Saturday, June 26, 2010

A Conversation in the CCU

"Lortab. I can't imagine why anybody would choose Lortab."

"Maybe it was the only thing he had around."

"Still....if it doesn't work the first time out, it seems like an awfully messy situation."

We're talking about suicide.

Everybody does it. Everybody, that is, who sees the aftermath of the incompletely-resected glioma, or the failed aneurysm clipping, or the treatment for whatever neuromuscular disease that simply didn't work, or the outcome of a bone-marrow transplant that didn't take.

"Valium," someone says. "Valium and insulin."

That's my preferred way to go: several cc's of regular insulin on an empty stomach, injected IV with many dozen milligrams of mixed benzodiazapenes. I've talked about it with one of the surgeons here: he's agreed to help me out when the aneurysm I'm surely cooking in my head blows. Another nurse has promised to be right behind him with a pillow. My friends at work say, jokingly, that if they both fail, they'll pluck my chin hairs until I'm extubated.

There's something about working with people who have gone through their days just fine until something either blows or blocks up in their heads, or goes out in their abdomens, or simply quits, like a heart, that makes you much more thoughtful. I leave the house neat and the cats' and dog's water dishes full every morning before I go to work, just in case I don't come back. I don't leave incriminating evidence around, or keep my changes of scrubs in the dryer.

Still, we wonder about the people who try to kill themselves, and who fail. It's not as foreign as you might think--probably every one of us has thought carefully and concretely about suicide, and not in a depressed way, more in an I-don't-want-to-end-up-like-them way.

But if you don't have that experience, if you don't have that knowledge, what is it like?

Is it the certainty that nobody's going to call to check up on you on this particular night that pushes you over the edge? Is it the fact that you turned down the invitation to the party that turned out to be a rocking good time? Is it that you never got over that one rejection? Or is it simply an accumulation of exhaustion and disappointment, a desire to rest, that leads you to chew and swallow and wash down with gin a handful of hydrocodone/acetaminophen 10/650?

I can easily understand how things can get that dark. After my husband and I separated, after a few other disappointments, the feeling of not-enough had gotten deep into my brain, so that I considered what the easiest, least-messy, least-traumatic way to go out might be. It's always run up against practical considerations, though: who else knows how much Max depends on belly-rubs at exactly the right time? Who could I count on to leave a specific size of water glass out for the cats? What on earth would my patients say? And who would call my parents and sister, and give them the news?

In the end, there is a gulf there as deep as the one that separates us from normal human beings. One one side, there are the people for whom practical considerations were no barrier; on the other, those of us who worry about details. On the one side, there is us: the people who touch the dead and dying and keep going; on the other, everybody else.

We think about it. We talk about it. We joke about it, even, but we know that a thread of serious business runs under the joking: if ever I am to end up in that bed, there, without the ability to swallow or breathe or toilet on my own, please kick the plug out of the wall. If ever I lose X amount of use of Y amount of my body, please bring me the ten-cc syringe full of insulin and the twenty-cc syringe full of benzos; here's my password so you don't get in trouble.

I don't particularly want to die. I don't look forward to it, as I think I would miss being alive. At the same time, it doesn't hold any particular fear for me. I've seen it enough to know that at some point you pass beyond pain and caring and simply get on with the business at hand. Being dead is a neutral state; dying is something I'm happy to avoid.

I wonder, though. I wonder about the people that decide that liver failure, of all things, is preferable to living. Christ, what a messy, awful, painful way to go. Same with gunshot wounds to the head: a gunshot wound to the chest is much less reparable and much less likely to go wrong. The guy in 23 who decided to take the handful of Lortab on its own, without the help of gin or Ambien, didn't know what he was doing. He's paying the price now, and we all wonder what on earth was so bad that smelling like ammonia and being on a ventilator seemed better.

No matter how bad it gets, I know I can count on Flashes lying belly-up on my lap and stretching out to his full length, purring and asking for belly-rubs. I know I can count on Max being excited to see me, and bringing me his bones for exclamation and approval. I know my neighbors will need a cup of sugar, or a biscuit recipe, or a bottle of wine. Notamus will always want to knead my bare shoulder as I'm falling asleep, leaving me with scratch-marks worthy of the most avant-garde body art shop in Bigtown. My friends will always call to check up on me and see how I'm doing.

I wonder--we all wonder--what it takes to go through with the Lortab without thinking it out thoroughly beforehand.

Edited to add: Anybody who can listen to A Prairie Home Companion's sound effects guy doing a skit involving juggling a chihuahua, a chicken, a chainsaw, a chuckroast, and a child and can still not feel slightly lighter gets my services for free. Seriously: how can you not be assured that humanity won't destroy itself after that?

Also edited to add, for Brad and for others who might be worried: Gracious, no, I'm not considering offing myself. I can *almost* understand why it might feel like a good idea to somebody, but... ... Being dead seems like too big a step to take. I wonder what separates the "almost" from the "did", you know?


bobbie said...

Having been on both sides of this debate, I'm not sure I know what to think...

On one hand is the ICU/ER nurse who is thinking "Waste of a critical care bed" and is muttering about showing them to way to do it correctly...
On the other is the person who has lived in that deep, dark dungeon...

'Tis a puzzlement...

woolywoman said...

Yup, insulin plus benzos. That's what we talk of in our unit, too. The problem is that it is such a permanent solution to problems that might be temporary. You just never know.

Sunflower RN said...

I think as care providers to the ill, we all think "what if that was me?". I have thought about it in the same way that you have. Not to actually do anything, but if I needed a way out, I would know what would work. I am currently working in psych, so most of my patients have tried at some point. How does one go from "I hate my neighbours" to "I'm going to kill myself"?

Loritab would not be my choice. In fact, I haven't found a way that would be %100 fool proof and not make a mess. I do know that I would not want to be on a vent for the rest of my life, waiting for the next mucus plug to do me in.

I think it would really depend on my head space at the time.

Brad said...

I had no idea you were living in a place of such darkness. I hope you are able to find your way out.

thursdaynextgal said...

After watching my mother die by inches for the past 13 years you'd better damn well believe I have it practically tattooed on my forehead to pull the fucking plug if I ever end up in that state (hmmm...maybe I SHOULD have it tattooed on me so there's no mistake). I completely agree with you - the death isn't what worries me - it's the dying.

shrimplate said...

Brad, it's just part of the job.

Moose said...

Once, while stuffed in a hospital bed, whacked out on IV morphine and the incredible pain it was for, I told the doctor that I'd long since figured out the best way to go: 2 handfuls of Benedryl and 2 full 1cc syringes of Humalog. Bang, zoom, 15 minutes later I'm on the moon.

Next thing I knew he had this completely panicked look on his face and was asking if this was something I was planning. "No," I told him, "But it's sure nice to have the option."

Similar to thursdaynextgal, my mom watched her mom suffer and die slowly. I am comforted in knowing that when the time comes my family will make sure the plug will get firmly yanked.

I like to say it as, "I'm not worried about death, I'm worried about the suffering before it comes."

Jenny McB said...

Anyone who works in the acute side of a hospital, ER/ICU and even lab people like me seem to have these discussions whenever an attempt comes in that goes to the Unit. We wonder about the thought that goes into the choices made and why some can live with diseases so painful that you can't imagine living.
I like how you tied your life in with what you see at work.

Anonymous said...

Joe, I can say without a doubt it's the pileing on of exhausfion, disappointment, worthlexxness, tears & an intense desire to simpmy rest that drives people to suicide....some of us are just to chicken to folloe thru.

Molly said...

I have the last few patches of my dad's painkillers tucked away just in case I need an easy out. I can't remember what it's called. The really heavy-duty stuff. Apparently if you scrape out the gel and mix with a bit of lemon juice to liquefy it, and inject it successfully, it's idiot-proof.

So far I'm hanging on, but. It's good to have something, just in case it gets to be too much.