Learning to Cope: The Balance Between “Tough” and “Human”

I still have dreams about that day. I replay it over and over again, hour-by-hour. What did I do? What could I have done differently? What would I do if I could start it over again? Would she be alive and at home with her young daughter and son.. Would her husband wake up every morning with less weight on his heart..

Working in Intensive Care, there are many challenging days. People passing away is a regular occurrence- sometimes they are brought to us for the purpose of passing peacefully and comfortably with the drugs we have available. Feeling content with my beliefs surrounding death and what happens after we die helps me to cope with the death throughout the unit. What I have found the most challenging, however, is when I can’t make sense of the death. Usually blaming age, disease, or lifestyle choices make it easy to understand and cope, but sometimes cases just don’t make sense to me.

I came in on a Friday morning at 0715 for my usual day shift, expecting the same patient assignment I had for the two days previous. Instead, there was a different room number, 18, beside my name on the assignment board with no patient name. This indicated that I would be getting a new admission and the charge nurse did not have the last name as of yet. I went to bed 18 to prepare as the patient rolled in from MOTS (multi-organ transplant unit). She was a 42-year-old who had just undergone what we call a Whipple procedure in hopes to remove pancreatic cancer the day before and was steadily declining in the MOTS. She was coming to the ICU for blood pressure support, close monitoring and likely a blood transfusion. Within 20 minutes of her/my arrival, she was sedated, intubated, had a central line placed, an arterial line placed, and was on vasopressors to maintain a decent blood pressure. I was sending blood work to the lab when her husband called from the waiting room for the first time.

The ICU at my hospital is a locked unit for the purposes of privacy and confidentiality, so patient’s family members must call in and speak with the nurse to get permission to have the door unlocked to visit. He was a quiet man with an accent I couldn’t place. He was asking for an update and to come in and see her, unable to hide the fear and concern in his voice. I told him I was not able to let him in at this time because of everyone currently working on her, but she was not stable and we had intubated her. I promised I would call back as soon as I got a chance.

That chance didn’t come. She continued to decline and require more and more medications to maintain her blood pressure and more support from the ventilator to give her body oxygen. All we knew is that she was bleeding somewhere and we started dumping blood into her as fast as we could. The rapid transfusion protocol was initiated by the ICU Fellow, so we primed the Ranger for blood. I had a designated runner who would be primarily responsible for running back and forth from the blood bank to ensure we had an adeqaute supply of blood and other blood products to give her at all times. By the time an hour had passed, we’d given her 12 units of red blood cells, 4 units of platelets, and 4 units of fresh frozen plasma. Her blood work was unchanged, if not worse. She was definitely bleeding.

At this point her surgeon was at the bedside, as he’d heard of her rapid decline. I was furiously recording everything I could, from volumes of the transfusions going through the Ranger, what medications were being infused (4 vasopressors, a proton-pump inhibitor infusion, antibiotics, electrolyte replacements, colloids, and sedation/pain meds… so far). I was also trying to listen and scratch down what boluses people were giving to maintain blood pressure and sedation. “1 of phenyl”, “3 of versed”, “I pushed a calcium”, “1 of epi in”.. there were about 5 people in the room at any point in the day and all were trying their best to help this lady, and I was trying to keep it all straight and make sure there were no mistakes. I had multiple scrap papers that I would scribble on and whenever there was a break (when my runner was going for more blood), I would furiously chart everything to try to keep up with documentation. They were illegible to anyone else attempting to make sense of them.

Her husband called again while I was on the phone with pharmacy, urging them to send up more bags of medications that we were running low on since we were running them at such large doses. I picked up his line and quickly told him I was unable to talk to him or let him in at that point, but the surgeon would be out to speak with him shortly. I’m not sure if he ever did.

Numerous teams all came by the bedside throughout the morning- general surgery, hepatology, nephrology, vascular, hematology, and probably more that I wasn’t able to speak with. They all wanted to know what happened so far, what she’d been given, and to see my chart and my notes of infusions and volumes. I had to ask what team they were from in order to tailor my reporting to them based on what they cared about within their scope. No one had a solution, everyone knew she was bleeding, which leaves only one option- she had to go back to the OR.

Once we got her ready for the OR, prepped extra infusion bags to take with them, and got consent from her bewildered husband, I watched her role away on the stretcher and was sure I would never see her again. In a nutshell, our livers are responsible for many things, one of them being blood coagulation. Her liver was shot from a clot in a main artery from her original surgery, so the liver was not able to produce these coagulants, and thus any bleed would not be stopped. We could give her as many products as the blood bank had in stock, but if her body was unable to coagulate, she would bleed out, regardless. This is what happened.

I went for my first break after she left at 1:30pm where I changed my scrubs because they were soaked from sweat from the events of the morning. I felt like I took my first breath since I arrived. I was just opening my yogurt when I heard the following overhead announcement: “Attention ICU, patient will be returning to bed 18 in 5 minutes” -my patient. I took 2 bites and threw it in the garbage and headed back to my bedside. Here we go again, I thought. This cannot be good if the OR couldn’t help her either.

She rolled back in with all of the same infusions, but requiring even more support from the ventilator. She was getting 100% oxygen (hint: you and I breathe 21% room air) and only had an oxygen saturation of 86% (goal: 92-100%). This was telling me that she was bleeding so much that her lungs were full of fluid and were fighting so much pressure from the bleed in her abdomen that they were not effectively oxygenating. We put a warming blanket on her because she had a temperature of 33.9 from the combination of the OR and all of the transfusions she’d received. All of the drugs we could give her were flowing into her limited central line access that I had to strategically run through bridges in order not to mix medications that were not compatible. Epinephrine, norepinephrine, vasopressin, dobutamine, fentanyl, propofol, midazolam, amiodarone, vitamin k, and countless bags of blood products were being hung and replaced as necessary. The room was filled with beeping from IVs, the monitor, the ventilator, the rapid infuser, and the discussions amongst the various medical professionals. I think we counted 52 bags of red blood cells alone that were infused throughout the day.

At this point, there were 2 Attendings (head ICU physicians) in the room, trying to get more lines and ordering more blood. The Attendings are the head honchos, the big guns, that only come in when the residents cannot handle a situation on their own. Having two of them giving my patient their attention was a bad sign.

After another hour of blood products, switching out empty infusions, and failing at ventilating, one of the Attendings decided to stop ordering more blood. She asked me to call in the patient’s husband and family. I knew what this meant. I left my patient in the hands of my partners who’d been working on her furiously all day and went to the waiting room where 10+ people jumped up when I called for her family. I requested that just 2 come for now, so her husband and brother followed me into the unit. At this point, I introduced myself to him and apologized for being unable to speak with him, or let him in sooner, expecting anger and frustration, rightfully so. Instead, he apologized to me for being a bother and thanked me for caring for his wife all day… that he understood I was busy. This made my heart break for him even more. It might’ve been easier if he was an asshole.

The 3 of us met with the Attending in a small, quiet meeting room. She explained what had been going on all morning, why we were having trouble, what happening in the OR, and what problems we were facing now. She explained how she didn’t feel any medical interventions we had available would be able to help her. He remained calm throughout the conversation and just kept looking down at his hands and nodding in comprehension. The Attending was compassionate and caring in her approach, something I continue to admire and respect about her. Those traits seem to be all too uncommon amongst many physicians, surprisingly. She asked for my input and I agreed with her, answered some of the brother’s questions, and confirmed what treatments we had given her in the morning. After we were done speaking, the Attending asked if the husband had any questions. He looked up for the first time and quietly said, “What am I supposed to tell my kids? My son is 16 and my daughter is 14. She needs her mom.” This was the first time all day that I had the chance to slow down and absorb the reality of the situation. When you’re running around and frantically trying to stay on top of tasks, it is easy to forget that it is someone’s loved one in the bed. This was a huge reality shock for me and I could feel tears welling up in my eyes. We, of course, did not have an answer for him. After the conversation was over, we invited them and more family members into the room where she was, so they were able to see everything we were doing for her, explain what the machines were doing and why they were no longer effectively treating her. I don’t know if this visual is more helpful, or more scarring, but often times it is a crucial reality check for family members. I continued to chart and manage my infusions, my partners continued to run through the last few bags of blood we had in the cooler, and the respiratory therapist finally increase the ventilator support to the maximum settings.

My biggest regret at this point in the day was not having the opportunity to give her a bath. From 2 ORs and all of the activity of the day (trying to place lines, infuse blood, and tape tubes) she was a mess. She had blood across her abdomen seeping out of her incision, blood down her neck from a failed intrajugular central line attempt, yellow iodine paint all over her belly and legs from the OR, and tubes and IVs everywhere. This was the last visual memory that they had of her- their wife, their sister, their daughter, their mom. If I had just cleaned enough that the blanket couldn’t cover, maybe it would’ve been a nicer image for them. This wasn’t the lady they knew. This wouldn’t be how I would want my family to see me. But there just wasn’t time. Or did I have time? Could I have had them wait, or would that have prevented them from being beside her when she passed? This is always one of my dreams. When having this type of shift, the aspect of “care” is almost completely removed from the situation. The primary focus becomes tasks, numbers, lab values, vitals.. not the mother lying in the bed. While these days are exciting, they don’t leave you with any sense of satisfaction, whatsoever.

Without getting into the details, the team and the husband together decided to stop enhancing care. We would not stop any treatments, but we would also not add anything as her health progressively worsened. This feeling is similar to sprinting an entire marathon, exhausting yourself and focusing on one goal, only to come up short and finish second. You stop running and the whole world catches up with you and there is an overwhelming emotional wave. You gave it everything you could but you didn’t win, you couldn’t do it, she died anyway.

Their priest made it in to read her Last Rights with her family surrounding her. I listened as I continued to try to catch up on charting outside the room, fighting back tears as I heard their soft wailing. Though I usually try to focus on my tasks, this day I prayed for her with them. The entire time the family was in the room, I told myself consciously to not look at the daughter. I knew that would tip me over. It is impossible not to put myself in her shoes. Her mother is close to my mom’s age and she is only 14. This is her mom, and we couldn’t save her.

When she passed, I went in to shut off the monitor so it would not alarm and quietly told them I believe she passed. Immediately, sobs emerged from almost everyone in the room. This wasn’t supposed to happen, she came in for a relatively simple surgery. The daughter must not have heard me, because as I was leaving the room, I heard the husband lean down and whisper to her, “She’s gone, baby”. This is a scene I see over and over in my head, both asleep and awake. This was a monumental moment for this girl and I was the one to deliver the news. Who was I to have this big of a role in her life? Who was I to witness that private moment? I stepped out of the room and I couldn’t even speak- I was overcome with emotion. My partner, an extremely supportive and more experienced nurse, saw that I was upset and went to get the doctor for me at this time. She went in the room and answered the family’s questions about what happens now and the funeral and everything. I have never been so grateful for a colleague, or so ashamed of myself. What a coward I was- they had just lost the centre of their universe and I couldn’t even finish my job. I tried to fight back the emotions, tried to think of something else (anything else), tried to focus on my tasks, but my eyes were already red and swollen and my words were caught in my throat. When they were ready to leave, each family member thanked me for my care and I just kept smiling and nodding and mumbling, “I’m so sorry.” I knew this time not to look at the daughter. The husband came out last and I couldn’t help but give him a hug. He was so sweet and kind and worried about his kids, despite the fact that he had jut lost his wife. He just kept saying, “thank you” and comforted me by saying that I did everything I could. Can you believe that? HE was comforting ME. What a special, special human being. I pulled myself together and gave them all of the information they needed in the hallway. We chatted a bit and I ensured that I would take good care of her while preparing her body, and asked if I could do anything else. Someone mentioned that it was Mother’s Day on Sunday. My heart broke a little more.

Witnessing people in the worst of times and seeing how they manage to cope is a magical part of nursing and often times gives me the motivation to do my job. They are humbling, while also helping me to keep in touch with reality. How can he remain so strong and so worried about everyone else when his world is crumbling around him? How can people still be so kind to me when we just failed to save their family member? Regardless of all the hate and awful things happening in the world, these are the people who give me hope and confidence in humanity. I wonder how they are doing today. This was a terrible, awful day and I’m sure I’ll have many more of them in my career. As complicated as the pathophysiology and pharmacology of the job can be, learning to cope emotionally in these situations will be something I continue to struggle with the most. I guess that being a nurse is knowing when to turn on your “tough” and when to turn on your “human” and finding the balance for those in need. Maybe these days will hold less of an impact on me as I mature emotionally and experience more cases, but regardless of these internal struggles, I feel so privileged to play a role in them.

 

 

 

 

 

* The photo I’ve attached has been floating around the Internet and depicting the “human” side of nursing. I’m not sure of their exact circumstance when this was taken, but I find that the humility and raw emotion that it displays is nothing short of intoxicating.