(This is a true story. Details that would reveal patient identity have been changed, to protect patients and to comply with HIPPAA.)
Inside the hospital walls,we still have the lights off, as night pales to gray dawn. In the outside world, alarms clocks go off and normal people start their morning. The day shift will be leaving their houses, and soon I can go home. Salvation is at hand. It’s been a busy night, but not a memorable one in the medical ICU. Not one of those nights that it occurs to you at 3 am that you haven’t peed in more than eight hours and you probably can’t slow down and go now. But it’s been busy enough and we’re ready to go home in an hour. Until there’s a rapid response down the hall and the swat nurse asks if he can just bring the patient right now because she looks really bad. Ok, I say, bring her up.
I log into the computer to see what’s coming our way. “Oh no. Avery, Mrs. Rivers is coming back.”
Avery looks puzzled for a moment and then his face opens up. “Shirley!” he says. “Oh God, what’s wrong with Shirley this time?”
I shrug. Mrs. Rivers’ name is not Shirley, but Avery has a particular way of getting close to patients, close enough that he can do things like call them by the wrong name, and they think it’s funny. He helped me out with Shirley last week when her frail heart was racing and her blood pressure was dropping. “She’s back for more of the same,” I say. “Her blood pressure is 50/20, o2 sats are low and they want to try bipap.”
“She’s a DNI,” I tell Teresa, the nurse who’ll be taking Shirley. “She did it herself. Said no vent, but want compressions. She said she’s had them before and they work.”
Teresa rolls her eyes. She’s hanging IV tubing in the patient’s room. “Well, we won’t be doing compressions. We got 1 hour til day shift gets here.”
When Shirley comes, she’s lost in white blankets in the bed. She’s frail, she weighs all of 90 pounds. We put her on our monitor, put her on bipap. Her blood pressure reads 45 over nothing, and she’s completely unresponsive. Teresa touches her neck. “Do you feel a pulse? I don’t feel a pulse.” A few others reach down, touch the tiny old woman’s neck, wrist, groin. Heads shake. We look at each other.
Shirley, before she was unresponsive, made two things very clear. She never wanted to be on a ventilator, and, if her heart stopped, she wanted chest compressions to restart it. Unfortunately, the doctor who signed this paper work with her did not explain that it is extraordinarily difficult, sometimes impossible to bring back a stopped heart without the presence of an artificial airway and mechanical ventilation. If Shirley had wanted neither, we would have held her hand and let her die in peace. If she had wanted both, we would have called anesthesia, put in an airway, and done everything to stabilize her. But as it was, as we stood there looking at each other, and in that moment of silence, we knew we were going to break her ribs and we knew she was going to die.
“Start compressions,” the doctor says. One of the nurses goes for the code cart. I delegate; you’re going to push meds, you’re going to draw them up, you’re going to record. In the middle of it all, Teresa is pushing on Shirley’s emaciated thorax, tears running down her face. I know with every compression she can feel the ribs pop as they break and then the chest feels all wobbly because the rib cage is falling apart. “This is criminal,” she says. But she keeps going.
After a few rounds of epinephrine, we get a pulse back. But there’s no question of bringing Shirley back. She’s too far gone. The resident, for some asinine reason, orders fluid boluses, blood cultures, a stat echo-cardiogram and an chest xray on a woman who is virtually dead. Poor Shirley. None of it will help her. Of her six children, none of them has a working phone number. Her husband must have passed years ago and she has no friends or siblings that we’ve been able to reach. In the clear light of day, two attending physicians make the case for futility (this almost never happens) and do not escalate care. Shirley dies.
But Shirley does not die alone. There is a nurse there. We were with her to change her name and make her laugh, to tempt her with food when she wouldn’t eat, to help her out of bed. We were there to try to save her life and we were there when it ended. This then, is nursing. It is science, paperwork, and heavy lifting but as Peggy Anderson wrote in 1978, it is about caring for other humans. This is the place where I never thought I’d be, never wanted to be, but now I can’t imagine being anywhere else. Nursing is not glamorous. It is messy and sad and awful, and it is uplifting and renewing and amazing. It is the science of disease management and prevention and the art of intervening in the human response to suffering. It is being able to give the right medications at the right time and knowing their purpose and side effects, but it is also how to approach the patient getting the meds, and how to teach him what he doesn’t know and how to make him smile. The profession is difficult to define; nurses write volumes trying. No other discipline so skillfully blends compassion and science, or mixes so well rigid policies with creativity. On the job, we hold lives in our hands and at the end of the day, we clock out like everyone else. We work with high stakes and drama, with monotone reality and with the heartbreaking agony of everyday pain and sorrow. I never thought I’d be here and today I can’t imagine myself anywhere else.