I need to hang this mannitol, like, right now. Now he ordered 3% saline, isn't that for brain swelling? Oh my god, I hope this patient doesn't herniate. He just added an epi drip... we already have 4 pressers on this patient. Now he wants us to take her to CT. Do I have to go alone? Will the vent even fit in there? What do I do about all these drips...there are twelve pumps running... Where's her family right now? What if I can't handle this?
I stand at the bedside, watching the blood pressure cycle again. The last one was 32/10, that can't be right, can it? The doctor is in the room shouting orders at me and my preceptor. We're going to lose this patient. The med student has the patient's legs at almost a ninety-degree angle, trying in desperation to get blood flow to her core and brain. "You need to squeeze that bag, now!" I shove the blue key into the pump with normal saline running and rip the tubing out of the guide. I hold the bag over my head and squeeze as hard as I can with both hands. "Call a rapid response!" The doctor yells. "We are the rapid response, what do you want me to do?" My preceptor calmly replies. I can see the worry in her eyes. We're in the CCU; we are the rapid response team. Respiratory is here, she can't do anything else to help. "Come on you guys, what H's and T's are we missing?!" Well, she's obviously hypotensive, I think to myself. Other nurses flood in, doing things I don't even know they're doing. One is recording everything on a piece of paper. I've never seen her before, she must work out on ACU. My bag is running out, I yell that I need another bag of NS and someone says they'll grab more. Someone takes over for me because there are orders literally flooding my screen now. I run to the med room and grab two pressure bags.
These things suck, I think to myself. They're plasticky and poor quality. I'm back in the room and look at orders. Mannitol, norepinephrine, mag sulfate, bolus, bolus, head CT STAT, the list goes on. Before I can even leave the room, someone hands me a primed bag of 3% saline. I check it against the order and hang it, moving as fast as I can. The patient has a triple lumen central line, no available ports. What can I put this line on? It's saline, I can probably put it with the pressers, I think to myself. I don't have time to check the IV compatibility, this patient is dead or dying. I hang the 3% and Y-site it into the maintenance NS after guiding into the IV pump and programming it. Then someone hands me a primed bag of mannitol. Then the mag sulfate.
The patient had a bowel movement right at shift change, we haven't even cleaned her up yet. The doctor says "Alright, she's stable enough, we need to get her to CT." My preceptor chimes in "We're about to get her cleaned up because she's had a BM... can we do that before we take her?" The doctor looks annoyed. "I really think she needs to go now, you guys, come on, time is brain!" He has a good point, I think to myself. Respiratory comes because she's on a vent; we can't take the vent with us so she's forced to bag this patient all the way to CT and back.
Outwardly, I look mostly calm and confident. Inside, I'm terrified. What if I can't handle this? Maybe I shouldn't have gotten into nursing. There are no new orders right now, just a few antibiotics to hang. We get the patient cleaned up and her family comes in. I'm hopeful. Maybe she'll pull through. Or maybe that bowel movement at the beginning of the shift was when it all ended for her.
The shift goes on. There's so much to do constantly, I take a brief twenty-minute break to shovel some food into my mouth and rehydrate. Then I'm back in the unit, checking on my patient. Her family is never far away, they think she's going to be okay. "Can she hear us?" They ask, their eyes pleading for me to say yes. "Yes, and you should hold her hand and talk to her... tell her you love her and to fight." I'm lying, I think to myself. This patient is gone, she can't hear anything right now. It hasn't been confirmed yet, but I really think she had passed right when the shift changed. Respiratory therapy is back, putting an EEG on the patient. Looking for brain activity, I think to myself. The family asks what the leads are for. I've explained what the numbers on the monitor mean, what each and every line and tube connecting to the patient means. Respiratory quietly says the leads will check for brain activity. The doctor had explained that things don't look very good right now. The family remains hopeful. I check the EEG monitor. Almost every waveform is flat. "How does it look?" The patient's sister asks eagerly. "Well, I'm not trained to read these things, so we'll have to wait for the doctor to let us know what he thinks." The sister's face falls. "Oh, OK.
Can I talk to her?" She gestures at her sister, lying motionless on the bed. She's not sedated, in fact, she not on any medications to keep her sleeping. "Yes, talk to her, hold her hand, you won't hurt anything, it's okay to touch her." The sister, fighting tears, walks to the bed and grabs her sister's hand. "Please, you have to fight, you have to come back to us..." I can't take this. I start tearing up. "You are not to cry in front of patients." The words of my clinical instructor in nursing school flood my mind. I excuse myself "be back in just a minute," and go sit at my computer at the nurse's station. Tears are flowing freely. I can't do this. Why did I pick this job? I can't handle this day anymore. The charge nurse asks if I want to go take a break. I have an enormous amount of charting to catch up on, I say and wipe my eyes. "Do you want a hug?" She asks. I laugh bitterly and say no because I know it will make me cry harder. I don't want the family seeing this.
I can handle grief. I've seen people die before. But, nurses are supposed to save lives. Why can't I save hers? Is there something else I should have done? What else can we do? The doctor is at my desk with my preceptor. There's another doctor next to him. They're going to test the patient to see if she has any brainstem reflexes. She won't, I think to myself. We gather supplies and go into the room. The doctor explains what they will do and why they will do it. The check her eyes for the doll's eyes; they don't budge when her head is jerked side to side. Failed number one, I think to myself. The other doctor, an emergency room doctor, uses a saline flush to squirt water into the patient's eyes to check the corneal reflex. No movement. I thought they usually to the cold water in the ears, I think to myself, but what do I know? She has no gag reflex at all. The family anxiously looks at the doctor. "She is not responding to our tests... I believe she is brain dead. I'm so sorry..." The family stands there, grasping what the doctor is saying. They all begin to cry. I can't help it, I silently cry with them. The doctor wants to extubate the patient. The family is in agreement.
We prepare the family for it, what it will look like. The doctor suggests I draw up some fentanyl just in case, so I do and re-enter the room with my stethoscope around my neck. The doctor explains we are going to shut off all the medicines that are keeping her alive, and then pull the tube out of her throat. I shut off the cardiac monitor, knowing it will alarm asystole in mere minutes. We pull the curtain and shut the glass door to the room. The doctor nods at me and I begin shutting off all twelve pumps, one by one, quickly but not too quickly. Respiratory therapy is there, red-eyed and grasping the ETT. The vent is off. The doctor tells her to pull the tube out. She does, and we all watch to see if the patient will take any spontaneous breaths. She doesn't, just a small sigh as her lungs relax. My preceptor listens to the patient's heart with her stethoscope, shakes her head and I do the same. No heartbeat. The family erupts in wails, the doctor silently leaves the room. What am I supposed to do now? I cry with them, I don't care if we aren't supposed to. I hug the sister, the husband, not only for them but for myself as well. We give the family privacy to say goodbye.
I cry the entire way home. I relive the shift, over and over and over. I have to go back tomorrow. Today was my Monday. I don't know if I can handle this. I cry myself to sleep. In the morning, I get up, shower, and get ready for the day. This is what it means to be a nurse, I think to myself. If this is what it is, I don't want to do it. I can't do it. But I do it, I go back. Because that is what it means to be a nurse.
