My First Code

I found something I'd written back when my first patient ever coded. It's from November 2008, written the night after this patient had coded and died. I went home from work exhausted, crashed into my bed, but was awakened by nightmares of the situation. I had this "fullness" feeling, like I was carrying something in me that shoved every other thing out-- rest, peace, or feeling connected to anyone else's reality. I decided to get it out the same way I get most of my other emotions out-- by writing about it. I usually journal or pray through my other emotions, but for this, I needed to share it with a nurse who wasn't there: someone who could hear my story and how I experienced it and why it was, now, haunting me. So I wrote to one of my nursing instructors. This is what I wrote to her:

I coded the first patient I ever admitted today, Ms. G. She came about a week after I started orientation on the unit. My preceptor and I cared for her steadily for about 3-4 weeks. After that, I needed to get new experiences, so I had to accept other patients, but I visited her almost daily. I spent a lot of time with her mother, also a nurse, and even when I wasn't Ms.G's nurse, her mother would come over and hug me and tell me how her daughter was doing and ask how I was doing.

My preceptor and I would go to Ms. G's room and have "spa days". We'd tell her family to bring in her favorite shampoo and conditioner, and we'd pull out the green bin and wash her hair FOR REAL (not just with one of those warmed shower caps). Then my preceptor would braid her hair while I got the room in order. Ms. G had very particular and orderly taste... she could be downright persnickety at times! The unit started referring to her as the CCU Princess because my preceptor and I gave her such special treatment. We'd lotion her with her favorite Ann Taylor lotion, and organize her bedside table exactly to her liking. When she started getting better, but also lazier, we created a daily schedule for her that incorporated specific times for her to get out of bed to the chair, times when she would be on pressure support rather than a breathing rate on the breathing machine, times for physical and occupational therapy to come, and even times for the massage therapist to come at the end of the day. (We'd jokingly made a deal that she had to earn her massage by doing her homework and sticking to the schedule). It was a great experience in interdisciplinary collaboration and individualized care that allowed us to plan to give her pain meds before physical therapy, time for a nap before her pressure support trials, etc.

I knew she was getting worse, but I didn't expect her to die today. I walked out of my patient's room and heard her nurse yell, "Get the code cart!" and I couldn't believe she was standing in front of Ms. G's room. My preceptor knew I needed experience in Code 12 situations, so she told me to get over there. Initially, I was the "med pusher", where I stood at the head of the bed and pushed meds through her central line while yelling out their dosages to the person charting the whole event. As we started doing CPR, one of the nurses asked the doctor to let me do the compressions for the experience. I did my first set of CPR ever today. It was surreal. I was doing what I'd always seen on TV and prepared for in school, but I wasn't scared or nervous... it felt very natural. I started feeling proud of myself for handling the whole event so well!

A doctor took over compressions when I got tired, and then we stopped for a moment to see her heart rhythm. Pulseless Electrical Activity... PEA. Nothing was there. The doctors pronounced her dead.

Somewhere between being pulled into the code and pronouncing her dead, I forgot who the patient was. I was totally task-oriented, completely immersed in what was happening rather than to whom it was happening. When they pronounced her dead, it all came stampeding back to me. I saw her mother approach her crying, kissing her forehead. I lost it. I had to get out of that room as quickly as possible, but the world moves in slow motion when a death takes place. I held my breath as I waited for doctors and nurses to file out of the room. I was suffocating. I ripped off my isolation gown and quickly walked to the bathroom where it all came out. I couldn't believe she had just really died. I couldn't believe I had just felt proud of myself! I felt guilty and overwhelmed and very isolated. I knew that none of my friends had just felt a woman die. They were all in offices or in graduate school, reading and going to meetings and complaining about their bosses. I just physically sustained a non-beating heart, and watched the decision to stop it all. I just watched a mother lose her daughter. I've worked it the hospital for 3 years now and today was the first day I've cried there.

I will interrupt at this point. This is how my morning felt that day. Even after the code and crying, I felt like I couldn't catch my breath-- like when you are trying to get your ears to *pop* and just want to take in a good deep breath. I couldn't breathe in deep enough. I felt heavy. I felt like you feel in an air plane when the cabin pressure isn't quite normal... I literally felt the atmosphere around me.

But that didn't last all day.

What happened next was amazing. My whole unit was very supportive of me, encouraging me on the "good job" I did in the code, asking me if I needed to take a break, etc. When things settled down, a few of us found ourselves in the lounge drinking coffee and mulling over the event. As the conversation progressed, we started telling our favorite "Ms. G stories", of her sassiness and strength, her family and her resoluteness. I said that I felt like she would stay with me for my entire career as the first patient I'd really grown attached to... and then, one by one, every nurse told me about their own "Ms. G". Many of them were patients from the CCU, so other nurses could join in on talking about those patients and their personalities. Everyone had their own version of my Ms. G.

I told her mother what an impact her daughter will make on my career as a nurse. Because she was a nurse, she knew what I meant by that, and she was very thankful for it.

I feel like I've really experienced the heavy privilege of being a nurse; daring to care for people and risking the potential for grief. And each of those more-experienced nurses had stories just like my Ms. G, but they told them with laughs and contented smiles and a gentle attitude of thankfulness for the experience; the privilege of caring.

I've shared my feelings about being a nurse on this blog before, and to many of my friends and family. I know that, for all of its lifestyle difficulties and absurd personalities, I'm incredibly blessed to be in a job I feel called to do... in a job I feel God created me to do (for now, at least). There's a movie, Chariots of Fire, about an Olympic runner who is a Christian, and at some point in the movie he describes why he loves running: "I believe God made me for a purpose, but he also made me fast. And when I run I feel His pleasure." I don't always feel God's pleasure when I'm at work, but I do feel it sometimes. And in that moment after Ms. G died, when I felt alien to the atmosphere around me, I think I vaguely felt what God was feeling then, too. Not pleasure, but grief, like when Jesus wept after Lazarus died. He knew he was on his way to bring him back from the dead, but he experienced the grief of human loss all the same.

And after the code, sitting among others who had lived through their own heavy days on the unit, I think I felt His pleasure. And now after 2 years of heavy days and joyful days, I see the arch of His emotions even better. His pleasure isn't always there, but it doesn't leave me for long.

Monster

There is a patient who came with the report that he was a "real charmer", with a glossy sarcastic tone. His story says it all: he has a drug history, including present use, and had a major heart attack while committing a crime. Ironically, it's lucky the police sought after him, otherwise he likely would have had the heart attack and accompanying cardiac arrest alone somewhere, doing drugs or passed out. The police involvement may have saved his life.

This was the report the unit received. He came to us intubated, all 4 limbs restrained, and on high doses of sedation. Per report, when he "woke up" from sedation, he became "a wild man", trying to pull out his breathing tube and fighting to hit or kick anyone near his bed. This is what necessitated the restraints and the heavy dose of sedative. This is all we knew about this man.

By the time I came to care for him, he had been extubated and his sedation was wearing off. He was beginning to show some personality, something most of us were dreading. "I'll bet he's a peach!", the nurses would add, giving me a "best of luck" look as they left. Truth be told, I was hoping he'd sleep for most of my shift so I wouldn't have to interact with The Monster.

It seems harsh to characterize a patient as a monster. After all, our patients are critically ill and usually desperate for good news or a sense of control. This context rarely brings out the good in people... desperation is an ugly color on anyone. Politeness and patience aren't commonly shown by even the most "civilized" patients in the early recovering stages from a major heart attack or arrhythmia. Gratitude and understanding may develop later, but we don't expect it at first. From this Monster, I didn't expect it at all.

To my surprise, he was pretty easy to speak with. His sedation (and illicit drugs) were slowly wearing off, so he was often disoriented and agitated/scared, but he re-oriented easily and was generally easy to care for. He didn't want to be in the hospital, and he was very clear about his intentions to leave if he didn't get exactly what he wanted. He used coarse language and yelled most of the time, but he wasn't really unlike many of the other patients that I've had... aggravated from not being able to eat, thirsty for anything with more flavor than "a few ice chips" as ordered by the physicians, and generally feeling caged into his bed without much say in matters. Add the shadow of confusion and residual discomfort from a breathing tube and a sore chest from CPR, and most of my patients express themselves in this way at some point in my care... just with less colorful language and a more mild volume. In fact, he was actually a little less offensive, in some ways, because his agitation was clearly directed at his situation and not the nurse "subjecting him to this", as some other patients imply.

The nurse passing him on to me that night began describing him to me in this way, and I commented, "He's not such a monster after all". We laughed, and she said 'good night' to our little Monster, and she headed for the exit. I slid into his room, finding him hot and sweaty from a fever, and confused (again). I went into his room to turn up the AC, and took off his covers, and offered to order him a fan. He grunted something obscene, and kept looking at his bed.

I went to his eye level and said, "Do you know where you are right now?"
"No." ... and some other expletive.
"You're in the hospital."
"I know that!" ... another expletive.
"Do you remember why?"
"No." ... you get the picture.
"You had a major heart attack. We had to restart your heart and give you a breathing tube. That's why your chest and throat are sore."
"Why am I so ** hot?!"
"You have a fever from an infection in your bladder and in your lungs."
"I had a heart attack?"
"Yessir."
"How did I get here?"
"The police found you and called an ambulance and revived you. The paramedics brought you to us. You've been in this room since then."
"The police found me?"
"Yessir."
"What do we do now?"

... I went on to tell him about all the different options. He scoffed at all of them, saying he hates doctors and doesn't want to stay here another minute. I did my usual song and dance about the necessity of staying in the hospital "a little bit longer", or else he'd leave and get sicker and have to return to a hospital for even longer, if he lived to return at all. Sounds harsh, huh? It's a reality. We see it again and again: patients who "hate doctors" and ignore chest pain until they can't breathe anymore and pass out... and usually end up with some degree of brain damage and/or need a major operation. This reality check usually helps with patients, but my Monster didn't care for any of it.

"There's no way I'm coming back after I leave."
"You have a lot of medicine still in your system, so it's not safe for you to leave yet. And you have two major infections that need to be treated or they'll get worse."
"I don't care. I won't come back. I'm just like that... I don't go to doctors."
"With all due respect, Mr. X, you didn't come to the doctors this time... you died and someone brought you back and here you are."
"Well that won't happen again."

I didn't pursue that response... what won't happen again? His heart stopping? Someone finding him? Him finding his way back to the hospital, conscious of it or not? None of these options sounded therapeutic, so I just let it go. At this point, because of the crime he committed and the medicine/drugs still in his system, he wouldn't be allowed to leave the hospital anyway. But I wouldn't tell him that. Again, that didn't sound like therapeutic information.

Reading through this conversation, I'm surprised at myself at how sympathetic I've become towards him. Again, he's not unlike many of my patients that come in with similar health issues. He just come in with a juicy story and sordid reputation in addition to his run-of-the-mill health crisis. But it was so easy to think of him as a monster when he was sedated and intubated, occasionally lashing out (not consciously), but otherwise totally unable to interact with the staff or show us his personality. When the opportunity to see his personality came, even his noxious language and demeanor couldn't obscure the Truth that he was a human being sitting in front of me, not a monster. He effortlessly transformed, in my mind, from a body to a person; a history to a story; a situation he survived to an experience he endured.

This may not be a universal perspective, but I know I'm not alone. People love movies and TV series about "the bad guys". American Gangster. Boondock Saints. The Sopranos. Goodfellas. Even the Ocean's 11/12/13 movies. All about bad guys with a heart of gold... or rather, a human heart. All about bad guys with underlying situations and pressures that explain their misgivings. All about bad guys who are conflicted and fighting with themselves... their "lesser demons". There's a new show on HBO about to premiere, Boardwalk Empire, set in Atlantic City at the beginning of prohibition, following the corrupt characters that profit from the radical law. I cannot wait to see it-- it looks so intriguing, and I know that I will be swayed to adore these characters which manipulate and enslave and abuse others for their selfish gain. I love knowing that I'll walk into this series disgusted with their behavior and lack of ethics, but will end each episode with a softer heart for them, until eventually I'll be cheering on their evil-doings because I want to see them succeed and be happier; and probably rooting against the "good guys" trying to shut down their operation.

I'm not cheering for my Monster's resolve to leave the hospital or to evade the police. But I do love that I feel a little more sympathetic for his situation. I love that, by the end of my shift, we were discussing his son and how he adores him and how his son thinks the world of his daddy. He showed me his tattoo for his son, and he softened when I asked him if he wanted to live long enough to watch his young son grow up. We talked about how he hates feeling confined. We talked about how after I leave at the end of my shift, another nurse will take over and propose a lot of the same things I've been talking about-- further care of his heart to prevent this from happening again. And he looked a little sad at the notion that I would leave him and someone else would take over.

I went into his room at the end of my shift to say 'good bye' and to wish him luck with whatever decision he made. He had already fallen back asleep. And like most sleeping people, he didn't look like a monster.

Security & Significance

I heard a sermon today that mentioned, in passing, that people are always looking for security & significance. This is the motivation behind people's ambitions, fears, standards, and goals: establishing some form of security and significance. This wasn't the point of the sermon, but in typical-Jenn-fashion, I managed to hear this one line and have it transport me immediately to my patients. I thought about it on a personal level, too, and quickly came up with a list of a dozen fears and goals motivated by gaining security and significance for myself. But I mostly thought about how often I recognize this in my patients, and how often I unknowingly try to appease or appeal to this motivation.

One of my favorite parts of working in an ICU is that I feel like I see people at a very raw state-- totally scared of a diagnosis, totally grateful for a treatment option, etc. In the rest of my world, people express emotions on a more muted scale, not wanting to be over-dramatic in fear or appear to be gloating in joy. But that veil doesn't appear in the ICU-- there's no energy for it. People leave the "socially accepted approach to sharing emotions" at the automated doors of the ER. What's left is a near-raw form of a human, untainted by learned social boundaries. And seeing a sliver of the population in a raw state sheds light on the rest of the population with whom I engage. My patients show a desperate yearning for security and significance, which is no different from "regular" people... it's just more obvious. EVERYONE is seeking security and significance.

(I'm not saying it's wrong to seek these things... I'm not even hinting towards that. The sermon just made the point that what determines how you define security & significance is what will harm or heal you.)

People seeking significance is easy to see in everyday life: wanting to be treated respectfully; not wanting to be just "a number" or "a statistic"; wanting to be unique and admired among colleagues and peers. And it's easiest to spot this desire when it is being threatened-- someone being rude to you and how you respond indignantly; people staying in jobs they detest for the coveted title or opportunity to leave a legacy; even titles like "best friend" or "one true love" indicate ways we appeal to people's desire to be stand out apart from others.

People seeking security is sometimes harder to identify. These ways are kept more subtle, not wanting to "show our cards" for fear of losing their value. But it's there, nonetheless: in how we save or spend money; in which relationships we keep or let fizzle away; even in how we fill up our schedules or claim our free time and hold it tightly. The primary motivation may be difficult to obviously see, but it's deeply there.

If in the real world people's motivation for significance is more obvious but their desire for security is less pronounced, how interesting that it seems to be the opposite for me in the hospital. I recognize both motivations in my patients, but the difficulty in soothing the fears related to losing significance is far harder than soothing the fears related to losing security. Let me show you.

Security: I can reassure my patient that my ICU is exceptional in caring for critically ill patients. I can assure them that we know how to identify issues and how to respond to them appropriately. I can declare that, even when the doctors and I aren't in their room, we are often doing a lot of work related to helping them move towards their health and comfort goals. I can promise them that I care deeply about their pain and relieving it; I can promise to return after 30 minutes to assess how their pain is responding to medications I've given; I can promise that my knowledge of pain management is extensive and that I have many safe methods of pain relief available to them. I can promise to explain things to them to the best of my ability, using videos and pictures, to ensure their understanding. I can pledge to take every reasonable precaution against exposing them to infections or allowing them to accidentally fall, to prevent allergic reactions or causing unnecessary pain. I can guarantee families that I'll call them with updates if anything changes, and I'll promise to be equally diligent in my care, even if they aren't at the bedside "reminding" me.

Significance: Oh dear. I don't even know where to start! This is where people want to stand apart form others and have unique value. I can promise my patients that, during my shift, they are my foremost priority. But the reality is: when my shift ends, so does my compulsion towards them. The reality is: whether that patient dies or improves enough to be discharged, there will soon be another patient in Room 4126 who will become my priority, and another patient after that, and another after that. I will care for, on average, 10-18 different patients per month. So, when my patient seeking to have significance is assigned to me, they are my priority... until 7pm shows its face or that patient evacuates my room. That seems to be a pretty short-lived significance.

Just because they stop being my assignment doesn't mean I never think of them... of course I do! This blog proves it: interactions stay with me, episodes of raw emotions are burned in my memory, and miraculous healings or devastating downturns remain with me longer than I'd like, at times. I remember names and faces and quirks about many of my patients. But how do I assure them of that, without naming a dozen other patients that have significance to me? Telling someone s/he is significant by identifying my hefty list of other "significant" people belittles the designation.

I have no fears that I actually consider patients insignificant. That is ingrained in me, so deep that I can't really identify where I got the notion, but the weight with which I respond to that notion testifies to how fundamental it is in me. Let me show you again.

While I was in nursing school, I had a conversation with a few friends about the eccentricities of being a nurse. One girl, another Christian in the nursing school, made the comment, "What good is it to help these people if we can't preach to them about the Gospel? Why bother helping their physical bodies if we can't help their souls?" I was disgusted. DISGUSTED. Why bother?? Because everybody is valuable, that's why! People don't deserve my attention because I can "save their soul"-- they deserve my attention because they have a soul! The image of God in all of us; the fact that every good thing comes from God whether the recipient believes that or not; the truth that Grace is offered to everyone, not just those who will accept it or those to "earn" it... these are things that are common to everyone, just like the yearning for security and significance. And because of that, because His imprint and His gifts are distributed to everyone, we are called to love everyone. People aren't projects-- they're image-bearers. And there is innate significance from that fact alone.

But how do I show that to my patients? How do I show them that I love them because they merely exist and are in my presence?

One thing I do know is that I can prioritize recognizing their significance over asserting my own significance because my significance rests securely in Christ: I don't have to assert it 24/7. I can strive to offer security by honoring my promises, and by continuing to love and care for and forgive people despite their faults. But I also know that my significance doesn't come from my ability (or, more often, inability) to keep these promises perfectly. Nor is that the source of my security. My security and significance come from promises that have already been fulfilled and other promises He will faithfully keep. As long as I try to remember that Truth, I can try to help others recognize it for themselves, too.

In the meantime, I guess I'll do the only thing I know how to do for my patients: give them my full attention. That's what everybody deserves, afterall.