Ask any nurse and they would swear that patients are simply different when a full moon is out. For whatever reason, patients who were previously improving suddenly start to find themselves getting sicker and, in the case of those already struggling against their maladies, vital signs abruptly plummet. It is during such days when one can see most of the nursing staff stay well past the end of their shifts as they frantically finish charting the relentless onslaught of tasks they had performed during the day. Of course, such shifts are not merely limited to the apex of the lunar cycle — although to a far lesser extent, I quickly learned that weekend shifts have the tendency to either pass at a steady rate, or in a frenzied whirlwind of stat orders so placed as to desperately stabilize patients headed downhill. As such, I recently worked such a shift that fit quite neatly into the latter category, on the day of a full moon, no less; every single staff member on the unit had been running around all day.
During this particular shift, I was on staff along with my coworkers, Kim and Jerusa. Us unit regulars were accompanied by a float nurse, and the nurses were in turn supported by Melissa, the nursing assistant present. We were understandably close-knit yet, with the amount of complexity present on the floor that day, it was nigh impossible to find a coworker for assistance on account of everyone busily performing tasks in their patient rooms; the unit floor would frequently resemble a ghost town.
See, the nature of critical care demands prioritization and constant re-prioritization which, at its most ideal, would allow for equal nursing care to be given between the two nursing assignments, but oftentimes results in a disproportionately higher amount of time spent in the rooms of sicker patients compared to the more stable inhabitants. In my case, I have a reputation for watching my rooms like a hawk — not only do I keep tabs on who goes in and out of my patient rooms, but I also frequently check on what is happening inside. Despite this stricter level of attention, most families enjoy and feel better looked after with my style of care, which in turn also inspires confidence within them when considering that if I am not present, I must be attending to something urgent.
But then, there are some patients who fall as outliers where I intentionally relax the intensity of my watch. Though oftentimes I do this for patients receiving end-of-life or withdrawal of care to give the family personal time with their loved one, a recent example of such an exception that comes to mind is the story of a patient I will refer to as “T”.
T was in his twenties and had the distinction of being one of our youngest patients on the unit. Although most of our patients are older individuals recovering from complex surgeries, T was present because the walls of his intestines were disintegrating. As they did so, he would lose copious amounts of blood and require extensive transfusions — everything from red blood cells, to plasma, to platelets. Then, he would require surgery to try and sew up the leaks, getting placed on a ventilator to manage his respirations in the process. Finally, as he endured the gradual process of becoming strong enough to no longer need his breathing tube, the cycle would repeat itself.
I have taken care of patients who get cantankerous after facing setbacks during their recovery and have never held it against them. What was special about T however was that he never once ceased to be the gentlest, most impeccably polite individual that I have ever taken care of. When his open abdominal wound would leak bile onto the bed sheets, he would apologize to me. When I would offer to get him some anti-nausea medication, he would accept, and then immediately apologize afterwards for the extra trip I would have to make to the medication room. On the days when I did not have him as my patient and stopped by for a social visit, he would thank me for my time. Even when I worked as his nurse, there was not a single instance where he did not thank me before I would leave his room despite doing so numerous times over the course of my shift.
Equally notable were the people at T’s bedside. Although his mother and father did not speak much English, they would always give the nurse a gentle smile and would graciously thank us for our time. “You a good person. Profesional,” the father would say in his accented English as he spoke the last word in Spanish. In the afternoons after high school ended for the day, T’s two sisters would join their parents and spend time at T’s side. Then, the family would do something truly special — after setting out to roam the hospital’s corridors, they would spend time approaching anyone they could find to encourage them to donate blood to help all the other T’s that were in need of the life-saving fluid. Towards the end of the shift, the sisters would usually stop at either the hospital cafeteria or a vending machine to bring back a snack for the nurse. I lost track of how many times I would see the two giggling and whispering to one another in T’s room before shyly holding out some goodies that they wanted to share with us. Cookies, animal crackers, chocolate bars, fruit drinks… there did not seem to be any particular rhyme or reason behind their selections (though this did lead to humorous speculation between my coworker Audrey and I after she once received a packet of animal crackers while I was gifted a bundle of cookies) but it was always a welcome and thoughtful gesture.
As I would enjoy my little snacks outside of their view however, it would be difficult not to consider T’s perspective. Due to the state of his intestinal tract, T had not eaten anything by mouth for a very long time. In the months that he had been in the hospital, T could only look on as his family ate their meals in his room while an IV delivered a concentrated mixture of nutrients directly to his blood. “What did you eat?” he would always ask as I would come back from lunch break. Sometimes I would rib him a little bit by asking why he insisted on torturing himself with the details when he himself could not eat before [jokingly] lying to him about how I ate the grossest, most unappetizing lunch ever and that he was lucky he missed out. As he would laugh at my overtly fictional description, his sister would pipe up, “it’s true! He always asks everyone what they ate! He’s so weird!”
In all seriousness however, T’s outlook seemed bleak and many of his nurses felt that he would not leave the hospital alive. As I would visit him, he would tell me about the food he wanted to eat once he got healthy enough to go home. He would tell me about wanting to catch up on the latest Marvel movies and asked what I thought about them. With time, his hair grew out and his body became swollen the way that many of our long-term patients do as their bodies fill up with IV fluids; T’s legs eventually became too heavy for him to lift and an order was placed in his chart to turn him every two hours to prevent pressure ulcers. As I would finish making nice with T, I would begin to leave his room and then, watching my rooms closely as usual, would see it.
His dad would slowly pull out a small bottle of mango nectar from his bag and offer his son a small sip.
Per my signed doctor’s orders in the electronic chart, T was on NPO status, a Latin abbreviation for “nothing by mouth.” For patients, this restriction would oftentimes be placed for good reason — for those with the weakened ability to swallow and move their bodies, liquids had the tendency to go down the windpipe rather than through the digestive tract. The extra moisture in the lungs would then form an irresistible breeding ground for pneumonia, sometimes with fatal consequences. T’s dad knew this, otherwise he would not have waited until he thought that he was unseen.
Then I would nod once, to no one in particular, and have a seat at my computer at the nurse station. I made a conscious decision to allow it.
Critical care demands, well, critical thinking instead of a blind adherence to computerized orders. It is a skill that I try my best to convey to my nursing students who are all too often ready to implement unrealistic expectations for critically ill patients on account of following nursing guidelines “by the book.”
T was young and had been connected and disconnected from the ventilator over fifteen times. He did not have trouble swallowing and, as mentioned earlier, I did not believe that he would overcome his illness. In denying T the tiny, careful sips of juice provided by his father, I would be depriving him of a luxury that he quite possibly may never experience again. On top of this, I would be preventing his father, who had long been forced to relinquish T’s day-to-day care to the hospital, from a fleeting gesture that allowed him to care for his son as a parent. I also applied this manner of thinking to the order stating that T must be turned every two hours — when he would be sleeping comfortably in bed, I chose not to wake him just to put him through the excruciating pain he felt when turning his body. Yes, I was technically ignoring orders, but I was using my judgment to care for T as a human instead of a medical record number; pressure ulcers were not T’s main concern.
Though I certainly was not the only nurse who had a good rapport with T and his family, I was always a little flattered when T referred to me as his favorite nurse. Even when I would be present on the unit caring for other patients besides him, T would ask his nurse to call me because he wanted me to give him his injections — he said the way I did it didn’t hurt.
During my shift this past weekend, I did not have an opportunity to visit T but I knew that he was in good hands with Jerusa. Jerusa had been a nurse for over twenty years and had a hand in my orientation as a new nurse. Instead, I spent the majority of my time running between my two rooms, who incidentally also had wonderful family members at their bedside. Melissa would give me her usual pretend-rage whenever I would ask her to clean one of my patients or check a blood sugar. The nursing staff would give each other “the look” whenever they made eye contact, non-verbally expressing what a busy day it was. Things were unrelentingly busy, but there was still a sense of normalcy to the day.
Then, as I am in the middle of suctioning one of my patients’ tracheal secretions, Melissa calls out to me from outside my door. “<Nightmaren,> there’s a crash cart outside room <#>.”
A crash cart outside a patient’s room is never a good sign. As an emergency cabinet full of powerful resuscitating equipment, a crash cart’s presence indicates either that a patient’s heart has stopped or that it is in danger of doing so. Melissa had just informed me that it was currently outside T’s room.
As I quickly told Melissa to re-situate my patient (who I left in the middle of suctioning), I hurried to T’s room where I saw his blood pressure on the monitor to be dangerously low and his family rushing out to make way for the influx of staff. He did not look good — T was already on the ventilator and the powerful medications we use to force blood pressures up in emergency situations were already running through his IV lines at their maximum doses. The physician assistant at the bedside was calling for additional medications for Jerusa to push into T, but the blood pressures continued to drop — T’s body was fatigued, and after months of being in the hospital, it was simply shutting down.
I was at T’s side when he flat-lined. I was holding his wrist, trying to feel for a pulse, just as Jerusa was desperately trying to do the same on his other arm. T had passed away.
As bodies tend to do when they cease to function, T’s mouth slowly began to fill with secretions, which I gently suctioned away so as to keep his face clean. In moments, the ancillary staff began to file out just as T’s sisters began to trickle back into the room. Upon seeing them, I hurried to shut off the monitor that was now depicting horizontal lines instead of vital signs — the family did not need to see that. “He’s… not breathing anymore?” I remember one of them asking. They knew already, but I shook my head to confirm their worst fears. Jerusa, overwhelmed with emotion, left the room. Although I was able to control the urge to cry, as I cleaned up the medicine wrappers that had been tossed into T’s bed during the emergency, gently pat his head, and pulled his covers to his chest to make it seem that he was resting peacefully, I simply could not look his sisters in the eye.
I left the room, and before I did so, I paused to wordlessly rest my gloved hand on one of his sister’s backs, walked towards the other, and did the same thing. I then left the room to head back to check on my other patients to whom I have a duty to, and that was my final interaction with T’s family.
Whenever a patient on our unit passes, the entire floor somehow knows. As I walked back into my patient’s room, I start to apologize for my absence, but the family member, a sweet older African American lady, cuts me off. “I know, baby. I know.” She told me that she saw a crowd gathered around the room I had just come out of and correctly assumed the worst.
My head was still spinning a bit as I began to check my patient’s medications, but I strangely found myself responding to her. I did not give any patient information out of course, but I recall telling her that the process never gets any easier — I do not want it to. T’s death was not my first, nor would it be my last exposure to end-of-life care. In all of my encounters with it, I have always seen death in the hospital to be an extremely sacred thing — an honor to bear witness to. For some of my families, if I have time, I make little keepsakes for them to take home in memory of their loved ones. I print out a strip of the patient’s unique heart tracing from the computer — something that can only be made by the beating of their heart — and immortalize it in a blood-draw tube that I prepare by meticulously scrubbing its label off. It is a simple gesture, yet one that is profoundly meaningful and treasured by the family for the rest of their lives. Sadly, I did not get the opportunity to do this for T’s family.
By now, the end of the shift was approaching and us day shift nurses were reluctantly logging onto our computers to catch up on charting. As Jerusa was doing this, I walked over to her to stand next to her.
“Thank you,” she said as she gave me a tired smile.
She did not even have to provide any explanation about why she was thanking me. In fact, I was not sure why she chose to say this. But we were trying to make conversation — trying to keep talking to try and reestablish some normalcy as our shift ended. Perhaps it was the powers that be that felt the same way because, inexplicably, all of the computers on the unit suddenly began to have difficulty logging into the electronic health record. As a result, Jerusa, Kim, Melissa, and I simply decompressed as we had no choice but to wait for the network to come back online.
We talked about T and how heartbreaking the entire situation was. Although his parents were not ready (how could they be?) T was ready to let go. Jerusa told me how at one point, T, unable to talk because of his breathing tube, weakly wrote on a sheet of paper asking if he could have something to help him sleep. Jerusa gave him something simple that was already approved and on his medical record — it did not have any side effects. Yet, when T closed his eyes, his blood pressure began to drop and his organs began to shut down. T knew.
That’s one thing anyone in the healthcare field can tell you. People know when they are dying, when they are about to die, and when they are ready to die. T’s clock had simply run out and it was time for him to finally get some peace.
One by one, as the computers began to connect to the network again, we began to log in to chart. As we did so side by side, we made small talk about things other than nursing. Although we did not talk about anything out of the ordinary, there was a sense of camaraderie between us as we sat at the nurse station, two hours past the end of our shift, speaking superficially to one another while inwardly reflecting on the day’s events. As we finally finished up, Jerusa suggested that we should leave together.
“You have a trip coming up, don’t you?” Jerusa asked as we rode the elevator to the parking garage. She was referring to my trip to Seoul in a few weeks, which would mark my first time visiting South Korea. She smiled at me her knowing smile — the sort of smile that can only be pulled off by those senior to you. She told me to send her some photos since she too would be vacationing in Arizona after today. As the elevator reached the floor where my car was parked, she gave me a small hug as I bid her off.
There are a lot of new experiences laying here in the future for a young person like me.
Food for thought, I guess.