A Difficult Conclusion

I have known of quite a few patients in the ICU that I’m in that have died. I have even cared for a few of them on a day shortly before their deaths. However, I have not yet seen a “code” situation or watched a person die, let alone clean up their bodies afterwards.

Today I had that experience. When I arrived on the floor a little after 6AM, the night shift nurses were all unusually busy, and both the night shift charge nurse and day shift charge nurse were in the same room, along with two other nurses and a respiratory therapist. They were shaking their heads frequently and running around, saying the patient's O2 sats were in the 70s-80s (which is pretty bad, but is by no means a death sentence.) When the charge nurse came out, I purposely (unknown to her) asked to be with a different patient, even though I knew the previously mentioned patient would certainly be an intensive learning experience.

Since my first day on the unit, I have been unbelievably petrified of having one of my patients code. The charge nurses always try to give us very sick patients because they are the best learning experiences for students – so I have gladly welcomed opportunities to learn. Regardless of my desire to learn, I have still been, simply put – TERRIFIED – of being in a code situation and having to give chest compressions, bag them, push epinephrine/emergency meds, etc. It doesn’t help that I have a pretty low level of confidence in myself, which is almost crippling at times. So this morning, there was something in the air about this guy – and I did NOT want to be on the front lines when he crashed, which seemed pretty likely.

About two hours later, I hear the calm, almost robotic voice of someone calling a code blue over the intercom system of the hospital. People came running from every corner of the campus – cardiac, chaplains, pharmacist, anesthesia, respiratory backup – everyone. Not to mention the three students (including myself) that were already on the unit. I walked over from my patient’s room to the room where the code was happening, and there were already 20 or so people crowding the room. The large glass doors were flung open, and one of the nephrologists (he was in the room when the patient coded) was giving chest compressions – but the nurses were clearly running the show. I walked over at the same time as the patient’s three family members came rushing to the room, and my heart broke. In a matter of seconds as they saw the nightmare scenario before them, they began crying and quivering and clutching each other while sobbing. I wanted so badly to say something to them and comfort them, but I started crying just looking at them and had to control myself and look away to remain “professional.” It was frightening to me too; I’d never experienced anything like it.

In a shortened version, here is what actually happened to cause the code blue. The man was (clearly) ridiculously ill. Among other things, he was on continuous renal replacement therapy (dialysis) and the nephrologist was in the room with the nurse to secure a usable access site for the dialysis. During this period, the nurse noticed that the patient’s already low O2 sats were getting lower, and he had no pulses – this is called PEA or Pulseless Electrical Activity. It means that, essentially, the patient’s cardiac electrical system is working just fine – so on an EKG, the heart appears to be just beating away and working fine. However, it is pulseless, meaning that though the electrical conduction system is working, the contractile abilities of the heart are gone, and so the patient’s heart isn’t pumping a drop of blood. The body can only sustain this for a small amount of time, because eventually the cardiac muscles stop receiving oxygen. At this point, this particular patient went into ventricular tachycardia and then ventricular fibrillation. The defibrillator was fired up while CPR was done, and then the patient was defibrillated. On the first try, they brought back a rhythm and pumped him full of a number of emergency drugs to bring up his blood pressure. Even though they brought back a heart rhythm, he was in respiratory arrest as well and his blood pressure was really almost nonexistent. Shortly after that he went down again and they attempted CPR, but the doctors told the family that there was nothing more they could do.

An hour or so later, one of the nurses asked if I would like to help prepare the body. I said no, but went anyway. We were taught about this in school, but I hadn’t yet ever experienced a death. Basically all of the tubes, IVs, catheters and other lines need to be removed and the body is bathed. Clean sheets and gown are then arranged, so the patient looks as clean and “normal” as possible for the family. This all sounds simple and nice, but I’m going to be honest – it was pretty disturbing. Because of chest compressions from CPR, air gets pumped into the patient and they kind of burp when you roll them – and it smells of their insides. Because the blood pools, the skin on the underside of the patient becomes mottled and purple. He also bled out of some of the small holes where his IVs were because his body wasn’t clotting any longer, and along with other body fluids, it was kind of messy. The oddest part of this was how the room smelled and how he smelled – it wasn’t any cleaning solvents, medicines, or blood or body fluids – I could distinguish those well enough. The smell was not unpleasant… it was almost a sweet odor, musky and fleshy. I wondered if that is what death smells like, when the body is just beginning to disassemble itself and dissolve back into the ground.

The whole day didn’t necessarily make me sad, but it got me thinking. Mainly I feel an awful, painful sympathy for the patient’s family. The look of terror and despair on their faces was more than I can handle, and I’m not sure I could work on a unit where that look is commonplace. It made me realize just how important a role nurses can play in saving a person’s life with smart, efficient decisions and delegating. But at the same time, I felt a deeper knowing of how gloomy, disheartening, and achingly real it can be.

Dying

My patient, Miss Smith (not her real name), is sleeping once again, as she has been most of the day. For the third time, she forgot where she was and what day or year it is. For breakfast I had to feed her slowly, bite by bite, and she was very proud of how much she ate - the most expressive she was all day. "Will you tell my daughter how good I did?" she croaked hoarsely. After she ate, I gave her a bath, careful of her paper-like skin, and noticed just how frail she was under all her blankets. Her thighs were only a little larger than my upper arms, and she was so dehydrated that her skin was dry and flaking over most of her body. Prior to today, I was nervous about bathing patients and giving them "complete care," but this woman was child-like in her confusion and for some reason it wasn't awkward - it just seemed like something that needed to be done - the care she deserved.

All day long I wished for a smile from her, something to let me know that she understands I'm here to help her. Occasionally when she opens her eyes I see a recognition in her face, but her cloudy eyes blink and its gone. I checked on her nearly every twenty minutes on my 12 hour shift - one, because she was my primary patient for the day, and two, because no one else on the floor seemed to care.

An hour after she ate, I found her sleeping once again, covered in yellow vomit full of all the food I had so carefully fed her and she had so painstakingly eaten. I made sure she was not any more confused or unconscious, and then internally freaked out. I found the charge nurse and she kindly helped me clean her up and change the linens. Miss Smith was still confused and disoriented, but luckily no worse than before, and there were no signs she aspirated the vomit into her lungs. I was sorely disappointed that she got sick - especially because she had just taken her pills for the day and was malnourished enough already. I gave her another bath, but she was bewildered and only asked "Can I go back to sleep now?" in just about the saddest way possible, like it was the only thing she wanted.

Later in the day her IV became infiltrated, and I berated myself for not noticing it sooner. Her painfully thin arm had a swelled lump the size of a grapefruit near hear inner elbow, and in a way to make it up to her I continued heating a wet washcloth to help it go down, checking on her every few minutes. At lunchtime, they brought her greasy ground beef and noodles and green beans, and I tried to pick them out for her. She refused them and turned her head after two bites, and I was kind of glad - the sound of her grinding dentures made me nauseous. It sounded like dying, like a desperate attempt to make old jaws process forced food when the body just wants to give up.

She left me thinking about death all day, and now still. Not so much death itself, but this act of dying so slowly and with such little dignity. This wonderful 97 year old woman left me wondering what she was like when she was younger. I wished I could talk to her, and kept willing her medicine to start working so she'd really wake up. Regardless of the effectiveness of the medicine, her Alzheimer's would've undoubtedly prevented us from having a meaningful conversation. I wondered what growing up as a young black woman in the early part of the last century was like for her, and what effect living through the wars and Great Depression had, and whether some mistreated part of her from long ago made her frightened of me. Mostly, I wondered what I would do if I went into her room and she wasn't breathing. I asked my instructor at the end of the day, and she was chipper and made a joke. The other students in my clinical made a joke about a student giving CPR chest compressions to a patient in the ER last week, how maybe it was him that killed her. I was the only one who didn't laugh. I wonder if it's because I'm an atheist, that maybe I have a different outlook on death and dying, because it's so final - there is nothing else after. Or maybe I'm the only one that hasn't turned myself off and become numb to caring for a dying human being. All I know is that I don't want to become numb.