My day - such as it is
Your average generally agreeable guy, registered nurse, new Canadian citizen and queer geek just returned to Manhattan for a stay after an amazing 3 years in Canada. Nursing is a second career, having spent 12 years way back when, as a software QA engineer.
Free time, what there is of it, consists of tipping back a pint or two with friends, going back to Toronto, traveling in general or trying to remain hidden with a good book.
A long-time patient from one of my places of employment passed away two days ago. I felt a bit of a bond with him, perhaps because he's one of the few Jews I've cared for since I've been a nurse in Canada. Downtown Toronto isn't exactly filled with members of the Tribe. I relished the times I cared for him, carefully removing his kippah before bathing him, making sure it was back in place when his care was done for the evening. On Friday nights if I was around, I'd turn on the bulbs on his electric menorah and whisper the Shabbat candle-lighting prayers as I stood next to his bed. It had been a long time since he was aware of much going on around him but I still felt it important to maintain his traditions.
Below is a recipe his wife hand wrote on parchment and gave to me after I complemented her on her banana muffins. When he still had a bit of an appetite and could safely swallow, she would bring him the muffins, always making sure to prepare extra for the nurses. I'm reprinting the recipe here in his memory. He was a good soul and I'm sure he'll be missed:
It's not that often I get to establish any sort of relationship with my patients. My usual schedule is two days, two nights followed by five days off. Typically, I'll never have the same patient more than twice, unless their stay in the ICU is particularly long or they're one of our chronics who's been there for YEARS. This week was unusual. Knowing how much I hate the night shift, the scheduler assigned me four days in a row instead of the 2+2. As such I had the same patient for four days, plenty of time to form a proto-relationship with both him and his family.
On the final day of the rotation, I finally gathered up the nerve to ask about their religion. I had wondered about it since Monday, when they sat at the patient's bedside at the stroke of 7pm, and prayed, rocking back and forth, their utterances in a Semitic language whose origin I wasn't entirely sure of. The patient kept a set of beads next to him, vaguely reminiscent of a rosary and the family members had similar ones they held while praying. My initial thought was that they were Muslim. However, on Tuesday, I noticed the patient had a little card taped to one of the bed rails that apparently depicted their 'spiritual leader'. The guy was clean-shaven, middle-aged, in a suit. He could have been a bank executive. Now I really had no idea of their faith.
It occurred to me to just ask the wife about their religion however I apparently forgot everything I learned in nursing school and assumed this question was too personal. On the contrary, we were taught to discuss this sort of thing with families in order to provide culturally sensitive and appropriate care. Why at this point I thought it was wrong I've no idea. As the week drew to a close and Thursday's shift waned, I realized I'd invested a bit of myself with this patient and his family. The job sometimes becomes an assembly line, the patients coming and going, coming and dying, etc, with little attachment. This case was a little different. I had helped sell the patient and the family on the idea of temporarily having a tracheotomy to give himself a chance to more quickly wean from the ventilator. I got him out of bed day after day, still connected to the vent and walked in little circles, impressed by his peripheral physical strength in spite of very weak lungs. I wanted this guy to succeed. I badly wanted him off this ventilator and back home with his young wife.
And perhaps this is why I had such an interest in his religion. These were clearly people of faith. Happy, appreciative of the care they were receiving, refusing to let themselves get down in spite of the odds their family member was facing. Their religion was apparently supporting them in this time of crisis and I had a genuine interest in knowing what it was. So I asked. Muslims indeed. A sect the wife described as 'very liberal', called Ismailism. I remarked to them that I had suspected they might be Muslim but the lack of facial hair on their spiritual leader, who it turns out, is the Aga Khan, threw me. They all, including the patient, had a great laugh with me and it struck me then, how much I enjoy the work I do.
There are those moments I come home and cry my eyes out. Then there are the moments like this. I marveled that only, perhaps in my career, could a gay Jewish nurse from New York be having a conversation about faith with a Muslim family from an East African nation. Remind me the next time I'm in a funk about the latest death at work, about occasions such as this one. Where I leave work for a couple of days off, flush with the warmth of the work I do, the benefits I provide and receive and the people I meet. Remind me, won't you?
Preparing to assist with yet another bedside percutaneous tracheotomy. We seem to do a million of these in our ICU. Someone sits on a vent for more than 10-15 days, talk of a trach immediately comes up as a way to wean the patient off the ventilator that much quicker. And there is some value to that thinking. The patient is only having to breath through about 6 centimeters of tubing instead of 22-30cm. Their mouth is free to have regular oral care. No more painful straps on their face. It gives their lungs a chance to recover from the increased work of breathing that ventilation via an endotracheal tube causes. Perhaps most importantly, the longer a patient is on ventilator, the greater their risk of developing ventilator-acquired pneumonia (VAP). I think the figure is something like 3% greater risk each day on the vent.
I find myself a bit torn these days with my choice of specialty, that being critical care. You're taught in nursing school that a certain amount of empathy is a requirement of the job. Otherwise you're nothing more than Louise Fletcher in One Flew Over the Cuckoo's Nest. My problem, I'm finding, is that I have an over-abundance.
Not with every patient, mind you. Those that die alone, I'm fine with. A tear maybe, maybe not. It's those occasions when the family chooses to withdraw life support from their loved one and they all gather round while I turn off the alarms, turn on the Morphine, Midazolam or whatever we're using that day to keep dying patients comfy. Invariably some are crying actively, possibly bordering on wailing. Perhaps they're brushing their loved one's cheek or forehead as they tell them they love them. And that's it. I'm officially a mess. More than once I have to excuse myself, wander down the hall to a window to compose myself, then return to the scene. This doesn't strike me as professional behaviour. I don't notice this happening to co-workers. Maybe I haven't been doing it long enough.
Again, if the patient dies alone, I tend to be very calm and collected. And when it's time to prepare the body to head to the morgue, I always do it alone. Almost every other co-worker tends to ask someone else to do it with them. Doesn't faze me in the least to be alone with the body. I take pride in the fact I'm giving them their last bath, taking a little extra time to treat them well one last time. It's a bit sacred for me, truth be told.
But the tears. I bring them home with me. That or anger and frustration. Not fun for those around me outside of work. Clearly I don't have the right grasp of my job. Should I have chosen another specialty? Something where no one ever dies and there's no chance to develop any attachment to the patient? Dialysis? Methadone dispensing? Weight-loss clinic? PACU? It doesn't feel at the moment that a career change is the answer. However, obviously I need to get the empathy under control...
Somehow I managed to pull out a passing grade or rather grades, on the critical care course - or the 5 courses that made it up. I've never earned 25 transferrable credits in such a short time in my life. Nor have I ever learned so much in such a brief moment either. It's fair to say I've learned more about caring for the critically ill and near death then at any point in four years of a Bachelor of Nursing program.
It's a bit of an odd feeling, too. Your whole perspective as a nurse working in critical care changes. At least it has for me. My view of the world as a nurse went from passing meds to 5 to 8 patients, keeping an eye on their nutrition and toileting, tending to other co-morbidities, to the other end of the spectrum - a single patient assignment with the simple goal of keeping them breathing until the next shift. ICU nurses strike me as part mechanic, part nurse. Constantly titrating IV drugs up or down, running and re-running labs, monitoring heart rhythms, in my unit's case, monitoring brain pressures, activity and neurological signs and tending to the family's anxiety and, in less fortunate cases, grieving. There's always some adjustment to be made as the patients are typically really unstable or they wouldn't be in the ICU in the first place. And if you screw up and miss something, before long, the consequences of your mistake could be irreversible. Profs always harped on the importance of critical thinking but I never realized its value as a floor nurse. Now, a different story entirely. It's a sea change from what I was trained to do in university. They always said that nursing school gave you only the barest minimums of training. Everything else you'd be expected to get on the job or from further education. And clearly that has proven true for me. Time will tell if I'm cut out for it I suppose.I attended my first staff meeting since joining the MS/NICU. Bottom line, it was the most troubling staff meeting I've ever attended and also my first real exposure to nurses who have clearly worked too long, become angry and divisive. Well-skilled nurses treated our manager who was running the meeting, like a big punching bag.
The issues? Endless, nitpicky issues for the most part, in my judgement. All designed to cut down the amount of physical labour they have to undertake for their *one* patient. They don't like having to check more than one Picsys (a giant automated pharmacy dispensing computer) for the occasional med. They don't like how they have to move a heavy pole of IVs when they take a pt to CT scan. They don't like that the ice machine was taken away after we moved into the unit's new home. And on and on. I might not have minded so much had their attitude been more pleasant. Instead, for one or two of these older nurses, they felt it was ok to be adverserial, contradict every valid point the manager made and generally come across as old, bitter and tired. If you can't address your manager or fellow employees in a nice manner, keep talking about how bad things on the unit have been in the past while solutions are being talked about for the present, and are generally crochety and uncooperative, perhaps it's time to take your Ontario Hospital Pension Plan and go home. The rest of us are positive, looking for solutions and ready to provide our very ill patients and family the best care possible.
