Hope in the killing fields

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Our 23 bed ICU has been converted to Covid-19 patients.

All of them.

I want to tell myself this is science fiction, but it’s not. It’s real. And we are scared.
As I enter the unit to start my night shift, we have a huddle of the off-going and oncoming nurses.

We are committed to fight this invisible monster.

After a brief update of all of our patients, we bow our heads and say a prayer. A prayer to protect all healthcare and essential workers across our nation. And our Universe. A prayer for safety and strength. A prayer for the patients stricken with this potentially lethal virus. A prayer for the families that are not allowed in to see their loved ones. Not allowed in to say hello, or to say I love you or to say their goodbyes.

ICU has always been my favorite job. The dynamic and strong work here. Fearless and endless, we never stop.

But this is different.

We receive our assignments. If we are lucky, we only receive 2 patients. Both on ventilators. We have a clean nurse to assist with adding our PPE’s. We also pray that we have the right protective equipment. N-95 masks, isolation gown, gloves, foot covers, and face shield. I am the “dirty nurse”.

I have to be prepared to have everything ready to go into that patient’s room.
IV antibiotics, IV drips like vasopressin and Levophed for those dangerously low blood pressures. Lab vials for the continuous need of lab work taken from the patients arterial line. Tube feedings for their nutrition. Morphine IV drips for their pain and discomfort, propofol for sedation.

Beyond all of the technical and mandatory medical needs of this patient, I have to remember there is a person on that ventilator. A person who is all alone. There is no family member with them. It’s me and the patient. And that steady beep of the EKG monitor and the pumping of the ventilator. The noises that provide no comfort.

This virus does not discriminate.

I have 30 year old male who was perfectly healthy and I have 64 year old lady. This virus is an equal opportunity employer.

In my 30 plus years as an ICU nurse, never have I seen this incredible death threat.
I check the ventilator along with the respiratory therapists at my side. Check the settings, suction the patient. Though the patient is in a semi-chemical daze from the pain meds and sedation medications, I squeeze this young man’s hand, I let him know we are here for him. That we are going to do everything possible to make him strong again. To let him walk out of this place and see his wife again and hug his little kids again. And pet his dog again. I tell him to hang in there. That we are doing everything possible to fight this monster.

His breathing is shallow. His lungs have taken a beaten. But I can see his pulse and I can feel his pulse.

I hold his hand. And tell him to be strong. I say a pray for him. For us.

I want to shatter inside myself but I know I can’t . We must stay strong.
He turns his head towards me.

And squeezes my hand back.

Hope.

This is dedicated to all of the nurses, physicians, respiratory therapists who dedicate their lives every day in the face of danger. Thank you for all that you do.

A lesson in never giving up

Originally published on KevinMD

Jim Henson, creator of the Muppets and Sesame Street, died at the age of 53. His diagnosis was toxic shock syndrome/streptococcus pneumonia — a deadly bacterial infection.

We were on vacation when we heard the news: The genius who opened the imaginations and hearts of our children … maybe you too … was gone. We were devastated and saddened that the magic Muppet man had died.

One year later, our ICU admitted a 32-year-old female named Sarah. She was beautiful with long blonde hair and a loving, devoted husband by her side. Her diagnosis: Streptococcus pneumonia — the same thing as Jim Henson.

Sarah was rushed past the patients lining the ER walls waiting to see an MD or RN. She had shallow, gasping respirations. The ER MDs, nurses and respiratory therapists ran to her, and she was emergently intubated.

A central line placed, pressers flowed through her veins … normal saline bolus after bolus. Temperature of 103.2 degrees. Blood pressure 72/36 with a heartbeat slow and thready.

As she entered our ICU, we were prepared: cooling blanket, the strongest antibiotics, 24/7 EKG monitoring, and BPs every 15 minutes.

After a week, Sarah was not better. She was spiraling out of control, and her organs were shutting down. We had to add a vas cath for dialysis.

The intensivists updated Sarah’s husband; it was grim. But every day we stood quietly by her side without fail to do everything possible for her survival.

Finally, the physicians approached Sarah’s husband telling him we did everything possible, but she wasn’t getting better. A DNR was recommended. And her devastated husband, Pete, agreed.

We continued our regime of care, and nothing was discontinued — but we accepted that Sarah was not going to survive this deadly disease.

Every day, Pete pulled up a chair and read her poetry out loud.

Every day, Pete held his wife’s hand and told her he loved her.

Every day, Pete would comb her hair and read poetry to her.

Every day.

Slowly, her blood pressure improved and we were able to take her off IV pressors. Her temperature dropped to normal. Her heart rate went into a normal sinus rhythm.

And as he held his frail, sick wife’s hand — she squeezed back.

Overwhelmed he screamed for the ICU nurses to come see what just happened. He asked the doctors to come to her room. And he requested that the DNR be rescinded.
Within another week the endotracheal tube was removed. Sarah gasped her first breath without a ventilator.

Physical therapy came to work with her every day. Her strength grew.

And finally, she graduated out of the ICU and to a step-down unit. Pete at her side.

Pete never gave up.

We didn’t either.

One year later, we received a postcard from Sarah and Pete.

Sarah was standing on a mountain top, and the words she wrote on the postcard read: “Thank you all for believing in me.”

Go quiet into the night

Originally published on KevinMD

I know what you’re thinking: She’s cold-hearted, cruel, and unkind.

But am I? Or are you?

Grandma Lilly is 87-years-old and in the ICU. She’s on a ventilator with her wrists restrained to the side of the bed. Grandma can barely see because her eyes are puffy: scleral edema. And her heart races: 140 beats per minute. Her blood pressure is low and Levophed and vasopressin drips are ordered.

Her family can’t talk to her as she phases in and out of existence. For her, end-stage renal disease means dialysis. And respiratory failure equals ventilator. She’s a brittle diabetic with uncontrolled fluctuating blood sugars.

Grandma Lilly can’t eat, and we feed her by a tube that goes into her nose and to her stomach. Tomorrow, she gets a PEG tube surgically inserted to feed her. She’s been on the ventilator too long.

Next comes the ICU package: ventilator, dialysis, pressers, restraints, trach, PEG tube.

Any second of clarity or awareness is pure brutality. There’s no pretty ending to this torture except through death.

Poor Grandma Lilly.

Oh, the memories! When we were kids, we’d chant for Grandma Lilly. She’d snuggle us up in that rocking chair and read books to us. Let us splash our feet in the puddles after a misty rain, built sandcastles at the beach, and gave us candy when momma said no.

She was our heart and soul, and we wanted her to live forever. But we don’t live forever.

There’s cruelty in putting an 87-year-old with multi-system organ failure on a ventilator; restrained, medicated, disoriented, and wishing for the tunnel to the hereafter.

“The choice can be yours”

Your memories will live forever.

The ventilator. Churning inspiratory and expiratory breaths … day after day as Grandma Lilly wishes for death.

Grandpa Joe is two doors away from Grandma Lilly.

He’s going to die too from cancer. But he’s led a good life. And he’s cognitive enough to say he wants to die peacefully with his family and his dog Rufus by his side.

Grandpa Joe is a DNR/DNI and has requested to be “comfort care.”

He is given a morphine drip that flows slowly through his vein for his excruciating pain from cancer.

He breathes slowly. But he’s happy and pain-free and surrounded by love. His room is dimly lit. Music seeps out and fills the ICU hallways. Frank Sinatra, Nat King Cole, Ella Fitzgerald and Billie Holiday.

A Boy Scout and an Eagle Scout, he was the only one in his family who got a college degree. We loved his campfires, the stories he told, the wisdom and gentle guidance. And here, his family sat around him. Good old Grandpa Joe. What a life filled with love. They held his hand as they told their loving stories of Grandpa Joe. They laughed and silently wept. Tears of love and happiness and letting go but knowing the pain and suffering of his cancer would be over with soon.

After several rounds of CPR and cracked ribs, little Grandma Lilly died.

Grandma Lilly left this earth tied down like a captured animal.

Grandpa Joe left this earth with quiet whispers of, “I love you.”

The choice can be yours.

Go quiet into the night.

This is our last dance.