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Monthly Archives: November 2014

You can’t save them all

[Content note: it’s 2:00 am and I’m on a plane and I have had a total of three hours of sleep in the last 36 hours and outside view says I am probably not coherent.]

I went out for breakfast with a colleague after my last night shift (one of the silly decisions that led to the three hours of sleep). It had been an awful night for her–struggling just to keep her patient alive till the morning, the new and inexperienced resident scared shitless, basically every nurse on the unit hanging around the room staring at the monitor. Once you’ve been an ICU nurse long enough, there’s something fascinating about a blood pressure of 60/40 and sats of 81%, and it becomes hard to stop watching it.

 

The patient died at 7:45 am, and she finished the obligatory charting, and we went out and ate a huge greasy diner breakfast and drank endless decaf coffee, and we told all the most horrific stories of our respective work experiences, and we laughed. We weren’t as loud and disruptive as a group of five nurses post night shift will inevitably be, but we laughed, and then we noticed we were laughing about horrible things, and felt bad. But it’s a coping mechanism, an absolutely necessary one, and probably a healthier one than alcohol or even diner breakfasts.

 

It got me thinking about coping mechanisms in general, and how I try to take the things I see at work and somehow, some way integrate them into my past, somehow accept them and gain strength from them without having to pull away.

 

And yeah, the things I’ve seen at work have sometimes been awful, and probably more awful for someone with my personality. Ruby says that I don’t have a dark side–I’m not 100% sure what this means, but I don’t seem to have that harder facet of myself that I can rotate into place to survive the things that would otherwise hurt too much. I don’t do indifference, but I also don’t do anger or outrage or hatred, which seem to be the emotions that, although negative, can bring strength. When something bad happens, I feel sad, I feel helpless, I feel guilty…and the feelings demand expression, catharsis, whatever you might call it. I want to feel sad for the person who just died, who was someone’s mother, someone’s sister, someone’s friend. I want to grieve, even if she wasn’t my family, even if I knew next to nothing aside from her name and age.

 

Since university, I’ve accumulated an extensive list of songs, movie clips, and bits of books and blog posts that can make me cry. Often these are songs that I liked but didn’t find all that sad back in high school.

 

Wish I could reassure you/Wish I could talk to you and tell you how I feel

I’ve been very careless/ This I don’t deny

But could we start again please
You surely know I love you/ But something in me stands aside and lets you slip away

Perhaps that’s what you wanted/ Perhaps I want that too
But could we start again please

 

Oh. My. God. Could there possibly exist a sadder song? Something in me stands aside, and lets you slip away… We stood outside the patient’s room at 7:45 am, exhausted after 12 hours, and watched her heart rate drop into the 50s, then the 30s, then just an occasional ventricular beat here or there. Watched the blood pressure go down to 30/10, which at that point is not really a blood pressure anymore, before we lost it entirely. She was DNR and was already maxed on every vasopressor and we were running epinephrine at 20 mcg/min, which was 5x the highest dose on our perfusion table, and we knew there was no winning this one–we had known it for days, really. You can’t save them all.

 

I don’t remember all of my patients, by any stretch of the imagination. The COPD exacerbations and pneumonias and urosepsis cases all kind of blur together after a while. But I remember the patients we lost.

 

I had a lady once for five 12-hour shifts. It was a week of ridiculous assignments: I had two intubated patients every day except the last. She had chronic lung disease, was back in the ICU for the second time that year, on a ventilator, sedated. She was on home oxygen at her residence and probably wasn’t that functional, but she had a friend in the residence who came to see her every day in the hospital, and sat by her bedside to talk to her, and asked me if I knew when she’d be coming back so he could get the room ready. It was one of the sweetest things I had ever seen.

 

She was my ‘boring’ patient that week. I turned her every two hours, sometimes every three or four hours because we were short staffed. I strained my back trying to turn her alone, when I was already late and didn’t feel like trying to track down someone else to help. I put dressings on her inevitable bedsores. I wiped her poop, and splooged crushed-up dissolved medications down her feeding tube, and cleaned her mouth despite her best attempts to bite me, and did the sort of really, really quick assessments that you get good at after a while. I tread the fine balance between ‘way too sedated’ and ‘wide awake and obviously terrified’, and tried to make sure she wasn’t in pain.

 

Maybe three weeks later, after several more four-day blocks of shifts, I had two other patients and was run off my feet and stopped midafternoon at the nursing station to print an ECG strip, and I saw that her heart rate was 30. I glanced over and saw the nurse and RT in the room, and knew immediately that she was palliative, that they were going to take her off the ventilator and switch her to comfort care only.

 

I didn’t have time to watch; she wasn’t my patient. But I did anyway, stood outside the room where she was alone, and watched her heart stop, and I wanted to say, I’m sorry. I’m sorry I called you my boring patient. I’m sorry I didn’t love you more, Fellow human, I want you to know that I know this is wrong, even though it’s the least wrong option. That for the last ten years you were slowly losing your strength, more and more constrained to your long term care room, tethered to your oxygen, and that the last three weeks of your life were spent helpless in a bed, surrounded by machines that beeped constantly, and that now there’s nothing more we can offer you except for a death without pain… None of that is right. We gave you our best, every step of the way, but that doesn’t make it right. I’m sorry that humans still have to get old and die. I’m sorry that I didn’t have the courage to go into the room with you and hold your hand, because you weren’t my patient and it would’ve looked weird and I didn’t have time.

 

…I wrote that, and cried the whole time, which is vaguely embarrassing because I’m on a plane surrounded by strangers. It feels right, though, to cry for a thing that really is sad and wrong and terrible. And the grief I felt, for a woman who wasn’t my mother or sister or friend, wasn’t just about her. It was about the dozens of other deaths I’ve witnessed. It was about all the times I’ve imagined death in all its worst forms coming to my friends and family–and by imagine, I mean really imagine, my brain knows what death looks like and thinks that providing vivid images is helpful. I cry like a baby every time I read Scott’s post Who By Very Slow Decay and it’s mostly because I’m imagining Scott as one of my patients, dying and trying desperately to communicate that he wants to go outside.

 

And yeah, that probably seems really weird to anyone who isn’t in the medical profession. It seems to be one coping strategy among others, similar to the ‘listen to sad songs’ strategy–lean into the sadness, experience it like it deserves to be experienced, and then move forward. Until the next one.

 

(A lot of people have asked me if I’m scared of death. Interestingly, I’m not, at least not for myself. It takes away a lot from the emotional appeal of cryonics…I tell myself “you could die!” and my brain is like “yeah, duh, I know that, hell, I’ve imagined about fifty different deaths I could have and the ripple effect it would have on my family and community, it’s not a nice thought and I don’t want to die but it’s not scary.”)

The Virtue of Abnegation and the Ideal Nurse

“I will be my undoing If I become my obsession.
I will forget the ones I love If I do not serve them.
I will war with others If I refuse to see them.
Therefore I choose to turn away from my reflection,
To rely not on myself
But on my brothers and sisters,
To project always outward
Until I disappear.”

-Abnegation Manifesto

I only saw Divergent recently, and I didn’t even notice this quote at first–the movie is so focused on Dauntless, they’re not trying to make you notice Abnegation. But when I actually read the quote, it resonated with me maybe more than anything else has ever.

My brain runs on virtue ethics. Given this, it’s not surprising that, in my training as a nurse, I tried to figure out what the Ideal Nurse’s virtues were and then emulate them as closely as possible.

As a nurse, you don’t interact with patients as a fellow human being. Yes, you show them compassion and empathy, but you do so as part of a role. And the roles are not equal. The patient is allowed to scream at you, they’re allowed to shit in the bed, they’re allowed to refuse to eat anything all day and then ask for pudding at 4 am. As a nurse, you learn to focus on the needs of others, and keep your own needs outside of the situation.

…I think it hit me, after I read the Abnegation manifesto, how much of my younger self’s conception of virtue was “the Ideal Nurse doesn’t have needs, therefore neither will I.”

I did a lot of not-very-strategic self-modification as a teenager. Making myself useful was one of the common threads (ability to react under pressure, etc) and being as flexible and non-needy as possible was a lot of the rest. I had a mantra, “be like water”, which I think meant something like “absorb any inconveniences yourself.”

This is all well and good–I still think that Abnegation, in moderation, is a good thing to be able to have. I would even like to be better at it than I am now. The problem was when I started building it into my self-identity, started to model myself as someone who didn’t have needs. Because then, when part of me did need something, I couldn’t endorse it–obviously, those voices weren’t really me.

I think this is maybe 80% why I had regular sex for six months, even though I knew I didn’t want it–because I couldn’t let it be about what I wanted, that would be admitting I wanted things.

To a lesser extent, I think this has caused problems with my introspection/luminosity. Even if I thought Abnegation was the be-all and end-all of virtues, it isn’t an accurate model of my mind. I do have needs and wants. I can override some of them some of the time, but I can’t override all of them indefinitely…and if I had to, pretending they didn’t exist probably wouldn’t be the best way.

Fundamentally, the movie portrayal of Abnegation comes across as sort of incompatible with Dauntless (my friend was startled when I claimed to identify with both), and at the very least anti-self improvement. To improve yourself, you need to turn inwards, to look in the mirror; you need to care about your reflection, and want it to be better.

And to really help other people, you need self-improvement; you need to be the strongest possible version of yourself, and that means knowing your needs and desires and meeting all of them in the cheapest ways that hurt others the least.

The Ideal Nurse is a mode, a role. The person playing that role has needs, desires, etc; she just isn’t trying to meet them in her interactions with patients, because she already met them on her own time–and that’s not selfish.