A Little Late, But Right on Time.

I moved from Nashville on November 21. Since that time there has been Thanksgiving, starting a new job, a major ice storm, Graduation, Christmas Break, the death of a friend, the beginning of the semester, and a weekend with DHS.

Despite being two weeks into the spring semester and despite having moved to start a new job over two months ago, I hadn’t lectured a single time until yesterday, January 27. I lectured twice, in the morning and in the afternoon.

I suppose I have been waiting for yesterday for years. Realizing as a college student that I eventually wanted to be back in the classroom, though, on the other side of the desk. I wanted to talk, to lecture, to engage minds in learning. But I wanted experience, I wanted time and personal investments to bring to the classroom. I didn’t want to be an inexperienced teacher who had little to offer.

There are some things that are second nature. Lecturing feels like that to me, but then maybe it’s just genetic.

I’ll have to admit though, I’ve had a lot of anxiety about walking away from the hospital, from the ICU. I frequently think about my “regular” schedule and still find myself trying to adapt.

ICU work is second nature, too.

I lectured yesterday. I taught students in a University yesterday. I did well. I enjoyed it.  

And no one died. Nice to have a job where no one dies.

Adaptation takes time, but all I have is time.

Blessed.

Granny Nanny

She’s been old all my life.

Funny how you see things, smell things, live things every day, but they don’t always directly affect you.

I don’t know my patients. They are who they are when they present to me, they are not who they were before they did.

Yet, today was different. She was not who she presented to be, she was the shell of the woman I have always known. The old woman who always had a smile and a twinkle in her eye, a twinkle that seemed to become more mischievous the older she became.

“She smells today.” My mother noted.

I know that smell. I smell it every day. But not here. I do not know it here.

She had trouble opening her eyes. When she did she couldn’t see clearly. Couldn’t hear. Couldn’t understand what she saw, what she somewhat heard.

She kept asking who I was, she thought I was Chara, the one with the boy. I didn’t correct her.

Her hospice aid, Gigi, came and bathed her and gave her excellent care. She knew her. She said she was her pal.

Funny. I take care of perfect strangers all the time and here was my own, lying in her bed, on hospice, and I was watching her pal, Gigi.

I went to the kitchen and listened as the hospice nurse explained to my great aunt about the medications in the hospice kit. This is for this, this is for that, this helps with this.

Funny. I was hearing a lecture about medications I give regularly.

It was time to leave.

I went and sat on her bed.

“I’m ready to go, but I guess the Lord isn’t through with me yet”, she said. I smiled.

“Are you Phil’s?”

“Yes,” I said, “I’m Tara”.

“Oh, you have a boy”.

“No, that’s Chara, I’m Tara”.

“Oh”. She smiled. “That’s right, that’s Chara”.

And there was that twinkle. And for a moment she knew who I was. For a moment I was Tara.

I rubbed and patted her back.

“Oh, that feels good. I may go back to sleep,” she said.

I kissed her head and rubbed her back and looked at the body of my 104 year old great-grandmother.

Funny when the patient is yours. When the patient isn’t a patient. Funny to know who she was and not who she is.

“I’ll see you later” I whispered.

And left her for probably the last time.

Beginning and End

I found myself standing at the foot of the bed, wondering about the day of their birth.

I wondered what the mother thought, how she felt as she held that new life in her arms. I wondered if she was full of joy and hope and excitement for this new life. I wondered if she, like Mary, had a song in her heart.

I wondered if there was a father in that room, smiling at the scene. I wondered if he bent down to kiss the crown of that head. I wondered what he felt.

I wondered because I found myself standing at the foot of the bed on what would be the day of their death. There was no mother, no father, no siblings, no children. There was no family for this life, this soul.

We waited until our shift was settled and then we went to our work. We: the nurse, the respiratory therapist, and me. We were the sole people surrounding this life who now lay in the bed.

I took the tube from the mouth and we stood there. We watched the rise and fall of the chest. We watched the monitor reveal the heart beats. We didn’t want her to be alone.

We waited.

My phone rang. Another patient needed something and I left the room.

I became busy.

My phone rang again. It was the nurse. The patient was no more.

I again found myself at the foot of the bed. I donned the stethoscope. I listened a final time to the chest. There was no rise and fall, no heart beat. I pronounced the patient, reported the time of death.

And then it was done. The life was over.

I stood alone in the room with the patient and wondered the course of their life. Wondered where the family went. Wondered where this body would go.

Hours later I passed the room: it was clean, the lights were on, the bed was made. It was waiting for the next life to come, as though the other had never been.

But it was. I remember.

Combat Zone

We were trying to do emergent procedures in two rooms, three other rooms were actively crashing, and a patient down the hall was in acute delirium.  The night was hellacious.

It never stopped.

It has been like this the last few weeks.

One moment we were coding a patient, the next I find myself alone, with their child, in a waiting room, telling them that they had died.

Another moment it seems like a blood bath. Attempt after attempt after attempt after attempt and then finally success at the Seldinger technique.  

Blood pressures bottoming out – pressors, fluid, pressors, fluid?

Rising lactate levels: 11, 14, 7. Mortality risks rising comparatively.

Rapid Response. Rapid Response - ICU Transfer. Rapid Response. Rapid Response.

“X wouldn’t want to live this way”. I find myself standing alone with the family. We withdraw heroic measures and introduce comfort care: ativan, morphine, extubate, pressors off. Death rattle, death rattle, death rattle. . . . death.

I’m not sure whose blood is on my scrubs.

At times, I find myself under such physical, mental, and emotional stress that it is like I’m in a combat zone.

When I was done with work on that third morning that is exactly how I felt: as though we had been in combat all night.

The stress can be addicting. I was off that fourth night, but I offered to work. I didn’t, though.

After hours of day sleep I was relieved; the extreme exhaustion had finally hit. It was a church night anyway. I got dressed. I left the house with my exhausted mind and body to be around “normal” people and smile and be polite and sing. But I found myself driving to the grocery store, buying milk and heading home. How can one be around “normal” people when they don’t feel “normal”.

It is now days later. I went to church this morning. Time allowed me to be “normal” again. I’m going back in tonight, re-entering the combat zone, or maybe just a quiet boring night.

Oh the ebb and flow of the ICU.

Someone Will Always Be There

It never stops. They are always there: the patients, lying in their beds; the nurses, caring.

There is never a time when someone isn’t there, never a time when the unit isn’t fully employed with people actively caring.  

When I’m away I sometimes think about the unit, the patients. I wonder how they are, how they’re doing.

Every unit I have every worked in has patients lying in beds at this exact moment with a full staff of nurses caring for them. They have never stopped.

It’s daunting sometimes to think about, to know that it will never stop, that they are always there, that there will always be a need.

Weekends, night time, holidays, Saturday morning, Thursday afternoon, Monday night, Halloween, Thanksgiving, Christmas, the Super Bowl. There is never a moment when there is not a need.

There is a responsibility of those who know to teach those who don’t know, this ensures that someone will always be there.

Teaching allows me an opportunity to always be there without having to always be there. Teaching provides an opportunity to create a legacy.

Teaching bridges the present with the future.

So, I find myself coming to a new bridge to cross, a new challenge to meet.

My goal has been to learn and experience and grow so that I would have a deep wealth of knowledge in varied areas of healthcare to share when the opportunity approached and the time was right.

The more I’ve learned, the more I realize how very little I know.

I’m excited about the coming months, the coming semester. I look forward to the spring of 2014 and the promise it brings, the opportunity it holds, the changes it will yield, and the new bridge to cross.

Caffeine and Diphenhydramine

Caffeine and Diphenhydramine

I look forward to the day in which these two agents don’t dictate my sleep/wake cycle, but the sun and the moon do, days that aren’t slept away and nights that are for resting.

It seems as much as life has continuously changed the last few years that it really hasn’t changed at all. For all my doing and traveling and going and learning I’ve really stayed in the same place.

Around the world and back again. But was I orbiting the world or was I allowing it to orbit me?

We had a retirement party for a coworker the other day. I watched the video of times gone by and remembered some of those times from my previous time at Vanderbilt. I wondered what it would be like to be somewhere for so long? I remember what it was like to be somewhere for so long.

I never imagined that my work would become my life. I thought my children would. But my child is furry with four legs, not a red head with two. I so deeply love her, though.

I’m excited about the future, about life, about work. I’m excited about the paths coming up. I’m excited for new experiences, new horizons, and new challenges.

Life is such a gift and I’m so thankful for all that it brings, and all the amazing opportunities I've had.

I am truly truly blessed.

Diary of an ICU Nurse and Why Doctors Die Differently

There are a lot of truths in this article: Diary of an ICU nurse.

And this one: Why Doctors Die Differently

I suppose there are moments when each of us who work in the intensive care setting has to ask ourselves what we are really doing for, or more appropriately, to our patients.

Dying is hard. Watching a loved one die is harder, it hurts.

We are all going to die. How do you want to die?

It really isn’t a joke. We all say we are going to tattoo DNR (Do Not Resuscitate) to our chests. We all tell each other to not let “them” do this to us. Funny though, we are “them”. We tell each other not to do what we do to other people to ourselves. And the saddest part of all is that we mean it.

We don’t want 911 called. We don’t always choose chemo. We don’t want CPR or ACLS. We all would choose to die.

We all would choose to die.

Choose.

There is no failure in death. There is no failure in allowing the natural to occur. There is no failure in receiving one’s fate. Yet we fight it.

Life is a beautiful and most precious affair. The goal is to not demote or negate its beauty. But death is a part of life. And believe it or not, there can be great beauty, great comfort, great peace, and even great joy in a quality death.

Hospice and Palliative care are greatly needed and greatly underutilized options that can help achieve a quality death.

Please talk to your family. Please talk to your ICU team. Please ask the hard questions. There is no reason not to and so many reasons to do.

Clouds of Truth

The clouds have been amazingly beautiful the past few evenings. The temperature has been right. The air has smelled sweet, like Tennessee in the fall. It’s been nice. Peaceful.

I’ve stared at those clouds and the shapes they form and the ease they move with the wind and time. They are stark white against the evening blue sky.

I’ve recently been engaged in a conversation with a friend. A while back we’d had a falling out. Funny though, I didn’t know.

Our perspectives are usually about our self. We read and understand life based on the paradigms we subscribe to or ascribe to. We receive information and then compute it based on our own paradigms. We interpret information based on the world views we have adopted.

Sometimes people share an argument and unknowingly adopt the same side. They present their sides so differently though that you believe you are in opposition to one another when in truth you are the same or similar.

Hard heated talks that become easy and simple and light are a true gift. Friends are a true gift. Reconciliation and communion is a true gift.

Truth is a funny thing. It remains constant like that beautiful sky. But life comes in and people and confusion and personalities and misunderstanding and culture and time and what you have are clouds. Somewhere between the mix of clouds and the beautiful blue sky lies the truth.

 

 

I suppose if you stay with it and watch and wait you may find life in time to be nice. Peaceful. 

Death and Dying

She smiled, that sad knowing smile, then she hugged me.

"Get some rest." I told her.

And then the newly widowed woman rejoined her family and walked away.

Since February of this year I have had 10 friends lose a parent. I've often wondered how that is. How does one lose a parent? How does one keep living? How does one continue to experience life without them?

I do not know the answer to these questions.

In college I once dreamed that my mother died. I remember waking in my dorm room. I was scared and confused. My chest was heavy and tight. I found it hard to breathe. It was a dream. I quietly began to cry. It was a terrifying nightmarish dream. It wasn't true. But for 10 of my friends it now is. I don't understand how they feel. I cannot relate.

Sometimes, I help people die. I help provide a quality death. I walk the family through what will happen, then it does, then they go home. Death really is that simple. It is the effect of death that is not simple.

"Get some rest." I told her.

And the newly widowed woman rejoined her family and walked away. It was 02:00 in the morning. She was going home. She was going to bed. And for the first night of the rest of her life she would get in that bed alone.

How can you "get some rest" when the place you rest is the quiet place that so profoundly tells you he is gone.

I often wonder if anyone will sleep with her. Working nights, those families leave to go home, to go to bed. I wonder if any of them think about the sleeping. I wonder what happens when they leave my unit. I wonder if they wake in the night to find their chest heavy and tight and unable to breathe, only to realize it is a truth and not a dream.

She smiled, that sad knowing smile, then she hugged me.

They always hug me. Why? I do not know them. I will never see them again. I try to say the right things. I stood with them through one of the most terrifying, horrific nights of their life. Over time I will not remember them. I will not remember the families or the patients or even why they died. I often wonder if they remember me, if they see me in their memories; that girl in the room.

But I suppose I hug them too. I suppose we receive each other.  

I think I will stop counting at 10.

Majoring in Minors

It’s the act of focusing on things that don’t matter and forgetting or overlooking the things that do.

I suppose in some ways the act of majoring in minors is probably one of my biggest frustrations. When people get caught up in the politics, the red tape, the outliers, they forget about the point.

Minor things are important, they have a role, but they aren’t the Major thing.

I once knew a nurse who worked on the weekends, but was always coming to work for meetings during the week. She was very involved in nursing protocols, patient management, and overseeing transfer orders. When she was on she would frequently call to let me know of all the minor details involved with her patient’s orders and administrative concerns, but she didn’t call concerning her actual patient’s care or health status.

I found it frustrating that this nurse showed such extensive attention to minor details and very little to the major, or the patient.

One Saturday morning I received a call from this nurse. She called about a patient: some minor detail needed to be changed in the orders, could I please change some of their medications, and when was this patient being discharged.

“Have you seen this patient yet?” I asked

“No,” she said, “they don’t speak English and I haven’t called the interpreter yet.”

I had seen her patient at 6:30; it was now 8:00. She’d been here over an hour and still hadn’t seen her patient.

“Oh!” I said. “Well, your patient does speak English. They need some morning pain medication. I’ve already discussed their discharge plans with them. And I won’t be changing their medication because they’re insurance won’t allow it.”

“Oh.” She said.

The patient was the major.

Details are important. Attention to detail is extremely important. But details are facts about the patient, they aren’t the patient.

The patient needed pain medication, needed to know who their nurse was for the day, needed to be seen, needed to be cared for.

Sometimes life gets in the way and we forget to live it, embrace it. We get focused on work and money and insurance and bills and groceries and … and all those minor details.

Yes, all the details are important. But you have to learn to see through the details to the majors, to what matters.