The first time I saw a patient try to die, I was hooked on adrenaline. This was years before our hospital started running mock codes. I was a few months out of nursing school and almost completely clueless, staring wide eyed at the travel nurse doing compressions and calling for help. I think I might have run to the phone to page the code team. I don’t remember. But I do remember afterward running the scenario through my head; if the patient is unresponsive, check for breathing, check a pulse. Call for help, start CPR. And every day after that, when I clocked in on the post-op floor that was my first real job, I hope that if a patient were to arrest, they’d do it while I was nearby.
As a new (clueless) nurse, I wasn’t taken very seriously. I watched the swat nurses, whose job it was to round on every floor and assess patients the nurses were concerned about, to respond to code and to sit with ICU level patients until they had a bed on the unit. They argued with the doctors. They knew their shit, they got things done. I’d gone to nursing school with the intention of becoming a midwife, but I was drawn to the adrenaline rush of Saving Lives.
After a very short stint in med-surg, I got a job in the MICU. When I started there, we were only a 16 bed unit, in a hospital that usually had more than 16 micu patients. The sickest of the sick came to us and as soon as they were remotely stable, got shipped out so we could take more sick patients. I learned fast. After less than a year, I was adept at deciding from report who was the most likely to crash, and I’d request them. Those patients became my speciality; the ones with low blood pressure who didn’t have access; with a bad ph but weren’t intubated and we were talking about dialysis, the ones with uncertain code statuses.
I got respect from the residents. “Her ph is 7.11, she’s a little altered and she’s on pressors. She’s satting ok on a 90% facemask, do we want to intubate her before she gets worse?” They listened to me. I was the fulcrum in the patient’s room, the locus. I’d update the consulting physicians, the family, the charge nurse. I learned to advocate for my patients, to argue for them, to listen to them. I’d rush to get supplies, asssist with procedures, titrate multiple drips, chase lab results. I knew when patients were getting worse. I could brief a fellow while doing CPR.
And when patients died, as the inevitably did, I’d wait for the family to be done, bag up the body and bring it to the morgue, and wait for a new patient, hoping it wasn’t something lame like DKA.
People would ask me, how do you do it? And I’d shrug. Because the enormity of the tragedy I witnessed didn’t bother me that much. It was my job. Not that it didn’t make me sad; it did. But it didn’t keep me up at night; I did it well because it was my job.
So here’s the dirty little secret, and I think it’s endemic in most new ICU nurses, and probably extends to the ER and to paramedics. We like sick patients. We like it when people are actively spiraling. The layman’s worse nightmare is when we can flex our muscles and show off our skills. If we spend more time tending to impressive machinery than an actual human, we are pretty badass.
To a certain extent, there is a time and a place for this, because if your husband is in multi-system organ failure, don’t you want a nurse who’s going to hyper-analyze every lab value, critique the vent settings and re-adjust the pressors manically? But seen through another window, we are very strange human beings, we adrenaline junkies. Most of us will never get a chance to do roadside CPR or pull puppies out of a burning building but in this controlled setting, we are lifesaving rockstars. And no matter how exhausting it is, it’s fulfilling as hell.
So here’s my theory. We start off like that, but it wears on us. Eventually, we start to see the humanity in all of it. We begin to mature. I started seeing wives a the bedside as widows-to-be. Started wishing that my end stage pulmonary patients were home enjoying morphine and ice cream instead of pitting their lungs against a ventilator. I cringed when I had to help put central lines in old women. The families ceased being annoying and became desperate or unfortunate. I didn’t seek out the crashing patients anymore; to my horror I found myself enjoying getting people out of bed, washing their hair, getting to know their families.
Recently we’ve had a couple of younger patients come in with no brainstem reflexes and we’ve made an incredible effort to stabilize them, because no one is dead until they’re warm and dead, or oxygenated and dead. I’ve found myself wishing we could just tell the family, look. It’s pointless. It’s an exercise in futility, because it is.
And the chronically critically ill! This is the result of so much of our heroic lifesaving treatment; the dialysis and/or vent dependent, depressed, pressure sore laden souls. They do not live, or die, but linger. Burdened by heavy choices, their families cannot let them go, and so they circle from the ICU to the floor to rehab and back again, maybe to a vent facility. Sometimes they are confused and they beg us to let them die, but they’ve lost their voice to delerium and I must pretend to be deaf to their pleas. This crushes me.
Many of our patients do live to tell the tale. But they are not the thrilling ones. Unpopular opinion; if you only want to take care of the sick sick and actively spiraling, if you’re only happy at the bedside when tending to complicated machinery, you need to grow up. If you’re annoyed when your patient isn’t fully sedated, or irate when you don’t get the sick patients, look at the humans who have entrusted you with their care. Through everything, that is the most important thing. It is what separates a technically competent nurse from a truly good nurse.
I think it’s clear from this that it’s time for me to leave the ICU. Each time I have a very sick patient I think, “Tending to technology manifests commitment,” from nurse anthropologist Helen Stanton Chapple. She’s right; by our attention to the machines, we show families that we are Doing Something, when all too often, nothing should be done. And they cling to hope, that demon from the bottom of Pandora’s box. And hope disappoints. This isn’t fulfilling anymore.
I’ll be going to primary care soon, a novice once more. I am grateful for all that I have learned, both from the ICU and from the patients. I’m not leaving because I’m burned out, it’s just clearly time for me to leave the adrenaline chasing to other people.