One night as the charge nurse working in a Pediatric Intensive Care unit for a Level I trauma center, I got a call from the ER. It was the kind of call that immediately sends your adrenal glands into overdrive. "We have two children coming in with multiple gunshot wounds. Can anyone come down to help?" My answer was an immediate "yes" before I even knew how to cover my unit. Everyone was in an assignment except for one who was our resource nurse for the shift. I quickly told her what was happening and asked her to call our doctors to see who could be transferred out in order to open beds in the event we would be admitting these two children. The rest would have to unfold as the night went on. I then grabbed my stethoscope and ran. As I was running down the hall to the elevators, and then across three units, through a long corridor connecting the "old" section of the hospital to the "new", down several floors, my heart and thoughts were racing. What will I see when I get there? Will I freeze? Will I be able to help? Who could do this sort of thing to a child?
I entered the ER through a door only hospital personnel had access to. And usually, my badge didn't work and I would frustratingly search until I found a way in. This time, the door opened on the first swipe as if to say "Come on in. We are expecting you."
Immediately, one of the ER nurses saw me and directed me to the trauma bay they were setting up for the children. I quickly donned my cover gown, gloves and mask.
The room was packed with people who all had that look about them one has when you are about to face something horrible. I remember scanning the room looking for the best place for me to be and busied myself assisting those setting up central line trays and whatever else I could help with when the first patient arrived. BAM! The doors flew open. The paramedics brought the patient in and placed her on the gurney. It wasn't a child though. It was an adult woman.
The ER personnel immediately began attending to her as I overheard the paramedics give report. "This is the mother. The four year old was pronounced at the scene. The two year old is on the way right behind us." Within seconds, the two year old was there. At that moment, the experience that changed my life forever began to unfold.
The rest of us who were there for the child jumped in. Most of that time was spent trying to get any sort of IV access. Two physicians worked on either side of her trying to start femoral lines. The IO she came in with failed as did several other attempts to place another. Several attempts at PIV's failed. There were no less than four people working on her simultaneously as nothing could be done, aside from maintaining her airway, until IV access was achieved. Somehow, she had a decent blood pressure and heart rate. Then finally, a working IO was established.
The doctors ordered a head CT and we raced down the hall to the imaging department. While the patient was in the scanner, I stepped out into the hallway to contact my unit and gave report to the nurse I left in charge asking her to get a bed ready. At that moment, the scan was over and we raced to get the patient to our PICU taking the same long, arduous journey I took to get there. Seconds seemed like minutes and minutes like hours. All you can do is breath, stay focused in the moment and try not to trip. Watch out for that bump on the floor. Grab that IV tubing about to get caught in the gurney wheels. Careful! An elderly patient is ahead walking the hall with his IV pole in tow. As I looked around, I noticed the same paramedics who brought her in were still with us. Hmm?...I thought, that is unusual, and we continued down the hall.
Finally, we were in the PICU, my comfort zone. My co-workers, our attending physician, the neurosurgeon on call, the house supervisor, and several police officers were there. I felt some relief. It was almost the end of the shift and there were a few nurses straggling in for the next and one "extra" nurse who came in early waiting for us when we arrived. As I turned her over to our staff and gave report as best I could, I realized I didn't even know her name. I saw the police detectives sitting outside her room and approached them. I introduced myself and asked them to tell me what they could. "Well, we are not sure of her name. This is what we know. The father went on a rampage and shot everyone in the home and then himself. There were several children, visiting relatives, and a couple others unidentified. The mother and this child are the only survivors at this time."
As their words flowed in attempts to answer my questions, they relived the scene in recollection. They described what they saw upon entering the home. They looked toward each other for confirmation as they recounted..."Oh yeah and there was that adolescent draped over the chair and down the hall is where the two year old was found." Then, all of a sudden my attention was drawn towards the patient. She was coding.
When I entered the room to assist, I saw my colleagues hand's shaking as they drew up the Epi. I saw the same two paramedics still there helping as they could. I saw the neurosurgeon who was in the process of inserting an EVD move away from the bed to make way for our attending who had tears streaming down his cheek. In spite of shaking hands and tears, I saw the team working in unison with multiple parts functioning as they should like a well-oiled machine. Everyone was focused at their task at hand doing what we are trained to do. The crash cart was in the perfect position. There was plenty of room for everyone to work. The Respiratory therapist was bagging her little body with perfect rhythm in precise flow. As I stood at attention, ready to jump in when needed, I noticed something very different in this resuscitation scene than what I had witnessed in the past. No one was edgy. No one was impatient. It flowed so kindly. There was palpable kindness flowing through that room. But then, within a few more minutes the attending "called it" and we let he go.
You see, she had been shot in the head. There was brain matter exposed. The CT scan showed her injury to be "inconsistent with life." She had been down for periods of time off and on while with us and possibly before she was found in her home. I didn't know the results of the CT scan or how much time had passed before the paramedics could care for her until that moment. I barely knew anything factual about her throughout the entire time I was involved in her care. I simply functioned in the moment, moving from one responsibility to the next while I contained my thoughts and steadied my own shaking hands. It was now a few hours past the end of my shift.
That didn't matter. I had to complete a pile of charting, as accurately as possible, to document the care I provided over several hours starting in the ER, to CT and then finally in my unit. I don't remember how many forms I completed or even if I completed all I should have completed. I did my best in that moment. It was time for me to leave.
As I entered my car for the hour long drive home in the wee hours of the morning, I began to cry. And then, just as the tears began to flow, I had to shut them off. I had to focus on getting myself home safely. It was as if I was two people at the same time. The one who just experienced one of the most horrific things a nurse can experience and was about to fall apart, and the one who had to hold it all together as if nothing happened for just one more hour until safely home where I didn't have to make important decisions with rapid fire speed that could effect a person's life. Once I got there, my family safe and sound, I began to recount. The more I recounted, the more questions I had and none of them could be answered. They were the philosophical types of questions like, "What am I here (on earth) for?" The analytical type like, "How on earth did she maintain a blood pressure and heart rate?" My mind went in circles. I finally fell asleep.
The next day I awoke and immediately remembered what happened the night before. I sobbed and sobbed and sobbed. I couldn't even have verbalized why I was crying...not in any sort of organized, "this is what the problem is" kind of way. I knew we all did all we could do. I knew I had functioned well in her care. I knew there was no satisfying answer to why people do the things her father had done, but the thought of returning to work terrified me. As the day went on, and the next passed by and the next, I realized I needed help and got in touch with the EAP folks at work. I learned I was traumatized and was told I had PTSD. PTSD, really? From there I received therapy, and it took the better part of a month to recover enough to return to work. I learned that it is not always the one incident that causes a PTSD reaction and that it often is a culmination of things over time that leads to that final straw. To be sure, this was, in deed, one of the worst situations I had ever experienced as a nurse. I have been a part of many tragic and sad situations as most nurses, paramedics, and doctors have experienced in their practice. What was different now? Why now? I began to analyze.
First, there was the call from the ER which had me scared. Could I measure up in this unfamiliar environment? In Critical Care units we receive the patients pretty much cleaned up, IVs started, ventilators running. In the ER that night when they first brought in the mother, she came in with a bang, quickly tossed onto the gurney, still in her underwear with her body covered in blood, and dirt as she had crawled out of her home, dragging herself through her yard and bushes as she attempted to escape, and get help. I hadn't even processed that when the baby came in. And then for her, everything we attempted to do to help her failed. Hours went by furiously working with not much more than a breath in between the changes and then we lost her. In addition to the to the gunshot wound in her head, she had a through and through wound to her forearm. Apparently, she had attempted to shield her face when she was about to be shot in the head.
These images tormented me. Pretty much, the entire night was not the usual sequence of events we see in the PICU. Yes, we have police officers from time to time investigating crimes, but I never heard one describe a scene such as what the officers did that night - lifeless, bloodied bodies strewn all over that home. I paused thinking how brave they are and was amazed at their strength. They were very respectful to us and quite patient while waiting for us to give them the information they needed and that took several hours. Then there were the original paramedics who stood by us the entire night and were very kind and helpful. They did not have to do that. Watching my colleagues pick up from where I left off with such competence and skill made me proud. Seeing the humanity in all who were involved and how well we all worked together - many had never met each other before and yet we functioned so well it was almost "textbook". Everyone was kind to one another and just a bit more patient with each other than what I usually had seen in these situations. There was emotion at every turn, both negative and positive. The compassion and sheer determination everyone involved had in order to try and save this child was powerful and had me awestruck.
We are trained to contain our emotions and personal opinions while caring for our patients. Most do. I did. However, this doesn't mean that we don't still feel emotion or have opinions. We are human beings and it is normal and natural to experience a multitude of emotions as we care for people who trigger things in us whether they are deep seated or on the surface. We are bombarded with tragic, sad stories, wonderful, almost miraculous stories, and to a degree, even the mundane. I now know, that when we get to the point of feeling like someone's appendectomy or broken femur is mundane, then it is time to pause. When we start to crave and feel excitement over only the biggest catastrophic, most ridiculously crazy train wrecks of patient situations, then we are starting to loose who we are as normal human beings. Having said that, to some degree it is also normal to loose a little sensitivity and even required to do so in order to survive and continue do the work we do. This is only my opinion based upon my experience, but I learned that it is important to take stock of ourselves from time to time and "check in" if you will, to make sure we are still "okay". It is important in order to stay healthy and strong in so far as if we want to keep going, do well and be happy as healthcare providers, then we must allow ourselves to feel once in awhile and retain as much of the "normal" as we can. If you "check in" and everything is okay, then you are okay.
All I am asking is that you all please just remember to take the time to care for yourselves, and blow off some steam when needed. It's okay to vent and even whine on occasion. Don't let your nurse back be broken. That back brace of cynicism, harshness and critical judgement of one another, perfectionism and self medication will fall apart one day. Added to the day to day experiences, the responsibility, the need for constant updating of knowledge and the scrutiny we experience from managers, and the public, it's no wonder there are so many nurses with broken backs. Literally and figuratively. Take care of yourselves, and please take care of and be kind to one another.
