE START BAGGING HES BLEEDING OUT! I HAVE NO PRESSURES< I HAVE A LINE...etc

Your precious little flower should not see that, people. And don't start me on VRE. MRSA, and all the other little alphabets soups that darling child can pick up, along with a dropped cheerio, from the floor. /rant off/

Anonymous said...

I took care of a patient who nearly died of CMV. Sure, it could have come from his brand new to her liver, but it could have come from anywhere. Oh.So.Scary.

BTW if I'm in scrubs, I do not touch babies, either. I go home and decon before I've visited friends who just gave birth. It just makes me feel better knowing I'm not potentially infecting the latest addition.

If I bring my child anywhere, it's where he can get in. If not, then, guess what Dad's doing in the lobby or next door at the mall, etc.--babysitting. If it says they can't come in, then they can't.

My child was allowed by staff in an ICU one time to visit his dying great-uncle for about 2 minutes...while he still could talk to him and give him a hug (comfort care was implemented right after that). It was one of the saddest moments of my life. The rest of the time, he played in the waiting room.

PaedsRN said...

We allow kids into our PICU to visit, we just keep anyone with an active illness out. But different countries, different rules I guess :) The kids have to do the same handwashing as everyone else, they kind of dig the alcohol gel I think. Generally we find they cope really well with the environment.

Jo, I've been an HN reader so long that I can't remember if I've said this to you before... last time I commented was probably years ago! Now that you're posting a lot of YouTube, the margins are getting cut off and I wanted to let you know how to change this if you'd like to.

What'd you'd do is go into your Blogspot control panel. In the design tab there's a link called "Edit HTML". In that tab you should see some style sheet definitions. You might have to scroll down quite a bit, but the one you want will look like this:

#outer-wrapper {
width: 660px;
...

Change that value to

width: 900px;

Then right underneath it should be another label,

#main-wrapper {
width: 410px;

Change that value to

width: 650px;

Then click the 'Preview' button and see if you like the new widths. If you want, I did a test page so I could see if it worked, I can send you the link (just won't publish it here for obvious reasons). Those widths are the minimum required to show the wide-format YouTube videos without having the edge clipped off.

Thanks as always for kick-ass nurse blogging :)

Anonymous said...

Midwifing death, wow. As a retired hospice nurse, let me tell you that you have it nailed. I couldn't ever do what you do, just too many bells and whistles in a unit, but do think about transitioning into hospice. I pretty much did it all in my day, starting with labor and delivery. Nothing was as rewarding as hospice. Trust me. I am a nurse.

Nurse J said...

jo, as you can see from the posts, many people love you, appreciate you, and love your writing. it insipres, teaches and just generally kicks ass. i dig you, too. i hope it helps you to know that so many people are pulling for you, even if it comes across the interweb tubes in comment sections like these. seriously, you rock.

Lisa said...

Thanks for the response. My mother spent some time in the ICU after being shot (fortunately, she made it) and I spent two days in the ICU unexpectedly after surgery, I can't imagine bringing a child in there.

As it was, I couldn't see my boys until I left the hospital as all the patient floors were off limits due to swine flu. While I missed them and they were miserable without me, it was for the best; it kept them from getting sick and kept me from being bounced on.

But children are stronger than we think and if someone important to them were dying, I think they would need that good-bye to help them process the loss. Certainly, the ICU is a lot less scary than a funeral home.

Heidi said...

Have you seen the hospice article in the New Yorker? I think you'll like it.

http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande?currentPage=all