"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"
Tuesday, May 19, 2020
These 6 nurses are all from North-East Pennsylvania and Western New Jersey. I have chosen to keep their identity and the organization they work for anonymous, because I wanted them to feel as if they could truly be honest with me and my audience. I have changed their names to something not their own, and any details that make you think you know this person are purely coincidental.
All of these magnificent nurses are ones that I know personally. Some have trained me in my practice. Some I have worked side by side with. Some I have trained. Some have been my mentor. All bring a different perspective to the table here.
Miranda is a Medical Surgical Nurse in Allentown, PA with over 6 years bedside experience.
Chris has a Doctorate of Nursing Practice and practices in a PA ICU with over 20 years experience.
Reagan is a newer Emergency Department Nurse in Stroudsburg, PA with under 5 years experience.
Nicolette is a Medical Surgical Nurse in Hackensack, NJ with over 10 years of bedside experience.
Kayla is a nurse in the ICU in Easton, PA with over 6 years bedside experience.
Tyler is a nurse manager in charge of 20-30 nurses on an inpatient Medical Surgical Unit in Pennsylvania, and has over 10 years of bedside experience.
Okay well that was the easy part. Introducing them. The hardest part is going to be what comes next. Taking their honest, heartbreaking, gut wrenching words and doing them justice. Presenting them in a way that will never be forgotten. Not tomorrow. Not next year. Not in ten years. Not when this goes away. Never. So here goes.
This virus has come in like a tidal wave no one saw coming. All agreed that when training to be a nurse or before they decided to be a nurse, no one saw this coming in our future. No one. No one predicted we would have a world-wide pandemic and shutdown. No one saw coming how hospitals would be right up there with the rest of the world, losing millions and millions of dollars and cutting staff left and right during a health crisis. No one saw a three month quarantine coming away from their loved ones, their own children. No one saw the stable ground being ripped up from under them but still showed up to work every day, ready to fight. THAT is what has inspired me the most about this group. All agreed that if they knew this global pandemic was coming back when they decided to become a nurse, would they still do it? They ALL agreed YES. They would still become a nurse. Miranda stated, "We are making history right now. This has made me honored to become a nurse." Kayla from the ICU shared, "I would still become a nurse because even feeling fearful, frustrated at times, and dispensable, I know I am saving lives that no one else could. If I wasn't watching over their loved ones as they struggle to breath, these patients would not have made it out of the unit. I am making a difference and that is empowering."
But despite always choosing nursing no matter what, this time certainly has been anything but easy. It has taken a toll on some of their emotional health, physical health and their families. When I asked what is their biggest fear right now, every single one of them said something regarding "fear of a loved one getting the virus", whether that was their child, spouse, or a parent. They didn't even mention fear of themselves getting it, only their loved ones. I too, can agree that is my biggest fear. In order to protect their own loved ones, they've each had to go through intense measures. Reagan shared, "I have a little girl at home and my husband and I are both ER nurses. It's tough for us because we can't just stay at home to keep ourselves and little one safe." So, appreciate that you can out there. Kayla shared that she hasn't seen her family, including mother, stepchildren and Nana since the beginning of the quarantine as she has been self isolating in between shifts. She shared that no matter the wait, when she gets to hug her family again for the first time, she will never let go. Nicolette actually acquired the virus herself which took a significant toll on her, her young son and husband, "My husband is an engineer that works for a company that makes ventilators. We were both much needed at work and at home with no alternative child support. Things only got worse once I got sick with COVID and had to isolate from my family. My husband became the only caregiver to our son, in addition to intensely working."
This has changed each and every one of them as a nurse and in how they approach their view of nursing, in some good ways and in some negative ways. Miranda shared, "Every day is uncertain and because of that I am anxious. I have been heartbroken many times when I see patients uncomfortable and fighting for their life...alone." As a nightshift nurse, Miranda shared that she was never personally a fan of family members lingering at the bedside but now sees the vital role and importance of family members being able to be present at their loved ones side- having that critical support system is key to recovery. She stated that is something in her nursing career she will never take for granted again. Reagan agreed from the Emergency Department sharing, "I have seen more people die in the past few months than I have in the past year. I've watched as someone cried at their diagnosis knowing they were likely never going to see family and grandkids ever again. We deal with tricky diagnoses every day, but this is just so heartbreaking." Christopher from the ICU shared that this pandemic has made nursing the dominant bedside force. Others felt differently in how they experienced this pandemic, sharing "This pandemic has strained my love for bedside nursing. Its not the sick patients or numerous deaths, its the political and poor administration support that we have at the bedside that I have never felt so dispensable", shared Kayla from the ICU. Nicolette agreed, stating "I lost trust in organizations and felt abandoned to drown more times than I can count". On the shift before she got sick herself, she had all 8 COVID patients, all in need of frequent and intense care. Tyler as a nurse manager shared how positive it has been seeing all of the love and the support (donations, food, cards, letters) outpouring from the local community. But as a nurse manager in a leadership position, he states "Its a difficult time to manage staff. They are scared and there is a lot of unknown. I feel like information is always evolving and changing and it's difficult to maintain trust amongst staff."
A common theme from the group was a newfound sense of anxiety but also calm and a mixture of both, for some. Everyone thinks nurses are immune, that they've seen it all so they can't be affected. But they certainly can. They too are so human and take in everything that is happening directly to their soul. Miranda shared that "this pandemic has brought out the cranky part of me. I've been on edge at work. We are all working so hard and stressed out. It's very exhausting at times. I've recognized this flaw and am working on channeling my inner peace." Reagan shared that "I am typically a very calm person but I struggled with a lot of anxiety in the beginning because there is so much unknown with the virus." But they all shared something positive that is keeping them sane during this tough time. Christopher goes out running between shifts. Reagan has picked up a new hobby to stay busy and tries to get outside with her family during the nice weather. Nicolette is looking into counseling services. Tyler disconnects from work when he goes home and plays games with his children and works on house projects. Kayla is working on her degree as a nurse practitioner. Kayla writes, "If I could give any advice, always keep your body and mind busy and the stress is easier to handle." I challenged them all to share a positive thing this crisis has brought them, and they shared many. Extubations and discharges home, seeing a newfound kindness and humanity in strangers, seeing themselves grow with new skills and hobbies, seeing a decline in COVID cases (thank you social distancing!) and seeing their own loved ones get better. Miranda shares from her organization "Every time a COVID patient is discharged from the hospital they play a song for the patient and we all line up at the door to cheer them on as they exit the building. The patients love it and we get to celebrate with them. This proves that there is hope out there. We can always turn negatives into positives." That was beautifully said by Miranda and I can attest with my own experience, after strenuous bedside work- having those positive moments where you can cheer a patient on together as one big community is something she will likely remember forever from her nursing practice.
American Healthcare will change, we have no way around changing at this point. We have already changed drastically and will continue to do so. Things we didn't think were possible "yet" or were on the backburner, now suddenly are the top priorities. As an informatics nurse, I've seen first hand a huge shift in the way patients are seeing their doctors. What once was a "once in awhile thing" that was originally advertised as an option a patient could do if they had the flu and just wanted to connect with a doctor via Facetime, is now a common occurrence. Most of our well visits and sick visits have been converted to "telehealth" visits. Doctors and nurses are also using I-pads to be able to round with their patients electronically from outside the room without having to enter into a COVID room multiple times. This prepares nurses to assemble themselves and get what they truly need to be able to "bundle their care" and handle multiple tasks for the patient at once. Patients are using I-pads to communicate with family members and to connect with specialist providers that may be home, in the office or another hospital. These are all things we were "slowly working on" that launched into all-hands on deck to make happen in a matter of weeks. But it truly all has made a difference and will permanently shift how we provide American healthcare. Miranda experienced that exact shift in technology, sharing "I have adapted to using more technology and allowing patients and family to see each other on Facetime on Ipads."
There are other shifts happening in healthcare, non-technology related also. Nurses are seeing a new sense of community, within and outside the hospital. "A lot of flaws in the system were exposed and with every tragic event we learn from that experience. I have seen great teamwork, also. What once used to be a battle of the departments has become a unity of the hospital. We are all in this together." Shared Miranda from the Medical Surgical floor. The Emergency department is also seeing a shift in care, Reagan states "the ER has been filled with true emergencies and less non emergency cases"- like the ER was always meant to be. This has shifted peoples train of thought to, "do I really need to go to the ER for this sore throat or can it wait until Monday when my doctor is open?" It has opened up more avenues for urgent cares and other forms of healthcare delivery with a primary care provider. The ER was always meant to be there only for true emergencies, as if you must be close to dying in order to come in (heart attacks, strokes, loss of some sort of function, a broken limb, a missing limb, trauma, etc.), but has evolved over the years into being that level of trauma but also bogged down with the "my leg has been sore for 2 years" and "i have a runny nose" cases. I too hope that the ER can see a permanent shift in care delivery mindset. The ultimate goal is to keep people out of the hospital that don't need to be there, and shifting as much care as possible to be in peoples homes.
These six nurses are some of the strongest people I know. They are exhausted. They are suffering. But they are showing up every day. For you. So YOU can stay home. They are working beyond their normal job roles to make sure you stay safe. Their hearts break a thousand times over each shift they endure. They are crying for and WITH your family members that they care for. They are scared. They need a little bit of extra love right now. So if you know a nurse in your life, give them some extra (non-physical) love right now. Kayla from the ICU asks of everyone in the community, "Don't call me a hero. Just say thank you, practice social distancing, and follow the recommendations of the department of health. Remember, practicing social distancing and wearing a mask is not about you, it is about the people you come in contact with. The world is smaller than you think. Don't think your actions do not have consequences, they can kill someone. It's also not just nursing that needs extra love and kindness right now, remember food services, grocery store workers, truck drivers, warehouse workers, police, firemen, and others in public service. Without them, we would be in true chaos." I couldn't have said it better myself, Kayla!
Thank you to my audience for reading and for listening to these six nurses stories. I am so thankful they all agreed to participate in my idea and to share their feelings, emotions, honest thoughts and stories. This is no where near over but we are adapting, we are getting stronger, we are learning. Healthcare is changing. We will come out stronger from this. Our nurses will come out stronger than they ever were before when this is over.
Thank you for reading. Thank a nurse.
Below is a picture that I saw from another local nurse. This is not one of the nurses that wrote in, but when I saw the picture, it composed every single emotion and honesty that every nurse out there understands, so with her permission I wanted to share.
Photo credit: Miguel Farias
A Writer in Nurse's Body
Friday, April 24, 2020
Monday, February 29, 2016
Wednesday, February 24, 2016
So I have a ton of homework to do, which makes me that much better of a blog writer! Hah. No really though, I write better when I'm avoiding doing something else. And I have a good excuse anyway, because this topic has been on my mind for about a month, clawing to get out.
Actually this may even count towards homework because I'm doing research on this for school, so boo yah!
Let me give you the first scenario I have, to slowly dip ya'll into my mindset here.
One month ago, I was assisting/as needed/general help down in our ICU department. After being there for a few, I quickly learned about a case down there. He was an 84 year old gentleman, who had been a code blue (he stopped breathing and no pulse) while on a Med/Surg Floor. He was a "Full Code" at the time, which means we do everything in our possible power to bring a patient back to the living world. We had brought him back to life, and any patient that goes through this automatically gets transferred to the ICU afterwards, no questions asked. There is never a case where we thump on someones chest and shock them and bring them back to life, and then are like, hey- want some apple juice? You seem fine to me! No.
So on he transferred to the ICU, hence where I met up with his case. I heard the ICU nurses talking, their "nursing spidey sense" that I know all too well was all in effect, as they all had a feeling this man was going to die that night again. However, this time his family had decided that this time he would not be a "Full Code". What happens if you aren't a Full Code? You have other options. But in my opinion (and I'll explain this more later) the best option is to pass away peacefully with lots of morphine and silence, and someone holding my hand so I know I'm not alone.
When the ICU nurses noticed his heart rate start to slow down, we knew impending death was soon. Our patient was trying to cross that line and was getting closer. We all agreed to go be with him, as his family had left for the night thinking he would make it overnight and they would say goodbye in the morning. Obviously that wasn't the case. We all stood by him, holding his hand, as we watched at his bedside his alarms going off, his heart rate slowing down dramatically, his breathing erratic. Me, being non-immune to all the alarms in the ICU, only heard the sound of the ventilator (breathing machine) pumping artificial breaths into this man, trying to keep him alive despite higher powers at play.
As sad as this case may seem (if you think that was sad, get your tissues out now), it actually wasn't as bad as it could have been. The reason this man's family didn't want him to be a "full code" in case he passed away again was because they had already seen him code the first time. The general public (hence his family) don't actually know what we mean when we say "Full Code". Doctors ask when you get admitted, usually regardless of your condition, "In the event of your pulse stops or your lungs stop breathing, do you want us to do everything in our power to bring you back?" Given that sentence, that sounds lovely, why yes! Bring me back! At the snap of your finger, or with your magical powerful wand. Bring my loved one back! However, what most doctors fail to mention is what a Full code really entails. It's not quick. It's not quiet. It's not painless. And its certainly not magical.
For my non-medical readers, let me give you a quick low-down on what happens during a full code on a typical case. Please don't read this paragraph if you get queasy! But I do intend to paint an accurate picture. We automatically begin CPR. You all have seen CPR on TV at some point I'm sure, and the patient always wakes back up within a minute or two. But have you ever seen CPR in real life? If so, you know that the recommended depth of compressions is 2-2.4" into your chest. Imagine someone right now pushing your ribs in 2", without you backing up. Pushing in 2" while you are laying down, helpless. Yes, ribs are usually broken. We also are doing this at 100 pumps per minute, no less. And we don't stop until the patient does return to life or a family member calls this effort off, or the doctor deems it medically impossible if the code has gone on too long. And that's not all. When we start doing compressions, someone is operating an external airway with whats called an "Ambu" bag, to deliver you 100% oxygen. This is only until we can complete something called "Intubation" where we insert a tube through your mouth and down your throat and into your lungs so that we can hook you up to a ventilator to do the breathing for you. Oh and that's not all. If you have had anything to eat or drink within the last couple hours, what do you think is going to happen when we are jumping up and down on your chest? Yeah, it's going to come back up! When you're lying on your back unconscious! And we will suction as much out as possible, but it still will be everywhere.
So, that all being said, do you think if Doctors really painted that picture when we asked patients if they want to be a full code, do you think as many patients or patients family members would still want to be a full code? I don't think so. Now I've witnessed hundreds of doctors have this very conversation, and some paint a pretty picture and some don't. However, very very few actually go into detail about what really happens. Why not? Because it seems harsh! It is harsh! That paragraph above is horrible if you imagine it happening to you or your family member. If you get admitted with a broken arm, we still ask you if you want to be a full code. We ask everybody, because you never know what could happen. Life works in mysterious ways. Just a few months ago I remember a case of a man admitted with a UTI (urinary tract infection) but otherwise completely OK. Then BAM, had a massive heart attack while on our floor and coded. You never know.
So if you get admitted with a broken arm or a UTI, and here comes the doctor asking if you want us to save your life if you die? You're automatically going to be like WTF, I have a broken bone- are you not telling me something? Am I dying? If I'm not, why are you asking me this?
Or if the patient does understand the fact that this question is asked of everyone regardless of diagnosis or age, then many patients think that we are "giving up" or "won't treat" the patients condition if they agree to not be a full code. Their logic may be, "well if they aren't going to save my life then whats the point of even being here, or being treated?" Well that simply is completely logical. It is a reasonable way of thinking, but I assure you it is not true. I can say with complete and utter 100% confidence that I have witnessed on so many cases, where the doctors and nurses do so much to help a patient feel better or improve their condition, even if the case is eventually terminal. I promise you, healthcare will never ignore you or not treat you for your current condition as much as possible just because you agree not to be a Full Code if death occurs.
Now don't get me wrong at all, some people should be a Full Code! Absolutely! Let's say you do come in with that broken arm, or are having a heart attack, or a UTI, or whatever- but you are otherwise healthy- You live a happy, meaningful life- You should be a Full Code! You also have the best chance to also survive a full code as your body is healthy besides what is going on now. If we catch your heart stop beating immediately, chances are we will definitely get it back to beating within a very short time frame, especially if your body is remotely healthy. What irks me however is when doctors are unrealistic with those that aren't healthy. Those that come in with terminal cancer. Or have advanced Alzheimer's disease or dementia, or have any end-stage disease (heart disease, kidney disease, lung disease, etc.) Doctor's hit you with what I call a "Double-Positive Whammy", they make you think that death isn't impending soon from your disease, but just in case it is- If you are a full code, we will do everything in our power to bring you back and it will probably be successful! No.
I have been doing a lot of thinking on this and a lot of reflection within myself, my beliefs, my patients, my nursing practice.... and I still firmly believe in what I'm what about to say. I know a lot of people may disagree with me, and I encourage that- Everyone is entitled to their own opinions, especially with ethically situations such as these. I'm entitled to your opinion as are you.
I don't care if you are 18, or if you are 30, 40, 60 or 100. If you have a disease that is slowly killing you, I see no reason to hold off the inevitable. Now that is a FINE LINE. For example, let's say a healthy person gets diagnosed with cancer. I completely support the notion of undergoing treatment (surgery, chemo, radiation, etc.) I mean, you were healthy before! But what about after 10 years of treatment after treatment? How is your quality of life doing? Chances are, the patient themself already has a different opinion about their own end-of-life than their family or loved ones do. What I intend to make a point of here, is that regardless of age, if an individual either has a terminal disease, more than three major comorbidities (any major chronic disease that takes a significant toll on your quality of life), or are experiencing a poor quality of life (not eating, not happy, unable to do favorite activities, hobbies, cognitively impaired, etc) then in my honest opinion, they at least deserve the honest picture of what a full code truly means, and then they can decide. I'm not saying it should be mandated that these cases should automatically be a no-code based on an algorithm, that would be unethical. But they at least deserve the honest truth about the decision. The rest is up to them.
The last scenario I would like to share with you (if you are still reading) is a case that really pushed my feelings over the edge. Recently my unit took care of a very sweet elderly lady of the age of 96. She had multiple medical problems and was admitted with anemia (low blood count) due to gastrointestinal bleeding. She was with us for awhile with no events. Sent home. Family brought her right back due to intense abdominal pain. Again she stayed with us for awhile. Her blood counts kept dropping, there was no way to keep up with it. Her internal bleeding was too severe. Meanwhile, she was absolutely miserable- She couldn't urinate on her own- leading to us straight-cathing her every couple of hours- she was in immeasurable amounts of abdominal pain, and she had a very poor appetite. And yet her daughter was her POA (Power of Attorney) and watched over everything regarding her moms care. And yep, You guessed it! This patient was made a Full Code. Decided by whom? You guessed it! The daughter.
One night, her vital signs started significantly dropping. The bleeding too severe for her body to compensate with. It came time that using our own nursing judgement, being that she was a Full Code, with the vital signs the way they were- she was quickly knocking down deaths door. If she was going to remain a Full code, we needed to treat her like a Full Code and get her to the ICU before she codes, that way she gets more intensive treatment to prevent that from happening. So we called what is known is as an RRT (Rapid Response Team) which is sort of like a pre-code. The patient isn't coding yet, but could be on their way soon if we don't fix the problem now. So of course during a RRT, a lot of healthcare personnel show up. Multiple RNs, Med Surg and ICU, 1-2 Respiratory therapists, a doctor or PA/NP, nursing supervisor, etc. We always draw bloodwork, usually put in a new IV. There's people everywhere and the bright lights are on in your face. Its like a code except you are awake and aware for it all. Well, this sweet lady is terrified and is screaming in pain. She's also crying, "Please, no." "Don't do this to me." "Let me die." "I want to die." "Don't do this." "stop this". And yet, because her daughter has the POA (who happened to be in the room watching this whole scenario unfold), the daughter has the decision on the code status. And despite her mom crying in pain and agony, the daughter demanded we do everything possible to save her. Maybe, maybe not- but if the daughter really knew what a code really meant, would she come to her senses and not want that for her mom?
If a loved one of mine were in the situation, don't get me wrong- Its awful. It's incredibly sad & frightening. But If i knew that my loved ones medical condition had made their life quality so horrible and they didn't want to live anymore, or they were in immense amounts of pain, I would never prolong the inevitable. I would of course want to treat them and care for them, but if the higher powers decide its their turn to go, then all I want for them is to not be alone and to not be in pain as they make that journey. I think that's the best gift I can give them as their own loved one.
Thank you for reading. I know its a hard topic, and a never-ending one. A very ethical one, and I know a lot of people will disagree with me. Chances are, not a lot of nurses will disagree with me, however. Because we see this every day. We see cases like these two every day. We are immune to the sadness, the awfulness of it all. We are trained to do what we have to do. If someone wants to be a full code, then so be it, we will do everything we can to save your life. Just be sure its really what you want for yourself or your family member.
With love and passion for humanity,
A writer in a nurses body <3 nbsp="" p="">