From a nurse's perspective... [View all]

[babylonsister]

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It’s 5:15 am and my alarm goes off. I sit up in bed and wipe my eyes and sigh. The sound of that alarm indicates the start of my 14 hour day. Time to wipe away any signs of grief from yesterday’s shift.

Yesterday’s shift, was something to grieve over. I started yesterday’s shift, just as I’ll start the one today. Alarm going off at 5:15am. Brushing my teeth and tucking my hair into a “I can run a marathon” tight pony tail. A hair do I know will survive what this 12 hour shift ahead of me will entail. I slip my scrubs on. Then apply some eyeliner and mascara that is sure to be gone and never retouched in a couple hours.

I arrived to work. Read our assignment board and write my name down next to two numbers. These two room numbers signify the two lives I will have in my hands for the next twelve hours.

In yesterday’s case it was just one. Just one because this patient was so sick that she was in need of one to one nursing care. I walk over to the night shift nurse, who I am relieving, and instantly read the worry on her face. She is bent over the flowsheet writing. Every three minute vitals in this patient’s case.

I take my gaze from the night nurse to my patient’s room. I see a face. A face with a 7.5 mm/25 cm tube inserted in her airway. I follow the airway tubing to the machine on her right that is breathing for her. I hear the all too familiar whoosh of the ventilator delivering her every breath. In front of the machine breathing for her, I observe the device doing the job her failing kidneys can no longer do. I watch the circle of blood leave her artery, run through the circuit of the machine, then return the clean blood to her tired body.

Then a quick gaze to the left, I see the ten iv pumps neatly aligned on the pole. The ten medications that are sustaining her every organ, because the septic shock has made them all so weak.

I then hear the all to familiar sound of the monitor alarm. Then my eyes see the flashing numbers in red. BP 60/40. I take a deep breath and sigh. That’s not good. Then most importantly my eyes gaze to my patient’s hands. They are entangled with another set of hands. A man’s hands.

I look at his face. I observe the tears rolling down his eyes and a box of tissues resting on a chair next to him. I take my second deep breath. Time to listen to report and find out what my next 12 hours will look like.

Septic shock. CRRT. Vented. Levophed. Vasopressin. Sodium Bicarbonate. Epinephrine. Zosyn and zyvox for antibiotics. Vitamin C and Thiamine. Heparin. Insulin. Propofol. Fentanyl. Then I listen to how this all came to be. That two weeks ago everything was fine. The woman in front of me was a healthy wife, mother, and grandmother.

Now a deadly bacteria is swarming through her bloodstream. Taking over every organ and body system.

I finish the bedside report and take my third deep breathe of the day. I know when I step into that room that I wrote my name down next to, I am starting a battle. A battle that I too often cannot win. A battle of life and death. A battle that ways heavily on my 24 year old shoulders.

So I put my battle face on and step in the room willing to give this patient and her family, my all. Now I must try to rely on my four years of education, two and half years of critical care experience, and my critical thinking.

I must do this all after I introduce myself to her husband and hand him a tissue to wipe the tears off his face. I must do this after hearing how he can’t believe he just signed a DNR for his perfectly healthy wife as of two weeks ago.

I touch his shoulder softly. Explain how sorry I am that I’m meeting him under these circumstances but that I will do everything I can for his wife.

I quickly increase the dosing of my medications after my latest blood pressure. I approach the Resident almost instantly with a list of my concerns and needs to try to save this patient’s life.

He agrees with me that an Arterial Line is needed. I am in the room as he gains consent from my patient’s husband. I calmly explain to the husband that he will have to step out for this procedure but that I will grab him from the waiting room as soon as it is over.

I then quickly gather and ensemble the Arterial Line set up. Then I throw on a sterile blue hair cap, and mask. I bring my flow sheet inside the room as I know every three minute vital signs are still required to monitor my patient’s every number appearing on all four of my machines.

In the midst of writing every number I see on all four machines, I now operate as a scrub nurse. Sterilely handing the doctor every tool he needs to successfully complete the procedure. We attach the arterial line and my head shoots to the monitor.

I take my fourth deep breath of the day and sigh as I realize the critically low cuff blood pressures correlate with the arterial line. The patient is now on 100 mcg of levophed. Her bp is still only 70/30.

I quickly clean up my patient. Wipe away the blood from her wrist and any sign of trauma that may alarm her family further. Then as promised I call her devoted husband back to her bedside.

I then start drawing the eight ordered labs from her. I quickly label them and send them to the lab as I know they will not be good. I then call my nursing assistant in the room to help me turn and bathe her.

My nursing assistant is my life saver. She walks in and instantly my anxiety is slightly relieved as I am reminded that I am not in this alone.

I look at every piece of skin head to toe on my patient’s body. Making sure there are no signs of breakdown. Then we clean her naked body while preserving as much dignity as possible.

I call her husband back in the room. I’m now on 125 mcg of levophed. I comb my patient’s hair and look at her pale skin. My fifth deep breath of the day is when I start to realize that she is slipping away despite my best efforts. And that time is not on my side.

I briefly step out of my room, only to be handed six slips of paper with critical lab values. PH 7.1, BICARB 8, WBC 50. I run to the MD to quickly report the values. I witness the first sigh from the doctor. “She’s not doing well, we need to talk to the family”. Those words that I’ve heard too often before.

I watch my attending go into the room. Her son from Georgia has now arrived. Suitcase still in hand. I watch my attending sit down and next to her family and deliver the news. I listen with a sinking feeling in my stomach as he states the words “she has a very little chance of survival, there is not much more we can do”.

But my heart cannot be heavy for too long. An iv pump is beeping that holds one of the life sustaining medications. I must quickly fix the pump before her blood pressure starts falling. Then, another alarm on the monitor. Blood pressure 59/35. I quickly titrate my levophed to 150 mcg. And max out my bicarbonate drip by the doctors order.

I take my sixth deep breath of the day, knowing that there is not much more room to go up on the life sustaining medications. I listen to the plea from her husband to try to keep her alive, so that her son from Ohio can see her. His flight gets in at 2:30. It’s 1pm.

My heart sinks as I know despite my best efforts, that may not be possible. It’s time for me to draw my next set of labs. I do my work quietly as more family members arrive and are faced with the horror of the illness that has taken over the person they love the most. I quickly run to the supply room to get more tissue boxes and chairs for family members.

It’s 2pm. I take my first sip of water since 6am . And quickly down a snack size bag of pretzels in front of my patient’s room. I’m now on 200 mcg of levophed. There is no more room to increase the dosage. I am maxed out. My bp is 73/40. Not good, not good by any means. But I hold on to enough hope that it will be high enough to buy us time for her son to make it to the hospital.

My labs are back. Ph 7.0 BICARB 7, WBC 55. I am losing the battle, I was feared to lose. I look at my patient. I wonder what her eyes looked like when she was healthy and full of joy. I wonder how her mouth, now covered by a tube, looked like when smiling during her happiest moments. I wonder all of this while watching her skin fall even paler.

It’s 3pm. Her eldest son has made it to her bedside. He collapses over her almost instantly. He mutters words of disbelief and shock. His father, who is just as broken, lays a hand over his shoulder in an attempt to comfort him.

It’s 4 pm and I start to see my heart rate fall. My blood pressure is now 59/38. It’s time to get the doctor. Time for the discussion that no family every deserves to hear. I take my seventh deep breath of the day. I listen to the attending tell my patient’s family that she is not responding to treatment and there is nothing more we can do.

I hear him talk about the all too familiar comfort care. And hear him say we will make sure she is comfortable and will go in peace with no pain. I watch her husband and sons shed more tears but shake their heads in agreement. I turn to make what feels like a very long walk to the desk to pull out a hot pink paper.

A paper that will be signed allowing us to stop life sustaining treatment. A paper that signifies the battle has been lost despite my best efforts.

I quietly walk into the room and start explaining how everything will happen. I explain how I will first hang the morphine drip and increase her fentanyl (pain medication). I then ask if they want the breathing tube removed. I go on to explain how I will turn off the monitor so nothing will alarm. No noises are needed. I then explain that I will turn off all medications that are sustaining her organs, as well as any machines.

“How long they ask”, “Not very I reply”. I go on to explain that it will be quick and peaceful because she is requiring so much medical intervention at this time. I watch her husbands face drop. I feel his heart rip into a million pieces as he has to say goodbye to the love of his life.A woman he built a home and family with.

I tell the family to take as much time as they need until they are ready. I quietly close the curtain and prepare myself.

I’m called in by the family a little while later. We’re ready, they solemnly say. I instantly hang and administer my morphine drip and increase her pain medication. I have lost the battle but this I can do. I can make sure she leaves this world in peace without suffering.

I then turn off every alarm on the monitor so nothing will sound. I then blacken the screen, so my family does not have to see any numbers on the screen.

After delivering a morphine bolus, I then slowly shut down every life sustaining medication. My stomach drops. I know this will precede to her death.

I tell the family for the tenth time today just how sorry I am and that I wish I could do more. I offer to put on pandora to play some of her favorite music. Frank Sinatra is requested.

I close the curtain and step into the empty room next door to bring up my patient’s HR and EKG. I watch as my heart rate starts to slowly drop. 80, 70, 55, 40... I watch as a normal heart rhythm faded into a course zagged line. I know what this means.

My patient is gone. I take my last deep breath of the day. But this time it is followed by a tear streaming down my face. I must now go tell the family the news.

I quietly walk into the room and utter the words “ I’m so sorry, but she’s passed away”. I listen to the cries of disbelief. The horror as my family realizes they have just lost their wife, mother, and grandmother.

I tell the family they can spend as much time as they need with her to say their goodbyes. I then walk over to a physician to call time of death. I write the time of death on my flowsheet. And wrap up any other remaining notes detailing the circumstances of the shift.

I watch my tear covered family exit the room. They hug me and thank me for all my efforts. I once again tell them how sorry I am and that I wish there was more I could do.

I then grab my nursing assistant and start to wash my patient. I comb her hair and take out all remaining tubing. For the first time I get to see my patient as she is. Free from tubes and wires.

I see her green eyes. The way her lips fall. The heart shape outline of her face. I see her in that moment, for exactly who she was before entering my ICU doors.

I then wrap her body. I tie the toe tag across her red polished toe. I fill out all the necessary death paperwork. And for the first time at 5pm I sit down.

I try to absorb the reality of the devastation of the past ten hours but I can’t for long. “Grace there’s a RR being booked for your empty room next door”.

And I’m forced to snap out of it. I put on my second suit of the day.

But now it’s Tuesday at 5:15am. It’s time to get ready for my second shift. So I do what I always do. I’m out the door by 6:30 am and walk up to the assignment board and write my name down next to two more numbers, two more lives.

These lives can’t know about yesterday or see any part of the damage I still feel. They can’t know that I lost sleep thinking about my patient’s family watching her slip away. No. These patients will not see that Nurse.

So I walk in with a smile on my face, an introduction to who I am and that I’ll be their nurse for the day, and write my name on the wipe board.

This is the reality of a day in the life of a Nurse, Senator Walsh. Anything but a game of cards.

*lab values, genders, medications, and other details were altered to protect patient privacy*ss