It’s empty in the valley of your heart
The sun, it rises slowly as you walk
Away from all the fears
And all the faults you’ve left behind
-Mumford & Sons
6:40 am. I had been at work 4 minutes when the PA system announced the MRT on the 5th floor. The night charge hurried off and the rest of the staff scattered to get report. That was the beginning of one of the longest shifts of my life. I wasn’t in charge and had a stable heart failure patient that was waiting on a CABG.
7:15 am. The MRT patient rolled down the hall, another nurse’s admission. She was a newer nurse who was easily flustered so I helped her settle the patient. The charge nurse and I were sucked in for a good 3 hours. I treated my patient, the nurse’s other patient and then went back to helping her stabilize her patient.
10:30 am. ”Kari, you are getting an admission from an outlying hospital.” I nodded and took report. He sounded uncomplicated. 6L NC, 1 pressor, awaiting a heart cath. I set up my room, zeroed my bed and went back to helping the other nurse. I was unconcerned because I was pulling a “princess shift” and would be leaving at 3pm.
11:05 am. ”Where IS EVERYONE!” A doctor yelled across our unit. I left the nurse and jogged into the unit to find one of my favorite critical care doctors directing my patient’s transport team into the room. I took one look at him and then looked at the doctor.
"Anesthesia?" I asked and shook my head. We paged respiratory stat overhead. My uncomplicated patient was purple, tripoding, on bipap and diaphoretic. He was cool and clammy to the touch and his eyes were bulging out with fear and anxiety.
11:15 am. Anesthesia was called overhead and his bed was swamped with doctors opinions and nurses attaching drip and lines, He was tubed, sedated and paralyzed. His heart rate was tachying along at 160, his blood pressure over 200.
12:00 pm. I kicked the last doctor out of the room and we got him prepped for the cath lab. EKG, labs, drips added. His blood pressure starting slipping down so we stopped the nitro drip. He was agitated and thrashing so sedation was increased. Minutes later his blood pressure slipped into the 60s. The cath team arrived and I smiled tersely and asked for them to wait a minute as we scrambled to stabilize him.
His pressure slipped further as we threw up emergent drips. Soon enough he was maxed on two pressors and his BP dropped to the 40s. His heart rate that had been so tachycardic plummeted to 50 with no palable pulse.
12:14pm ” Someone call a code!” I yelled out of my room as my coworker started compressions and we hooked him up to the code cart. The cardiologist somehow wandered into the room seconds after I yelled and he was followed shortly by the critical care doctor. We didn’t call the code overhead- we silently coded him. We followed ACLS and for 9 minutes he flipped between complete heart block, PEA and asystole. He was purple despite the RT bagging him aggressively.The cardiologist looked at the critical care doctor and shook his head. ”We arent making any progress- he has had multiple epis, atropine, calcium, bicarb…I think we should call it.” The critical care doctor nodded. I had just taken my turn at compressions and the next nurse was poised to start. I ripped my gloves off and an expletive escaped my lips in frustration. I had him for an hour and 23 minutes at this point and he was dead. The RT unhooked him from the ambu bag.
"Does he have any respirations?" the doctors asked.
"Agonal" was the response.
"Ok… lets call it." The cardiologist started removing his gloves.
"Wait! He has a pulse!" The critical care doctor stared at the monitor as the pulse ox started showing a waveform again.
12:23 pm. He spontaneously regained a pulse after CPR was stopped. We bagged him, and his color pinked up. His blood pressure rebounded and we emergently shipped him to the cath lab.
His coronaries were clean but he had severe Aortic stenosis and needed an emergent vavuloplasty. His blood pressure slipped precariously close to death many times. I was called to the cath lab multiple times to paralyze him, bring medications and just help out.
15:30 pm. He was rolled back to me with an Impella, 5 pressors, no sedation and more lines dangling out of his body then we could count. I gave up on my princess shift and the hours flowed past as I worked hard to stabilize him. The charge nurse and another nurse helped as much as they could. If there was ever a time for a patient to be singled or doubled- it was then. He was a true trainwreck. I maxed him on epinephrine, levophed, vasopressin, dopamine, neosynephrine and his pressure stayed 80 systolic. He continuously plummeted to the 60s and we gave half doses of epi push from the code cart. The cardiologist basically dropped him and ran away to his next cath.
9 hours. That’s how long I stayed in his room doing everything I could possibly think of to save his life.
9 minutes. That’s how long he was actually dead while we did CPR and pushed life saving medications before we gave up and he didn’t.
59 seconds. That’s how long it took for him to regain a pulse after we stopped.
3 hours and 39 minutes. That’s how long it took them to stabilize him in the cath lab.
9 people. That’s how many swamped him when he returned from the lab.
9:20 pm. That’s when I finally left the unit. 6 hours after my scheduled time to leave.
9 AM. That’s when I woke up today with him on my mind and texted his night RN to see if he had made it through the night.
That’s how many lives he has and I couldn’t help but smile when she said he was still alive and actually doing better. Miracles do happen.
"Kari?" A voice from the doorway said quietly. "You have a minute?" It was the daughter of one of the patients that had been on our unit for weeks now.
I quickly joined her and she smiled apologetically.
"Sorry… Something popped off my mom and the monitor is beeping…" She said.
I smiled and nodded. I entered the room and the patient looked at me smiling. Her bright blue eyes were mischievous and full of forgetfulness. She was suffering from dementia in the midst of many other disease processes. In her hand dangled one of her EKG leads, the source of the beeping.
"Well.. What is happening in here?" I said smiling and putting my hands on my hips.
"Oh, he was just trying to rip my shirt off…" She said nonchalantly, her blue eyes sparkling with humor.
Her husband who had been sipping his coffee and reading the paper choked on his coffee and then started laughing.
"Whoa, whoa, whoa… it is frisky in here!" I said laughing.
"You know it!" The 75 year old winked and glanced at her husband who still sat chuckling in the corner.
I attempted to check my patient’s radial cath site without waking him but was unsuccessful. As he startled awake, he coughed and got short of breath. I looked at him as he took a couple deep breaths.
"You OK? You look like you are short of breath…" I said with concern.
He looked me in the eye and said without jest.
"Honey, that’s because I am old!"
I couldn’t stop laughing.
But if you close your eyes,
Does it almost feel like
Nothing changed at all?
And if you close your eyes,
Does it almost feel like
You’ve been here before?
"What is 7 doing?" My charge nurse said looking at the monitor "Oh wait… is it taking a blood pressure?"
I looked at the monitor and jogged quickly to my room. Her arterial line had flattened as a 10 beat run of slow Vtach had filled the screen. It wasn’t taking a pressure, she had been in a non-perfusing rhythm.
Her blood pressure rebounded quickly and my charge nurse walked to the doorway.
"Not taking a blood pressure, huh?" she said with a sheepish grin and handed me the rhythm strip showing the run. "She is trying to die…"
There was no family in the room to hear us. I glanced at the patient. She was mid 60’s, known drug user who had cardiac arrested in the field. They assumed from a drug related cause since her heart was OK. She only had a sister in another state as her next of kin. She was on our hypothermia protocol and her prognosis was extremely poor. Her pupils were fixed and seizure like activity was obvious from the doorway.
I shook my head slightly and looked at my friend.
"Not on my shift. I don’t want her to die on my shift." I said firmly.
"Well… she is trying." She said as we walked towards the nurses station.
"Oh, She will… but, not today. I’m tired of people dying all around me." I said and sat down.
"What? By now… You should be used to it!" My friend said giving me a typical ICU nurse look.
I looked at her directly and shook my head slowly.
“I don’t ever want to be used to it.” I said as I stirred my coffee. ”I don’t want death to be normal.”
Now let me at the truth
Which will refresh my broken mind
-Mumford and Sons
You were on our unit for weeks. You were intubated 3 times, coded 8 times and yet…your family wanted to persist. You were 82 years old.
I was not your nurse until today. We met in passing and I knew your history and family on sight from the long days. I knew clinical details, but nothing personal.
Tomorrow was your birthday. I knew that.
Today the goals of care for you were changed from making you live longer to letting you live the last days in comfort.
In our unit, people don’t usually spend a long time on comfort support. Usually once the enormous amount of mechanical and chemical support is removed, bodies fail. At 11 am you were switched from everything to ensuring you were at peace. You lingered. At 1630 I took over your care from another nurse. I had never had you, never really met your family. I introduced myself and made sure they knew I was available.
You started bradying down from 60 to 40 bpm approximately 25 minutes after I took over. 40 minutes in your blood pressure dipped and your breathing became shallow. At 51 minutes, your heart stopped beating and your blood pressure dissolved into a flat line. I held one hand while your nephew held the other. He sobbed deep tears and the finality of the monitor’s silence made the grief palpable. I didn’t say anything I just laid my hand on his shoulder, and set the tissues nearby.
What do I say? I had been a part of this persons life for less than an hour. We didn’t know each other, had no rapport. I was simply the nurse who saw the last heart beat, the final breath. I was simply there for the final curtain call. I was simply…there.
I’ve never known a fire that didn’t begin with a flame
And every storm will start with just a drop of rain
But if You believe in me that changes everything
So long, I’m gone
"I’ll drive!" I volunteered quickly as my dad rubbed his eyes and mumbled about finding a hotel room. He acquiesced and I slid behind the wheel. I was ready to knock the 5 hour trip out of the way.
Ten minutes later the glow of brake lights slowed our travel to a mere crawl and before long we were stopped. We checked the radio, the travel hotline and nothing came up. And yet, here we sat in bumper to bumper traffic.
My dad fell asleep and my mom read in the backseat as I put the car in park, the red glow of the other cars surrounding us. We waited.
I flipped stations, sang along with the songs I knew and tapped my finger on the steering wheel.
The time ticked by slowly. We had left at 7:15 pm and hadn’t even made it an hour away from the house before the traffic slowed us.
I gave an exasperated sigh and called my sister to google what was causing the issue.
"What on EARTH! Two hours of sitting in traffic…" I moaned.
45 minutes later my brother in law texted me.
"Fatal car crash. Multiple vehicles…"
I relayed the information to my parents and we sat for a few moments deciding what to do.
A creeping guilt settled on me.
"Oh man…" I muttered "Somewhere…someones life is being ruined by a phone call.."
"That is true…" my mom softly replied from the backseat.
We turned the car around in search of a hotel.
So much of what we do as humans on this earth is taken for granted. We work, we see family, we play with friends. So much life is lived without a thought. We worry about things that seem so important…. until the phone rings.
The headlights shined back against the miles of cars waiting for the road to be cleared.
Everyone was headed somewhere…and someone was headed nowhere.
Better days are coming soon
Just hold on I promise you
You’ll never be alone
The shadows fell darkly across the room as I tiptoed in. The room was almost heavy with suspicion and hostility as I attempted a quick in and out visit. No such luck. The eyes opened in a scowl and the mouth turned down.
“Pull my blanket up. I need a drink. Why is it so cold? Where is my doctor! I want to leave. I need to call my family!” The bitter diatribe started and a chilly feeling settled in my heart.
I like being a nurse. Give me a sick patient and a worried family and I will do everything to keep them alive. I will educate, placate and medicate to their hearts content… But, demanding, angry, hurtful patients that simply berate and are malicious… No, thank you.
I walked out of the room after 20 minutes, my knuckles white from clenching my fists, my jaw set. My only thought was, ‘How can someone be so truly hateful?…. When is my shift done?!’
I took a huge breath and walked to my next patient. The blinds were pulled and the ventilator’s soft whir filled the room. He was resting quietly, unrestrained but arousable on the vent.
I set about my morning and a comfort settled on my soul. The room had a sense of peace and quiet about it. I turned down sedation, opened the blinds, made my plan for the day and awaited the doctors. I was busy giving meds and settling him when his wife arrived.
I braced myself.
I had just been accosted with nonsensical anger and open hostility in my other room. I was prepared for more.
The white hair framed a face that was kind and a smile graced her lips.
"Well, hello dear." She said in a soft southern drawl as she extended her hand in greeting.
I smiled in response and grasped her frail hand as she introduced herself and settled in a chair.
"Any crisis overnight?" she said quietly.
I turned from where I was scanning meds and smiled.
"Not one." I said and then explained the plan and what changes had been made.
She smiled and nodded pleasantly. When I finished, she thanked me for the update and walked to the bedside.
She linked her fingers through her husband’s and stared at him for a few beats.
"Hi honey" She said softly and then bent to kiss his forehead. "I am here… you just keep resting so I can take you home soon." He nodded and his fingers squeezed hers.
Hours later, he was startled awake after we turned him. She waited quietly until we finished and then walked to his side.
"Honey… I am here with you…You just rest ok? They have to turn you… but, it is ok… I am right here…" She said softly. Her hand stroking his head. His startled eyes calmed and he nodded as his eyes closed. Moments later he drifted off to sleep.
I smiled at her.
"Well.. You are hired!" I said quietly. "You can rub all my patients heads and make them sleep if you want!"
She laughed and resumed her seat at the window as the afternoon sun streamed in.
After days of hostility from patients and families,it was like working in a utopia. I don’t know if it was the sunshine pouring in the window or that her soul was made of pure gold… but, something about that room made the day seem brighter.
On second thought… maybe it was seeing the contrast between love and hate that made the difference.
All I know is that I went from wondering why I am a nurse to wondering how I could ever do anything else.
Well, it’s really not so bad to be fading away.
Come on along with me and we’ll go fading away.
You can hardly even hear me because I’m fading away.
- James Taylor
"You knew you were in charge, right?" The night charge nurse said as she hustled back to the unit after responding to a medical response team call.
Our unit has recently been delegated the task of responding to the MRTs( Medical Response Team) in the Heart Hospital. Many hospitals have Rapid Response teams or Medical Response teams. I used to go on my own volition at my old job, now it is required. A “MRT” is called to alert providers that a patient needs more support or advanced care than it is currently receiving.
Now, as soon as I swipe my badge I become part of a medical response team that requires me to not only take care of my patients but also any patients that decide to crump in the entire Heart Pavilion.
I glanced at the night charge out of un-caffeinated eyes as I sipped my coffee.
"I know now." I said and shrugged. I listened to charge report and then took my patient assignment. I got report on my patient and before I could even enter the room the PA system ricocheted across the unit.
“Medical Response team- 5th floor Heart Hospital Arm 1. Medical Response Team- 5th floor Heart Hospital Arm 1. “
I glanced at the other experienced nurse on the floor and half smiled.
"Be back. Watch my lady. Neo, Lasix, fentanyl drips. Vent, restrained…She is ok." I said as I pocketed my charge phone and strode out of the unit.
I barely made it to the 5th floor before the PA system blared again.
“Code Blue. Heart Hospital 5th floor, Arm 1. Code Blue. Heart Hospital 5th floor, Arm 1.”
I have developed a bad habit of not smiling, striding into crisis with my eyebrows up as I grab gloves and survey the room.
The room was in shambles, nurses ran in circles. Only PAs were there, no doctors among staff. The code cart was open and for a second I simply got my bearings.
Then I focused on the man lying in the bed. His forehead had sweat beads, his skin pale. The code cart was attached, showing a heart beat on the monitor but he seemed disoriented. One nurse attempted to get an IV, another held a non-rebreather to his face. Minutes ticked by and then suddenly his eyes rolled back. His skin drained of color and I looked at the monitor as ventricular fibrillation filled the screen.
"Charging!" Yelled his primary nurse as the defibrillator started its familiar whine. His body convulsed as the shock hit him. The room paused and then relaxed into a chaotic busyness as he converted to a sinus tachycardia.
A whimper caused half the room to turn.
"His wife…." Someone said in a strained voice. "She is in the bathroom…"
I turned and looked into eyes full of terror as we continued to work on her husband. One hand covered her mouth, the other clung to the door frame. I was recording and the patient went into VF again before we could comfort her.
"WHY!?" The voice shrieked behind me. "WHY is this happening?! Why is he doing this?!" I turned and the words lodged in my throat. A manager quickly walked to her side and spoke quietly. The wife was not appeased and looked more stressed.
Minutes later an ICU doctor and my favorite cardiologist walked in. They surveyed the room and their eyes found me. They knew me and had worked hand in hand with me for 2.5 years.
"Kari. What happened?" They asked.
Part of me wanted to say I didn’t know because I actually didn’t, but my mouth started spitting out data.
"VF arrest during shift change, CPR was started and then he was shocked back to sinus. He has been shocked 4 times- so far each for VF and converted back to sinus tach, sats are borderline and he is anxious, mentation is deteriorating. Why don’t we intubate him? He has one peripheral IV, blood pressure is ok, he has lasix going and we are starting Amio. Electrolytes were marginal- we are going to give some potassium." They nodded and a page for anesthesia was sent overhead.
"What is happening? WHY is this happening!? I don’t want him to be a vegetable… I don’t want him to be a vegetable!" The wife said from a crack in the bathroom door. Her voice stressed and filled with emotion behind us. The ICU doctor turned and stared at her. I leaned over to him.
"The wife. She won’t leave the bathroom, she is upset. I told them to page the chaplain."
"Ma’am. We don’t know why. We will find out as soon as we can. We need to get him to the ICU." He said firmly.
I continued to record, filling paper towels with details that I was sure to forget later. Anesthesia arrived, intubated the patient and we stabilized him in a liberal sense of the word.
4 Stepdown nurses, 6 shocks, 5 IV attempts, 4 respiratory therapists, 3 cardiologists, 1 pulmonologist, and 1 ICU nurse and we were finally moving to the ICU.
I stood outside the room filling out the code sheets as the cardiac surgical ICU nurses did their thing. The cardiologist and pulmonologist asked me questions and I dutifully answered to the best of my ability. I finished my paperwork and started hunting for a sticker.
"Is this him?" I asked the cardiologist as I opened a chart.
"Yes." he replied glancing at the name.
"Ok… Wow. I just spent 2.5 hours with the guy… I didn’t even know his name." I said with a look of regret.
Sometimes…You don’t save the day. Sometimes you show up and don’t comfort anyone.
Sometimes you have replies but no real answers.
And sometimes, you realize that you leave a stranger the same way you met them… still a stranger.