Sunday, November 15, 2009

Tales from the CVCCU

As part of our training, we interns have to go to the cardiovascular CCU at Holy Kamole. They deal with things there that, thank Frog, I will never have to see. Bone-marrow transplants gone wrong I can handle; neurological disorders hold no sway in my nightmares. But heart and lung and kidney and what-have-you transplants? Are the stuff of horrid, horrid dreams.

I am meant to do a thorough neuro exam every hour. I am meant to understand dermatomes, Brown-Sequard syndrome, and incomplete cord transections. I am not meant to handle eight vasopressor drips on one patient.

So it was with fear and trembling that I got to the unit to follow an experienced CV nurse. The patient she had was one of those who requires two nurses: every once in a while, you'll see a one-on-one (for instance, if somebody's undergoing continuous, slow dialysis), but two-to-ones are very, very rare.

What does it take to be a two-to-one patient?

Let's start with a rare genetic disorder that only about a thousand people in the world have, and make it one that only, say, vegetarian left-handed expatriate Iranians living in Hungary are prone to. (Of *course* that isn't the real disorder. Do you think I'd violate HHIIPPAAA that way?) Be certain that your patient fits none of those categories.

Add on the necessity of not one, not two, but three--so far--solid organ transplants over the lifespan of this particular patient. If you can make one of them a re-transplant, so much the better.

Make sure that that weird genetic disorder isn't diagnosed until after the first solid-organ transplant; that way, you'll stand a good chance of ruining whatever organ you transplant the first time with the complications of said genetic disorder. (As an added bonus, make sure that the patient's sisters and brother all find out that they're carriers of this nasty disease, and fuck their brains, their future plans, and their reproductive decisions up as a result.)

If you can manage a rare-but-dangerous viral infection, tack that on as well.

Oh, and be sure you put in for an order of adult respiratory distress syndrome, with a side of sepsis.

What you end up with is an absolutely beautiful young woman on a ventilator, with a midline incision that runs from belly to brisket, six pressor drips, and very little chance of ever waking up.

I left my job at Planned Parenthood the day that a twenty-seven year old woman came in with her pregnant thirteen-year-old daughter. The woman asked me if I expected her to cry over her daughter's being pregnant; the idea that any other possibility would present itself showed me such a huge gulf between her experience and mine that I could no longer deal with the disconnect. I had thought that that was as bad as it got.

Until I saw a smart, funny, gorgeous girl of twenty-three hooked up to hinty-bazillion machines, all of which were dedicated to keeping her body alive until, frankly, her parents and siblings could work up the courage to say goodbye.

The day wasn't made any easier by the fact that I had known her before, years ago, when she came in to our floor and ended up being diagnosed with that crazy genetic disorder. I thought then that she wouldn't make it to nineteen; I was wrong. Her parents showed me the pictures of her on the campaign trail for Obama, the snapshots of her hanging out with Sasha and Malia and Michelle and Barack. They told me about how she felt so strongly about particular issues up for debate in the Texas Legislature that she disregarded the advice of her doctors and went to testify as an advocate for battered women, how she ignored the symptoms of organ rejection in order to go to a conference on providing health care to uninsured people. There was a framed picture of her getting her Master's degree on the table by the bed.

And two pumps with three channels each, a balloon pump, a ventilator, and three pages of IV drips that had to be administered at exactly the right times.

I guess it bears mentioning here that her parents and older sister recognized me the minute I walked into the room and called me by name. It sucks when people you have to disappoint remember you so well.

We walk a fine line, nurses and doctors. On the one hand--and I think this is more true of nurses than of doctors, except in rare cases--we gain a degree of intimacy with families that would be inconceivable in most settings. On the other, we have to maintain that professional distance that allows us to advocate, to educate, to break bad news.

Sometimes, that last is easy. You can manage, even with people you see more than once or twice, to keep your distance. Sometimes it's very, very hard. And sometimes, despite your best intentions, you fail completely at being a detached professional person.

I was not the person who extubated her. I was the person, though, who turned off all of the drips, and hung the morphine up, and titrated it so that she didn't show any distress, and who laid my useless expensive stethoscope against a chest in order to hear what wasn't there.

I was the one who had to look across her body and tell her parents and her brother and her sisters, "She's gone, now."

And I was the one who broke every professional boundary imaginable by standing in her room with them and crying over the loss of a reasonable, decent, driven young person who had bad, bad genetic luck.

In a way, I'm glad it was me. I was there when she found out she had this thing wrong with her that would shorten her life; I was there when she told her parents, quite matter-of-factly, "This won't change any of the plans I've got." My ability to translate medicalese into English eased their transition from normal family to family with dangerous medical condition; it helped that I could put things in every-day language and thus calm some of their fears.

But even two nurses, six drips, a balloon pump, and all the translation talent in the world can't save somebody, sometimes.

Still, I'm really, really glad I was there. I'm glad I got to see what she'd done.

I'm glad I got to say goodbye.


Penny Mitchell said...


You are truly one of the good ones, honey.

Alpine, R.N. said...

I didn't know you could HAVE six pressors going at once!

I'm so sorry your day was hard, but I'm glad the family had a nurse who wasn't a stranger.

bobbie said...

Ye gods and little fishes ~ that is TRULY the shits. I agree ~ I am so glad it was you that was there... and I think you should feel NO regret over crying with them. Sometimes you just HAVE to be more human than "auto-nurse" for your own mental health.
Hugs ~~~

REH said...

For the family, I am so glad you were there. For you, I'm glad you can see the good. You are truly awesome.

Anonymous said...

Hugs, to you, Jo. What a courageous young lady she was/is. Your experience is exactly what we go through with hospice every week. And, yes, the young ones are the ones who shatter my heart. It's an honor to be there for them and their families.

Unknown said...

Well written.

I can only hope this won't happen to me in the future, but I bet it will.

Anonymous said...

That family, that patient, the next patient, and we are lucky to have you. Thank you.

An Open Heart said...

How lucky for that patient and her family that you were there.....


spider said...

thank you for being there for her and her family.

painting with fire said...

What a heartbreaking story. I'm sure the family found some comfort in your presence and in your shared grief - I know I would. She sounds like an extraordinary person too - what a loss!

Crabby McSlacker said...

Sounds like she was an incredible young woman; so tragic for her to be taken so young. The family was lucky to have had you there.

And if crying with them somehow wasn't professional, than screw professionalism.

Hugs from here too.

CCSutton said...

From everyone who has had that short, but long, wait at the side of a hospital bed, thank you.

Anonymous said...

This was a beautiful post. From a newbie nursing student, I say "well done and thank you."

woolywoman said...

You do good work. Crying is not outside the boundary zone-not feeling for the loss of a lovely family member is outside the boundary zone.

Peace be with you.

missbutton said...

It is absolutely not unprofessional to cry with your patients. It's another thing if you completely lose it over your own issues. But crying with the family is authentic and can be part of a therapeutic presence. What a gift to give the family; the knowledge that those providing care for their loved one truly cared.

I'm sorry that you had a tough day, but I'm also glad that you were there.

Cami said...

You are SO in your element, career-wise AND blogging-wise. Thank you for sharing both the funny moments and experiences like these.

HeidiRN said...

The nurses who cried with us when our little boy died are the ones I think of even today... and they'll always have a special place in my heart for it. I can't put into words how much it meant to have them express the emotion at his loss - it showed that he was more than a job for them. This family will be just as grateful to you, I am sure. And if that's unprofessional, then I will be right there with you, because when I decided to go to nursing school, my inspiration was those nurses. And now you! :)

ElmoRN said...

I used to work hospice for almost 2 years. I cried with many of the patient's families...the ones I had gotten to know and some of the ones I hadn't. I agree with the rest of the posts, it shows that you are human and empathize with their loss.

That family was also blessed to have you there. You were someone they knew, trusted, and had seen that you really cared. Some days it gets so hard physically and emotionally that you question your career choice, but like the others said, you are a jewel! Never forget that!

Keep on being yourself! You're part of the reason that nursing is one of the most trusted professions in the U.S.!!