The unit is a train wreck. All fourteen beds on our ICU step-down unit are full.
All fourteen of our patients are critical: heart attacks, sepsis, a drug overdose on suicide precautions, and several chronic ventilator patients. And we’re understaffed—again. Mr. Peck in room 324 is crumping. He isn’t my patient on this evening shift, but Cheryl, who is assigned to care for the 92-year-old man, is an LPN. As the team leader for our half of the unit, therefore, I am responsible for Mr. Peck’s IVs and labs, and he needs to have blood gases drawn at four o’clock.
It’s the early 1980s, and Mr. Peck is caught in that difficult bioethical dilemma: He has been living on our unit for the better part of a year, unable to survive without the ventilator that was initiated to help him through a bout of pneumonia back in January, and unable to die while he’s on it. Today hasn’t been a good day for him; the oxygen saturation levels in his blood have been going down, his carbon dioxide levels are rising, and the doctors have been making adjustments to the ventilator settings trying to get his blood gases stabilized. The timing of this arterial sample of Mr. Peck’s blood is important, and I am late.
But Mr. Peck is not just another old guy with emphysema from a fifty-year, two-pack-a-day cigarette habit who came to the hospital with pneumonia and ended up on our unit on a ventilator. Pecky, as I know him, lives across the road from my grandmother in a once-rural township in a house that my family still refers to, even after thirty years, as “the new house.” When, they were first married, my parents rented an apartment from the woman who lived next door to the Pecks; that’s where I spent the first nine months of my life. Living right across the road, my grandmother probably shared root cuttings of irises and peonies from her garden with Mrs. Peck. My uncle, only eight years older than me, might have stopped at his house on Halloween night, holding his pillowcase open as Mr. Peck, who seemed old even then, leaned forward from his rocking chair on the porch to add apples and Hershey’s kisses to the trick-or-treat booty.
Mr. Peck’s daughter Rose and her husband came to live with him five or so years ago in that house on the hill. Rose doesn’t have any children, so she was glad to have the chance to look after her father as he grew older and more frail after her mother’s death. She has come to visit him every evening after work since her father was transferred here from the ICU five days after being admitted to this community hospital. And, though Mr. Peck is often unconscious and always unable to speak because of the breathing tube that protrudes from the tracheotomy opening in his neck, Rose talks to him as if he is part of the conversation. She tells her dad all about her day, about the roses blooming in his garden, about how he has to get better and come home soon so Jesse, his hound dog, will come out from under the table where he lies night and day, muzzle resting on his paws watching the door as if he expects his master to hobble through it with his work boots and walking stick. On a good day, you can tell Mr. Peck is listening. He follows Ruth with his eyes as she moves around the room straightening things up and tucking the starched white sheets around his shoulders. He blinks once for “Yes,” twice for “No.” Sometimes he even tries to smile. More often lately, though, Ruth can’t tell whether her dad knows she’s there or not.
This evening will be another shift where I don’t sit down until midnight. The three-by-five index card where I jot notes about my patients during the change-of-shift report is full, front and back. Not only do I have two of my own critically ill patients to assess, medicate, comfort, consult with the physicians about, carry out procedures for, and communicate with family members about, I also have two of Cheryl’s to oversee. All I can do on evenings like this is to put one foot in front of the other, starting with the first thing that needs to be done and marching on until I’ve turned everything over to the night nurses and finished my paperwork. Mr. Peck’s four o’clock blood gases are at the top of this priority list, the first step.
When I walk into his room, Mr. Peck seems to be dozing, lying slack-jawed in the pristine hospital bed, his eyes closed, his stubbled face pale. He’s flat on his back tonight, his thin arms tucked neatly at his sides on top of the waffled white blanket covering his body. An IV pumps saline solution and an antibiotic into his right forearm that is bruised from countless needle sticks. His catheter bag contains an adequate amount of dark yellow urine, the ventilator is pumping at the proper rate, and Mr. Peck’s chest rises and falls with the mechanical motion of the machine’s surges.
“Hi, Pecky!” I shout over the hiss and whir of the breathing machine. Mr. Peck doesn’trespond when I address him by his nickname, but that’s not new. I place the disposable blood gas kit on the bedside table and prepare for the procedure. The cardiac monitor electrodes attached to his chest send their signal by telemetry to a screen at the nurses’ station, so I can’t see his heart’s pattern. Palpating at the pulse point on his left wrist, though, I can feel a regular, if not overly strong, rhythm. All is well, I think. As well as can be expected, that is.
I open the kit, assemble the equipment on a sterile drape on the table, then lower the safety rail at the side of the bed and sit down next to Mr. Peck’s legs preparing to take the needed specimen. Unlike a regular blood test, gases are taken from an artery, not a vein. Arterial blood is pumping fresh from the heart, not sleepily trickling back for more oxygen. A person bleeds more readily from an artery, and it can be harder to stop that bleeding, so the technique is tricky, requiring not only skill but a bit of luck as well. This procedure intimidates me more than I like to admit; there’s something about its invasiveness that makes me feel like I’m overstepping some boundary, like I have no business being here trying to suck out this vital fluid from someone so sick. But like so much of what I do, I have to ignore this squeamishness and get on with it. So I take a deep breath and focus on the task. We need to know what’s going on in there, I remind myself as I snap latex gloves over my hands.
“OK, Pecky,” I say as I carefully swab his left wrist with an antiseptic solution. “This is going to feel cold.”
I always talk to patients when I’m doing a procedure; I want them to know what’s happening, even if they’re unconscious. One of the first things I remember learning in nursing school is that there are signs that people have some awareness of what’s happening to them and can still hear, even if they are in a coma. It intrigues me to think that, even though someone is unresponsive, they can still hear me and be comforted by what I say. It’s one of those passing bits of trivia that I’ve pulled into my way of doing nursing, and even though it sometimes feels like I’m talking to myself, I still speak, letting the person know what I’m doing and what they can expect.
With the syringe in my right hand, I feel again for Mr. Peck’s pulse with the first two fingers of my gloved left hand. Finding it, I mark the spot by sliding my fingers apart along the artery and placing the needle directly over the pulsing vessel. “Pinch,” I warn as I gently push the needle straight down through the skin and feel it enter the artery with a “pop.” The stick is a success; the pumping blood flows through the needle and slowly pushes up the syringe’s plunger. But it’s dark blood, not the bright red, well-oxygenated kind I want to see, and the flow stops before the plunger rises to the one cubic centimeter mark.
“Damn!” I mutter, because less than a cc of the precious fluid is not enough to get an adequate reading. The scribbled list on the 3×5 card in my pocket nags at me as I try to decide what to do. I turn the needle, hoping to move its opening into a better position in the artery, and feel again to find the pulse that has escaped my probing fingers. Sweat forms on my upper lip, and the back of my neck gets warm. I don’t want to have to restick this guy, I think. I know it hurts, and I really don’t have time for this.
“Hang on, Mr. Peck,” I say, probing again with my fingers for the pulse. “Just a little more. I’m sorry.”
I happen to glance up at his face as I say this, though, and I realize something is wrong. His eyes are still closed and the ventilator is keeping up its pace, but his color has faded to a dusky gray, his lips are bluer than they were when I started, and I still can’t find his pulse. I yank out the needle, putting pressure on the artery to keep it from bleeding with my left hand as I pull on the stethoscope that hangs around my neck to listen to his heart with my right.
“Mike, can you come in here?” I try to keep my voice steady as I call through the open door to the resident physician standing at the nurses’ station directly across the hall. But the edge in my tone blends with the alarm sounding from the monitor at the desk, and Mike Baxter is already on his way in to check on Mr. Peck.
“I was trying to get gases and his pulse just went out,” I explain to the doctor as he too feels for a pulse in Mr. Peck’s neck and listens to his chest.
“His monitor shows a bradycardia,” Mike reports, and I realize that this dangerously slow heart rate means Mr. Peck is dying … right here in my hands, maybe, even, because of the procedure I was just trying to perform on him.
“Are we going to call it?” I’m asking whether we should call a “Code Blue”; should we start CPR and sound the alarm that will summon a team of physicians who will perform the life support measures that can get Mr. Peck’s heart back to a life-sustaining rhythm again. But I’m hoping for a merciful negative response.
“Well,” Mike says pulling the stethoscope from his ears. “He’s a No Code.” He sounds uncertain.
When it comes right down to it, none of us can quite step aside when someone is dying; we always want to “do something,” even though we know it’s sometimes better to let the person go. Mr. Peck’s condition has been steadily deteriorating for months; with his age and poor health, there is very little likelihood that he will ever recover. In the days before advance medical directives were common, doctors, in consultation with the family, might make the decision or patients like Mr. Peck who are not able to decide for themselves that CPR will not be started if his heart should stop, that a Code Blue will not be called. We would, essentially, allow him to die.
I am relieved when Mike says Mr. Peck has a No Code order, and my first thought is, Great! I’m done here. I can get started taking four-o’clock vital signs…at 5:15!
I slap a Band-Aid on Mr. Peck’s wrist, gather up the sterile drape, the syringes, and the remains of the blood gas kit, and head toward the door, leaving my patient in the hands of the doctor.
“Is there anything you need, Mike?” I ask, pausing at the doorway to see Mike Baxter take my place on the bed next to Mr. Peck.
Mike shakes his head and puts the stethoscope to Mr. Peck’s chest again. He’s is watching over him. It’s not exactly a conscious thought, but somewhere inside I know that this resident is standing vigil.
Tears well in my eyes, and I wish it were me sitting there, wish I had the luxury of accompanying my grandmother’s neighbor—this man whose body I have washed, whom I have fed and turned and tended, whose daughter has become a friend, whose story is woven with my own, this gentleman who has become more than just the patient in room 324—to the threshold as he passes into the next life.
I flee the room, a knot in my throat choking me, and head for the nurses’ station, grateful that the area is empty; everyone else is out on the floor tending to the needs and routines of the rest of our patients. I stand at the telemetry console fixated by the monitor image of Mr. Peck’s heart grinding to a halt, and, despite my best efforts, I can’t contain the tears that roll down my cheeks.
Where is my objectivity? my brain screams. I’m not supposed to cry!
In the ten or so years that I’ve been a registered nurse, I’ve grown a thick skin, an emotionally protective layer that keeps me from feeling the pain I inevitably inflict on others in order to help them heal. It’s another thing they taught us in nursing school, this “professional objectivity.” It’s supposed to keep me from getting so caught up in the drama of human existence that I can’t work effectively. In reality, it’s just how I get through the day. Now this dying old man is getting through the layers of my shell. It worries me, and scares me.
Too late I notice Mike approaching the station as Mr. Peck’s monitor goes inop. He’s gone, I think, as I swivel to the wall and escape to the medication room where I swipe at my tears and start collecting meds for my other patients. But Mike must have seen my face.
“Are you OK?” he asks. He is right behind me, touching my arm with a gentle offer of sympathy.
“Yeah. I’m fine,” I lie, trying not to look at him, hoping I sound indifferent, hoping too that he doesn’t believe me.
When I arrive on the unit the next day, the ward clerk tells me Jackie, our head nurse, wants to see me in her office. Down the hall in the broom closet that is Jackie’s work space, she gets right to the point. She tells me I shouted at Cheryl last night. This surprises me. I remember the LPN asking me what she should write on Mr. Peck’s chart; I don’t remember that my reply was unusual. Jackie tells me everyone on the unit heard my angry response: “I’ll do it.” Jackie says Cheryl is very upset at being treated this way. Jackie says she’s disappointed in me. Jackie reprimands me for unprofessional behavior. Jackie tells me this is an official warning. Jackie says she hopes nothing like this will happen again. Jackie doesn’t ask me for an explanation. Jackie doesn’t invite me to talk about the man who died in my hands last night. Instead, Jackie sends me back out to the unit, a train wreck again tonight. I’m late for change of shift report now, and I’m not sure I even have the energy to get one foot in front of the other.