december pages

dear muffin,

hi. remember me?

I feel like a wombat that just crawled out of its cave after a long hibernation, blinking in the crystalline sun & suddenly remembering what wind tastes like. [whether or not wombats actually hibernate is entirely irrelevant.]

the fact of the matter is, nursing school is over. the chapter is closed, every word read. I am now one of those post-grad creatures wandering between the world of textbooks and an ever-growing pile of job applications. I said goodbye to Harper for the last time today & felt just a bit sad. a chapter of my life was lived in those hallways, and I'm always sad when a page turns. no going back.

mostly, though, I miss the ER. I miss Doug & Kate & Chris & Diego & Rachel & Justyna & Kurt & Lori & Ryan & Amber & Dr. Sevier & Adam & the other Adam. I miss the jokes and teasing. I miss the crazy patients, nice patients, frightened patients, grumpy patients. I miss the warm rush of satisfaction when an IV slides into place. I miss feeling like a grown up as we all hang out in the break room, eating our lunches and talking. I’ve grown over the past 8 weeks, and I know I’ll remember these days as some of the best in my life.

* * * *

the ambulance theme song catches my attention from across the nurse’s station. I close my charting and jog over just as Kate, my preceptor, picks up the receiver. “This is Northwest Base, go ahead.”

“Northwest, this is Palatine 25. how do you copy?”

“loud and clear, Palatine. go ahead.”

“alright, we have a 73-year-old man found non-responsive at home after a suspected heart attack. he was PEA on the monitor when we got to him, but since then we’ve been able to feel a carotid a few times. pulse is gone now. we started compressions, put in a King airway, & got a line in him. bringing him in now, ETA 6 minutes…”

someone scrambles to call a Cardiac Alert for room Bravo-2. we pour into the room with a crash cart, clearing the floor, piling equipment and priming bags of fluid. we are ready when the paramedics burst in with the wheeled stretcher, delivering chest compressions as they approach.

a paramedic gives report amidst the flurried activity. “we’ve given him 5 doses of epinephrine but haven’t gotten a pulse back. he’s gone into v-fib a few times, but mostly he’s flat-lining.”

I catch sight of a tech about to draw blood; in a burst of courage I flag him down.

“hey, I’ll start an IV and get blood from that instead.” he nods and pushes the tubes and tourniquet in my direction. I jump in without thinking twice.

the patient’s arm feels like cold wax beneath my fingers; dead weight. there is no twitch when I slide the needle into his vein, no exclamation of pain. his arm jerks rhythmically as someone delivers chest compressions. I calm my breathing and search for the blood flash. bang; got it. the IV is in. I hang a bag of fluid wide open and step back.

“I need a med nurse!” someone calls. I don’t even hesitate.

“got it! what do you want?”

the doctor considers. “epi. let’s try it again.”

I have never set up an epinephrine cartridge before. once, after a simulation, my instructor passed a cartridge around and explained how it works. “you pull off the yellow tab, twist the two parts together, and you’re set.” now, staring at the pieces as I dump them out of the box, it seems more complicated. I jam the cartridge into the injector and double-check with the tech.

“did I do that right?”

he nods. “you’re good to go.”

“Kate!” I call as I scrub an IV port. “first dose of epi is going in... now.” she nods and records the time.

thump, thump, thump. the room is still except for the tech delivering chest compressions. it feels like we’re holding our breath as we wait for the epi to take effect.

flat line.

10 minutes of compressions and 2 doses of epi later, the doctor uses an ultrasound to check for heart activity.

“I got nothing. anyone object if I declare it?”

no one speaks. we know there’s nothing else to be done; 7 doses of epi would jump-start a stone.

“alright,” says the doctor. “I’m calling it at 4:33. you can stop compressions.” the tech steps down from his stool and drags a shaking arm across his forehead. compressions are a workout by anyone’s standard.

“I’ll send the family to the viewing room. go ahead and get the body ready.”

suddenly, the room is quiet. it’s just me, Kate, and a tech. Kate is filling out her time-keeping page, so I turn towards the bed.

the white body lies bare, glaringly pale in the fluorescent light. his chest is extended as though with a deep breath; the ventilator left air in his lungs. I stare for a moment, half-expecting an exhale to relieve the tension. but he lies rigid.

“hey, would you mind…?” the tech points towards the man’s eyes, and I realize I’m the only person still wearing gloves. I step over and gently press the man’s eyes closed, but not before I see the vast emptiness staring up at the ceiling.

“the family is here; I’ll take him over,” announces someone in the doorway. with that, we are alone in the room, left to clean up papers, plastic packaging, and EKG stickers off the floor. to prepare the room for the next patient.

life is a thread. this christmas, look around you at the people you hold dearest. notice each one. because pages turn, & you will never return to this one.

I hope today’s page was beautiful for you. tomorrow, we will share a page. & I am thankful for that.

love always,

rory

ER

hello, muffin.

I missed two IV starts today. they should have been fine: the first was a 36-year-old man with veins you could see from across the room. he looked me straight in the eye & gave me a big, relaxed smile when I asked to start his IV; somehow, that unnerved me more than anything. the other patient was experiencing a possible heart attack. his face was bunched up in pain as I set up my supplies. I couldn't feel his vein, but I could see it faintly traced beneath his olive skin. both times I slipped the needle in & felt my heart drop when the little red flash didn't appear. the nurse silently took over, giving no further indication of my failure. but I felt it.

in post-conference, the other students eagerly asked what I did in the ER. I gave a brief report & admitted that I missed two IVs. "Both of them?" their eyes said incredulously. but they were quick to reassure me. everyone has to learn somehow. it's okay. it's no big deal. let it roll off. 

God gives us what we need. I needed a little humbling today. 

highlight of my day: being assigned to watch a patient's 4-year-old daughter, who spoke only Spanish. but that was alright, because we both spoke the language of Peekaboo, Fishy Faces, & Listen-To-Kristen's-Heart-With-Her-Stethoscope. she was my shy little friend: no questions asked. when it was just me & her, I didn't have to worry about looking grown-up and official. [I dislike acting like more than I am, but I stubbornly insist on trying anyway. let.it.go.]

as I did my 0945 charting, it hit me like a thunderbolt. 11 September. September 11th; 9/11. today. I looked around the ER with new eyes, wondering what it would be like to see its halls transformed by chaos and unbelievable reports from the field. trauma patients pouring in through the paramedic bay, trauma alerts sounding over the intercom, each room a scene of tragedy happening in real-time. what would it be like? what was it like? 

I can't even imagine. God help the people whose memories are forever stamped with that scene. may He bring them the comfort that can only come from His presence.

can you feel that? that's your heart beating against your ribs. it's your lungs expanding in perfect harmony. 

it's a gift. 

always,

rory

life is beautiful

dear muffin,

she was nervous. I couldn't blame her.

terse replies were all I could draw out as I finished my work; her face was taut, expressionless.

it's doubtful that anyone in the history of the scalpel has not been nervous in those moments of waiting. moments before the wheels begin to clatter along tile floor, rolling past sterile operating rooms. after all, the idea of having one's insides opened to the world has never been a pleasant one. 

"okay then! I think we're ready." the nurse deposited an armful of IV bags & tubing into my waiting hands. "make sure you keep that piggyback higher than the primary fluid," she said in my direction. 

we helped the woman onto her feet, allowing her to smooth back disheveled blonde hair, & began the procession. the nurse led the way with routine briskness, followed by the patient herself. I took up the rear, holding the IV bags at shoulder height & keeping the train of tubing off the floor. 

her surgery was scheduled for 0800 hours, which meant it was already 30 minutes behind schedule. but no matter. the mass of foreign tissue growing below her diaphragm would be removed, the incision sutured, & before she knew it the whole ordeal would be over. still, no reassurance can shorten the moments before the plunge.

inside the operating room, every surface glinted in sterile perfection. scalpels arrayed with mathematical precision, gauze neatly stacked, suction equipment hooked up & tested. sterile blue drapes were spread over the table, ready to receive the patient.

"and, the surgeons are here." announced the circulating nurse. "Michelle, you want to get them ready?" the scrub nurse nodded & began unfolding blue plastic gowns as the surgeons poured into the room, followed by the woman's husband-- who looked ready to faint. while they scrubbed in, the anesthesiologist struck up small talk with the patient.

"so. how're you feeling?" he asked after a moment. the woman laughed shakily.

"you know that part on a roller coaster, when you're going up & all you can hear is 'click...click...click...?' that's what this part feels like." 

"alright!" announced the head surgeon. "we're a go." the light glanced off the first scalpel as it went in. 

blood. blood trickling down a swollen abdomen. the smell of burnt flesh as cautery hits blood vessel. the surgeons opened the skin with a smooth cut & then burned back the yellow fat beneath. I moved to get a better view.

there; I could see it. a mass rose into sight as the abdominal muscles separated. it was smooth, taupe-colored, with a complex pattern of blood vessels visible beneath the surface. it was larger than I had imagined. the surgeon made one final slice, reached in deep, & pulled. as he lifted, the foreign body came free in his hands.

he held up 8 pounds, 3 ounces of tissue. & as he moved it towards the light, it kicked him.

the room launched into motion. nurses closed in, transferring the now-wriggling mass to a table. the table disappeared from view as blue scrubs bent over to perform a well-practiced dance.

"heart rate 150."

"BP 67 over 35."

"O2 sats?"

"68."

"looks good!" announced the pediatrician, laying aside his stethoscope. a nurse gathered up the bundle & brought it over to the woman & her husband, who was furiously rubbing away tears of joy.

"Here you go," said the nurse with a smile. "Congratulations; she's beautiful."

-rory

0500

dear muffin,

it's dark at 0500 hours. dark & cold. bursting out of the revolving door and into the hospital is always a relief: warmth, light, & the smell of cafeteria coffee rush forward. 

this morning was no different. in a blink I found myself walking around an oncology unit with the night-shift nurse & the oncoming day nurse. my pen tried valiantly to keep up with a steady stream of patient information, IV drip rates, recent vital signs, & critical lab values as the night-shift nurse delivered her report.

slipping into the first room, I peered through the darkness and detected a shallow rise & fall beneath the bed linens. lying on the bed amidst blinking monitors & an IV pump was a man younger than my father.

"former army doctor. stationed in the middle east." the night-nurse says. "he contracted hepatitis while working there; he's terminal now. comfort care only... there's nothing more we can do for him." 

I watched as the IV pump's blue light blinked across his face. it must be nearly impossible to sleep with so many distractions: lights, beeps, blinks, alarms. nurses checking on him, talking in his room. talking about him. 

we moved to the next room, and I gently closed the door behind us. the nurse was talking again.

"...and here's 11A: he's septic. history of cancer of the head, neck, esophagus, liver, & kidney. his magnesium level is down to 1.2 this morning." she gave the oncoming nurse an exasperated expression. "the doctor's been steadily increasing his dosage, but he just keeps dropping. we don't know what's going on." 

the little old man craned his neck out of the bed linens. his head was wrapped snuggly in a knit beanie. 

"eh? you're who?" he said when I introduced myself. "oh, hi kristen-the-nursing-student. it's not wednesday anymore." he cocked his head & glared at me.

I must have looked uncertain.

"THAT!" he said, pointing to the whiteboard opposite his bed. a preprinted calendar had been attached, and "wednesday" was circled in blue dry erase marker, followed by yesterday's date.

"oh! no, it certainly isn't wednesday anymore. here, let me fix it for you." I rubbed out the old date & circled thursday, then added my name beside the nurse's. suddenly I was struck by how much my signature looked like a kid's, squeezed in beside the nurse's official-looking scrawl.

the nurses had already left me behind, marching on to the next room & the next patient. I walked over to the man's bed and & gave him a big smile. 

his eyes were surprisingly clear. pained, but bright. in them I could see the toughened weariness that comes with long medical battles. his chart had told me that this was the fourth time he'd been hospitalized with sepsis in the last ten years. this time they'd had to insert a chest tube. [which is exactly as unpleasant as it sounds.] as soon as the tube was in place, 3 liters of infected fluid came flooding out of his lung cavity. I didn't even know there was room for 3 liters of fluid inside the lung cavity.

a portion of my mind began a routine assessment of the man. airway open; oxygen running smoothly at 2 L, nasal cannula. wheezing. a coarse cough that sounded like it could drown him at any moment. breathing so labored that it made his abdomen heave with the effort. but eyes bright, and locked onto mine.

"I'll be back in a little while," I said. "...but is there anything I can do for you right now?"

do for me? those eyes asked. what can you do for me?

"nah," the man said. "I'm fine. thanks, though."

I spent the rest of the shift trying to do something for him. I'd like to think I brightened his day; made him more comfortable, explained something that had confused him. for 6 hours, his problems were my problems & my sole responsibility was to help him through the day.

but at the end of every shift, I go home. I share my stories with my family while heating up leftovers for a late lunch. stories. that's what the patients become.

"oh, you shoulda been here last night." the nurse said when I joined her back at the nurse's station. "I had to call a code on 504A. I saw her heart monitor go flat, so I figured her chest leads had just fallen off... but I walked into the room & she was all slumped over. blue. she had a 'do not resuscitate' order in her chart, so we couldn't even touch her. the entire code team had to just stand there & watch as she died." the nurse sipped her starbucks & went back to charting.

my patient could code tonight. he could stop breathing & never start again, like the patient in 504A. I would never hear about it. from now until forever, he's a story to me. just like 504A is now a story to that nurse.

it's a strange business. 

and on that cheery note, I toddle off to bed. count your blessings as you fall asleep... at the top of my list tonight are 1) health. this may sound funny coming from a girl who currently sports a fever. but a day in the hospital never ceases to drive me to thankfulness. I could have lymphoma, heart failure, brain tumor! amyotrophic lateral sclerosis, Hashimoto's encephalopathy, schizophrenia! but all I have is a slight, non-threatening elevation of body temperature that will most likely resolve itself in under 48 hours. gah.

2), this amazing planet God has given us. if you haven't watched this video yet, go do it. http://www.danoah.com/2011/11/the-most-amazing-time-lapse-video-ive-ever-seen.html

and 3), the heroes who daily risk their lives for ours. may we never take for granted the sacrifices they make for us.

always,

rory