ICU musings

There is a lot to see in the CICU- stories about families, love and loss. You get to see people at their most vulnerable, their weakest- not only the patients, but the families.

Some stay for weeks and never have anyone with them. Others never have family leave the hospital. The vented patients when coming up are so grateful, so aware of the love that surrounds them, and I feel it brings them back. Then those that are alone so often never wake up, their lives effectively over-  as no one that wants them to come back and resume their lives. Often these are the ones that I find compelling- what made them get to that point? What made them so alone?

Dr. W. remained vented for well over 2 months- his family loving him, his grandson driving up from Notre Dame to watch every game in his Granddads room, sitting next to him, giving him the blow by blow account of the game, cheering for the usual victory-sharing with his Granddad even though there was no obvious response.  Dr. W's neuro status was questionable at best. Late one night when I was in his room, he began to track and I told him what a wonderful dad and granddad he must be, as his family was there, had been there and was so obviously in love with him- his eyes lit up, and he smiled over the vent. 

Dr. W never made it home, but his change to his next life was bathed in love. His was a life well lived and more importantly,  loved.

This past weekend, we had a patient that had WNV- this in itself was surprising, as his is one of 4 cases we saw in MI 2 years ago. He had a caretaker that was amazing- his attention to Mr. J was more then impressive. Being somewhat slow, I did not figure out that they were actually lovers, or had been before this horrific event occurred. He blamed himself- no amount of convincing  and praise for his care was enough to change his mind. He made it out of the CICU, and became (surprisingly) floor status, and it was during this walk that his partner told me their story.

They had been together for over 18 years- met at a Jazz festival in early 1991- and he moved from Canada to be with Mr. J. They were happy and all things good until WNV hit in 2007. When this happened, it struck hard and fast, ravaging his body and brain equally. He went to n extended care facility and almost died in the 3 days he was there post initial hospitalization. 

At this point, his partner decided that he would take care of Mr. J - forgoing his life, even if he did not say this to even himself.  Mr. J was unable to communicate, save for small looks and a sly smile. He has the softest of laughs- one that spoke volumes about him, his being and why his lover stayed so close to his side.  It was clear to me- he did not sleep the entire time he was there- so aware of every move the staff made, being kind to all, yet ensuring that nothing would harm his love. I told him how lucky Mr. J was to have him, and his comment back brought tears to my eyes. 

"I am the lucky one- I want to keep him alive as long as possible, as when he goes, a larger part of me goes along with him."

Reflections and attraction

you have to place faith that nothing happens without a cause, reason or purpose. I believe this to be, even when I feel I am struggling the most. I am sure I do not know any of the answers with out the benefit of hindsight, (bless that beast...) and when I do see, it becomes oh-so-very clear to me.

I will say one thing- I like clarity.  Not a fan of muddy waters.

With that being said, how can illness be explained? What makes someone so sick they die in a hospital? Why would that happen? This seems to have no answers. It does make me think, however, that maybe sometimes we are tools for others. If turn-around is indeed fair play, perhaps that's what it's about. Now I admit fully here that I am unsure about this, but it does make me think.

When I was working in a step-down unit, run by SV, the unit, feeling and compassion was amazing. These people came into my life to learn something, and in the turnaround,  I learned from them.  For me, the floor was a better place to work, only because there was time for people to change their patterns- the life patterns that got them there in the first place. Certainly, having an episode is a wake up call, or it should be, for living better, both from a emotional as well as well as physical prospective. 

When you work on the floor, you get to spend a lot of time with these people- and got to know them fairly well. Some of the more memorable ones--the woman who would not get better- finding out her dad had been in the exact room, same bed, and never returned home. We moved her, and she got her pacer (I think that was it...) and she got better.

Then, the man who kept infecting his incision with his own feces as he was finally getting attention that he had wanted his whole life.  Psych got involved for that one....

One of the saddest, the CEO who collapsed crying against me in fear, saying he could run a million dollar company, but could not handle having a heart issue and was very scared of dying. (he didn't.)

The woman who came in who said NOTHING for days. She was in an odd, very perplexing rhythm.  Some family member came to visit and it was in this way we found out that her son had jumped to his death 3 days before she was admitted, and she actually missed his funeral. Her heart was indeed broken.

Then, one of the most amazing- the man who was slipping away from dementia,  in a rare moment of clarity,  grabbing my shirt and pulling me towards him saying the most amazing words I have ever heard from anyone..."I just want to hold them in my heart" when his family was leaving. For this was a rare moment where anything he said made sense and to have it carry such meaning....

There was the man who once being put on heartmate realized that he had been living his life as the wrong gender and felt that the gender transition surgery was more important then getting a new heart. He was an interesting guy anyway, and totally toothless, as all his teeth had to be removed before the transplant could happen. He put a mirror on the back side of his door, so we did not see it, and would dress in womans clothes...so funny, sad, too, I suppose, but funny, in a strange kind of way. So, - well, I can't say it, because is sounds mean, but ...well, to hear him talk about it. Put it this way, you need your teeth to talk!

The absolute love and commitment of J to her husband while he waited for his heart- day after long day staying with him and keeping him up even when he got down. He was the one that named my little $100.00 Flinstones  car "the speck", as he would wait for me in the morning to get to work and knew where I usually parked. I so wanted to put a "Hi there!" sign on my car- but the damn thing was so small, I am sure he never could have read it from the 7th floor. When he left, with his new heart, strong and tall, we all cheered and cried.

Ah, then, the whiney man who coded. For some reason, I was at his head, and made it VERY clear that he was not leaving on my watch, get back here- it's not your time, buddy.... The next week, he says that is the only thing he remembered- his wife told me that it was the first thing he said when he woke up. To this day, I swear he coded just because he felt lazy...yes, I know that's not true, but he was that sort of person. What a kick in the ass I must have been. :-)

The poor guy who sat quietly in his room, never asking for anything at all, covers always pulled way up to his neck, finally getting a heart. He was out of the ICU in 3 days- remarkable to say the least.  I went to see him on the surg step down the next day. He was so happy and looked so alive- and boy, was he talkative- I believe he said more words in that short time then the entire month or more he was waiting on our unit. As I was there with the PA, he got a strange look and said "I have a headache". He was rushed to CT- it was massive bleed and nothing could be done. As each sense left him, and it was indeed each sense, you could tick them off, he still was grateful even while knowing he was dying. His last words were "Please tell everyone thank you...."

The boyfriend and girlfriend- she loved him so, and when he came back from being cardioverted (what is the spelling on that??) she kept saying that something was not right- she could not pinpoint it...but, indeed, something was not right. He ended up on ECMO, and did indeed die. If the RN's had just listened to her....

I watched med students become amazing MD's- Sanjay for sure, he was exceptional from the very beginning- clear, communicated well, was funny as well as very kind for the patients and never seemed rushed.  Brad Dyke- who remains at the U- not only an exceptional person, but an amazing MD- who truly cared about each and every patient that he took care of as if it were the only one. I miss working with that team- impressive care, great compassion and an honesty that is missing often in residents that I see on midnights.  

This all leads me to why I am doing this. Why I press on, why I push to learn things that I should have learned years ago, and why I am putting myself in a position that is, to say the least, difficult at 46. I love making the connection, I love letting someone have another chance, and if the end is the way it is to be, I want that transition to be as easy for them, both patient and family, as possible. I respect and value life and have a fairly strong believe that this life is not what it's all about. There is more....

When that gut feeling occurs, listen...

We were sending a pt off to the OR, and my resident came up as transport was taking him down. He stopped them- and said..." I just don't feel it's safe right now...something is bothering me."  He sat at that monitor for ever, staring at it, staring at the tapes. "It's sinus, but there is something." People were very irritated...this guy was a PITA, and his family worse. Very intense, very critical. Frankly, we wanted him gone. I spoke to B and said..."trust it, it's okay, don't worry about what people say. It is you that has to make the decision." He said back "I don't understand what is it, but he keeps popping in and out and something is just not right."

He is one of the "good ones" right now. I really like him a lot. When Mrs. X told me she wanted to withdraw, I called him in to her room. As she was telling both of us, we both began to cry. This woman had been fighting for so long and the only reason she was fighting was for her husband. She had been on the list for ever, but no heart came thru- she kept getting sicker and sicker. She touched so many lives with her strength. But she was done.  It was past hard for her, and understandable. But the compassion that he showed....

So, I just found out that the patient died during the procedure. B was indeed right. That 6th sense is one to be listened to, isn't it?

At 98, you SHOULD win

It seems, on every level, that at 98, you would be able to win if you say "no". No to C-pap, no to being in the hospital, and her only positive, yes, it's time to die.

You have to wonder WHY her kids, both men very much into adulthood, keep on pushing- and she keeps saying (in her own garbled, missing her teeth, obviously pissed off way) "I want to go home!" This is VERY clear. The only thing that seems clear to me in this scenario.

Each turn hurts, each move is excruciating for her. She is weeping everywhere, and has no control. Since we are trying to keep her alive, she has had no sleep, so the ICU psychosis is setting in. Starting an IV in someone this age? Well, it's one thing that no one wants to do. RT is annoyed at the decisions being made. RN's and MDs are just amazed. She is DNR, she is miserable, she is 98.... good God, what is the logic here?

Giving it the what for....

I wrote the other day about the man we had in the unit- Perhaps a racial issue, perhaps a big black man having an RN that was gay? Not sure. But whatever it was, this man was NOT clueing us in on what was going on with him. He was in obvious pain (and obvious cardiac issues- you don't get a room with us that easily....Viral- sucks, I think, of all the horrific things...3 months ago, fine- now? Waiting for a heart and getting worse.)

I gave him the Annika Pep Talk- one that I reserve for times when I know I am stepping over the line, know that it might not be in my best interests, but, doesn't matter. I am compelled. And so, in I go, sit right in front of him and give him "the" talk.  The poor guy can hardly look at me- still in pain (did not help he had stepped on his cath, as he was trying to get up...MAJOR pain, there- and well, I can only imagine. Luckily, was able to deflate and push back and things appeared okay....)

"You MUST tell us what is going on. We cannot read your mind- and you are here to get better- and we want to help." He seemed to listen, and then right before I left, I said. "Look, I want you to get better, and I care that you get better, and your wife cares, and...well, just so you know." With this, he looked up and said "Thank you."

So, the thought was he had an abdominal bleed, or something. He was to be sent to CT- and of course, I went home.

When I came in, I talked to his wife and told her I gave him the what for. She asked why, and she listened, and said he does not communicate well- and she thanked me.

This is before we found out he is VRE, and...I am not sure about the actual details, but he is throwing clots into his brain, and they fear that he is just filled with pockets of infection. I don't know why, as it was busy when K told me this, and I don't understand exactly what the deal is, but whatever it is, it's not good. Not good at all. And damn it. Damn it. I sit here crying- because it's just the most horrible thing- his kids came in, and could not face him, as he had changed so. And, he is not going to get out...just not going to. And none of it is his fault at all. Younger then I am....

Before I left this AM, I went in to say goodbye and told him I'd see him in 5 days. He was still in the same place he has been for the past 2 days- sitting on the edge of his bed, unable to lay back, as he begins to choke. I just rubbed his shoulder for a moment- and tried to give him something that would make the coming week easier....

He is going to be one of those that people forget- and I don't want that to happen- because...no one should ever be forgotten. 

Then the Quad down the hall- dirty young man (41), and he is PROUD of it! I could understand him as I lip read, and he was filled with things to tell me. Funny guy, been a quad for 20 years- was hanging his head out of a car and hit a guardrail. Drinking- yet, this man, in his words, shitty to have happen, but he would probably have died if this hadn't happened...in some other way that would have been a lot worse. He was sweet in his own way, and knew that his being taken care of well depended on his being a nice person. He was very successful. 

The KFC lady- has a husband that is a sloth, too and she is hyper. We had good stories to share!

 Then, watching the SuperBowl with my lovely txp w/u lady- (but...not to be, but she doesn't know that yet. Pressures just too high.) She wanted the Cardinals- me, too, I always like the underdog. 

 Then, Mr. C, at 25, one eye (he is the one that says I have a big butt- in total jest, but it's really funny- the story is just great- but for another time...) and his family- wow.

One quick thing- Black family groups have it all over us. They are so committed to each other, so intact when they are a unit. It's impressive. Care is the primary thing. I think it's because they are a matriarchal society- so the female values of care/love/compassion with a certain amount of "attitude"  are stressed above all others. Just an observation from the past years of taking care of people. It's amazing.

 And it's very fun to talk about the cultural differences between white butts and black butts. Apparently we have it all wrong....

90 year old love

At work, its been kind of nuts. I do have this lovely woman who is 90. When someone tells you they love you and they are 90, it's all good with me. She knows that her end is near, and it is. I thought we were there, but she rebounded. I just held her- K is her RN, and we sat with her and when she was having the most trouble, she just sat up so I could hold her. She must weigh about 90 lbs. She had the sense she would not make it thru the night- even though her numbers are good. She kept saying "Thank you," and was so kind. Her docs are okay- but what can you do? so, comfort care, and hopefully a kind, sweet end. She wants to see her husband, and her son (who was killed by a drunk driver on Dec 23rd, many years ago. He was 28.) Her husband died a few years ago, and I heard about her life with him, too. It was a very lovely and happy life. She was fairly dismayed at the lack of dignity she experienced in the ED- "Everyone saw Everything! I was so embarrassed!" and then she told me a bit more about her husband- they must have had a very nice life :-)!! She is ready as I have ever seen anyone. She only has 10cc's out thus far this evening- so, hopefully....

I got a bit more about my other, very quiet man from K- his entire situation has been caused by...3...bad...teeth. Yup- and, pretty sure he is not going to make it. He is VRE, so, it's hard for me to spend a lot of time with him because of precautions, but I have gone in and spoken to him a couple of times tonight. He has been very kind, and thankful for everything we have done. He also has spinal involvement now- from the pacer lead that got infected. So, he is one sick man. 36 years old. I guess there have been some interesting family dynamics that have occurred since I have been gone. From what I understand, wife number 2 is not actually his wife, but was signing his papers as his wife. Wife number 1 got offended.... oops!

Otis

Okay, O - as we now know he is called, is out of our unit. He is in step-down, and as of this AM, should have been in OR getting a valve. Whatever happened to get him from waiting to die to this, I don't care. The man is getting better, in spite of the dire predictions. So, he is a happy one.

I have enjoyed thinking about him and hoping for him and praying for him. I did make him the center of thoughts- and if that was anything that helped, then good for him.  I am glad he is getting out. I do think that he will be changed for the better when he leaves- he is talking, and more outgoing. I am glad. I hope I get to see him again.

Mrs. R did indeed die on Monday. I hope her passing was okay. Mr. W died this morning- I was with his wife as she said goodbye. She wanted to be alone when he passed, and she held his face, kissing him as he took his last labored breath. It was very peaceful- his pressure just kept dropping, and then asystole ... nothing dramatic, thank God, just quiet. She will be okay. And, she will see him soon.  

It's so very strange that we have so many patients on comfort care right now. I am not sure where this is coming from- but odd, and very atypical for us. We have two still there that are heading towards comfort care. I am not sure why we are keeping them- well actually, their 02 requirements are too high for hospice. So, we get them. It's okay, but I worry that we may miss a point where a patient that needs a bed does not get a bed.

Mr W continued to run into V-tach- I guess they had the same issue all weekend, too. I took a picture of him for his family and sent it to them- he looked great; this was before his horrific run of tach-flutter (!) and his at least 6 shocks- just last night. Talk about PTSS....  He was so grateful for that to occur- seems as if we should make computers available for patients in the hospital so they can stay in contact. His wife was just out of hip-replacement surgery and can not visit him. He heads to OR for LVD on Wed- I hope he makes it there. He is also on the list.  So praying for him, too.

So, here is the quote for the weekend. From Dr N-  "Do not trust anyone who is wearing a bow tie in a code. Just don't".  Point taken. Patient did not even make it to us.... He was a bit pissed....