Saturday, June 04, 2011

Sometimes nothing works.

Bad is having a patient with no IV access who is currently critical, and on whom starting an IV is like sticking a rock.

I'm not a bad IV start, really. I manage to get crazy shit on veins in the thumb, for Christ's sake, when nobody else can get anything. You give me a coding patient with a foot that's unburnt and relatively perfused (for a foot) and I can start a 20 gauge.

Really bad is not being able to advance a catheter, and having to give meds through the sixteenth of an inch that you've managed to float into a vein with prayer and incantations and maybe a chicken waved over the patient.

Worse is the situation where they've been okay, then not okay, then sort of okay while the labs say they're not okay, and the clinical signs say they're really touchy, but you still sort of think they're okay, maybe, but suddenly they crump.

Worst is when you acknowledge that they've crumped. You've got eight channels running in the CCU and they're not getting any better, but you keep playing with the Levophed to try to keep their BP within range.

Oh shit is when you realize it's all over. You can't do anything more; you've used up all the tricks in your particular bag o', and it hasn't been enough. All you can do is watch this thing, this person, go down the drain. Slowly. Despite all interventions.

No matter what you do, sometimes it isn't enough. Sometimes, in the face of all your training and all the things you've picked up over the years and even all the little crazy tricks you've tried that might not be in the protocols and might even be a bad idea, it isn't enough and the person, the life you've tried to save, the thing you've invested so much time and emotion in, they die.

It started out fine. She weathered a few bumps in the road, what with electrolytes and pressures going nuts, and she did okay. Then she fell over and there was not a damned thing I could do. I'd known her for two years, with her pulmonary hypertension and her crazy blood sugars and her dialysis, and I knew what had to be done.

None of it worked. None of it *worked*. Something, somewhere, ought to work in cases like this. Nothing does.

I guess, once you have enough experience, that you shrug and go on and say, "It just wasn't meant to happen." You deal with the next thing that has to be done and you put that last thing behind you, no matter how big it was.

I can't do that yet. I don't know that I'll ever be able to. This is where I feel most alone: I can't call Beloved Sister or Sainted Mother and say "I lost somebody tonight," because, for one thing, it's not something they could understand. For another, it was less a failure of things I did or didn't do, but more a recognition that nothing at all was working.

Sometimes nothing at all works. You do the debriefing and the root cause analysis and you go back over your charting and your actions, and everything is right, but nothing worked. You know it's not you, specifically--that the human body has tricks up its sleeve that we can't even imagine--but you still feel like you weren't enough.

Sometimes nothing works. Those are the times you remember when stuff that you did *did* work, and you wait and hope for the next time that that might happen.

The times that you fuck up through comission or omission are better. The times when there is nothing at all in the world to be done are the ones that keep you up.


Lynda Halliger Otvos (Lynda M O) said...

Jo. I just lost my second sibling in less than three years and they were both under 50. Brother just went on Wed night late. He had had a massive MI on Thursday 5/26. He turned 48 the next day and died five days later. I am heartbroken again and there’s no one to talk to this late at night so I sit, with you and your heartaches and join you with mine. Thanks for listening.

Eileen said...

Hugs of the virtual kind Jo - because many of us DO understand what it was like for you. That's part of why you have a blog isn't it?

messymimi said...

Words aren't enough here, but they are all i have.

Please accept my condolences.

Anonymous said...

Wow. This is going to be an interesting blog to follow. Thanks for doing this. :)

bobbie said...

I've always been able to "move on" (though I grieved) in those situations...

I'll listen anytime you need it ~

terri c said...

Thank you for this, Jo... And condolences to Lynda. How awful. Yeah--they WILL die, and someday, so will we, and ain't that a kick in the teeth. It's especially tough when you have come to know and love them, I think. Warm thoughts to you Jo, you rock.

Eileen said...

LH-O - if I knew you you would have been welcome to call me anytime. I remember the feeling of not being able to call anyone oh so clearly. But for some reason - even when it is the middle of the afternoon the people you want to call because they might understand have all gone shopping, working - anywhere except at the end of the phone! Virtual hugs to you too.

Rosanna said...

Jo, I'm sorry for the loss of your longtime patient; and, Lynda (first in Comments), I'm also sorry for the recent loss of your 48-year-old brother.

Simply because of circumstances/the situation/the relationship, to me personally there's "hard"; then there's "hardER" for caregivers and/or survivors; and (although different) ............ both of your current deep sorrow, after deaths ............ are in the "hardER" category, I think. I'm just so very sorry.

Rosanna said...

(Cont'd, i.e., to post or not prn, i.e., *your call*, Jo):

In regard to patients; and not knowing whether or not you'll ever be able to put that last thing behind you, no matter how big it was ............ *41 years* ago, (i.e., your AGE, Jo, I think!!), when I was in Nursing School ............ one of my fellow classmates died in our Nurses' Dorm ............ in the hallway, directly outside of the door to my room.

To make a long story short, my classmate----(bubbly, blonde-and-blue-eyed, and our Junior Class President, too)----had previously had Open Heart Surgery, a few years before, by the world-renowned Dr. Michael DeBakey. Early one quiet Sunday morning in the Nurses' Dorm, she jumped out of bed; and was sprinting down the hallway----(to answer the phone at the end of the hallway, i.e., pre- cell phone days!!)----and the suture line of her heart ruptured internally, instantly causing her to drop ............ in the hallway, directly outside my door. When the Hall Phone kept ringing-and-ringing, I opened my door to find her, supine on the floor ............

Another nursing classmate and I did 2-person CPR----(being students, we didn't know what else TO do)----even while our stricken classmate....was placed on the Ambulance stretcher....then carried down....from the Second the First Floor....out into the Ambulance....then into the Hospital ER across the street....where the ER Physician and ER Nurses then took over.

That long-ago day, I ............ unsuccessfully ............ tried to *BLOW LIFE INTO* a wonderful young girl, whose Nursing Career was cut short, before it really even officially began. Later that same quiet Sunday morning, when her parents arrived at the Hospital, the Nursing Supervisor met them outside. Her poor mother's anguished screams ............ reverberated ............ from the outside walls of the Hospital to the walls of all the surrounding buildings/houses, and back again. I have never, (and will never), forget how those cries of her mother sounded to me, as a Nursing Student ............ 41 years ago.

So, in my intervening 35 years of active Nursing, experiencing the deaths of many other patients, (Med-Surg Nursing; Skilled Gerontological Nursing; College Health Nursing) ............ (i.e., although not NEARLY as many deaths as you've probably already experienced, Jo, in your Nursing Specialty over the past nearly 10 years) ............ I did go on.

But, even though my classmate who died was (technically) "My Patient" ............ for less than 30 minutes, (unlike your patient, who was your patient, throughout two years) ............ I don't know whether I'll ever, really, be able to put it behind me. I vowed, that tragic day, to be the best nurse that I could be, i.e., to honor my classmate; and the good nurse I KNOW my classmate wanted to be ............ and would've been, too.

Just My 2¢ said...

Thanks for doing your best. I'm an engineer and the laws of thermodynamics tell me that death and corruption eventually always win.

But then there's LIFE! Life struggles against entropy. It's wonderful and miraculous, and unfortunately, temporary.

Ya done good, kiddo!

danielle said...

Linda - I am so sorry for your losses. Way too much - you havent had a chance to get over the first loss.
Jo - sometimes yo have to just step back and realize, we can only do what we can do - it is not always up to us.Sometimes it is the patient who is jsut tired of it all, and has met all thei goals (the cancer pts I had who held on long enough to say goodbye to their families proved that to me) and other times, well, whatever Being you believe in, it is Their decision. They are the ones who have provided the knowledge and the caring that we give...but ultimately it is up to Them (Him, Her, whoever). You cared - that is the most important thing; - and you gave it your all - that is the second most important thing. Now you have to give it all up to whatever Higher Being you believe in (or dont disbelieve)and realize they are the true Higher Power who makes those decisions.

Elyse said...

Not surprising you would remember that so vividly. What a way you found to honor your friend - taking her along the nursing road in spirit like that.

I've had a fascination w/ the dorm-hospital affiliated nursing schools of years gone by~~ some stories are tragic, some are comic - maybe I was unduly influenced by the movie "Night Nurse"(1931) w/ a very young Barbara Stanwyck :)

I think most of the time the distance-closeness weight finds it's proper balance if you don't try to mess with the process. I have a handful of "never forgets" from my early years at Children's Hospital. No, I don't think the ideal is to get to the "shrug" state. I know I never will and am OK with that.

Anonymous said...

I understand Jo. Every feeling, every thought, every "what if," every bit of the denial anger incomprehension etc etc. Just like what you can offer the palate surgery patient you mention in a later post. We get it. You did good. And will do more good. I'm sorry.

Osa Morena said...

My mother-in-law had decades with COPD. After 6 weeks as an inpatient, the last two in ICU, we made a decision on the Friday before Mothers' Day to do no more surgery, and let her go. She held on until early Mothers' Day morning. Yes, in a way, there was nothing more to be done. But on the other hand, the care that the ICU staff provided for her and for us, especially over those last two days, was nevertheless an enormous gift, and a blessing in a very difficult situation.