Hoping They're Not the Last Words

Two patients during my 16-hour shift.

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Hoping They're Not the Last Words

The First Patient

I arrived in the unit the other day and got my assignment. First patient is COVID positive on the ventilator, about a week into the intubation. A gentleman in his 70s who was vaccinated in April. He was intubated at another hospital and flown into our unit. So none of us have spoken with him personally, but his family calls a couple times a day and we know there are five grandchildren anxiously awaiting grandpa's recovery and return.  He underwent a few nights of proning with reasonable amounts of sedation, never required paralytics, and his chest xrays show improvement. Oxygen requirements are also improving, the plan for the night is to wean sedation while keeping him comfortable, but try to wake him up a bit more to assess mentation and then do a wean trial. Maybe this is one of the ones that will make it!

Our success rate this round, which really has only ramped up in the last month, appears to be slightly better than what I would estimate was about a 15% success rate the first time around. We've already had at least four patients come off the ventilator and go home. First time around almost no one survived once they went on a vent. Especially those with diabetes or obesity. Those patients were like virus candy, it just ate through them. However, this time around they're younger and healthier. Ranging in age from 21-87 so far this time, the majority are in their 30s, 40s, and 50s. And many report no significant comorbidities, maybe diabetes or asthma, but most of them appear to be like just another person you'd run into on the street. 

Brutal Honesty

We've become more direct and matter-of-fact in our communication this time around. We can't sugar coat it anymore, that didn't get through to people. Now we say things to patients like "If you don't lay on your stomach, you will die", "if you insist on eating and drinking while you're on high flow oxygen, you will die", and "what do you want to tell you family before we intubate you in case you never come off the ventilator alive?" There's a level of detachment that many of us have developed that I think helps to keep us from outright blaming the patients (even if they didn't choose to get vaccinated, they didn't choose to get COVID either), but also keeps us from getting too close.  At least most of the time.

The Second Patient

The second patient on my assignment is only a year older than me. A soft spoken man who doesn't speak English as his native language but can communicate just fine. His wife doesn't speak any English, so his son, in his early 20s, is the main point of contact and a source of information for the family and to give us more background. The patient's wife contracted COVID , she had been vaccinated in the Spring and was asymptomatic. He had foregone vaccination thus far, and didn't even have a reason why. He just hadn't gotten around to it, assuming that there would be time for a long time to come. He works hard as a cook, loves his wife and son, and he is scared to death. Maxed on high flow oxygen by nasal cannula with a non-rebreather over the top of it, his respiratory rate is in the 50s and his oxygen saturation levels are fighting to hit the high 80s. He's tiring out, the sweat is on his forehead and making a thin layer on his whole body. His hair is matted to his head after a week of sweating and restlessness, shoulder length with a hair tie stuck somewhere in the middle of a giant snarl that has worked it's way into a pile on the back of his head. He can speak in broken sentences because he's still recovering from the physical transfer into the critical care unit bed about 45 minutes earlier. He's trying to prone but feels like he cannot get a deep enough breath in that position and starts to panic after a few minutes. I go in to do my assessment and he asks whether it's possible to get something to drink because his mouth is so dry. When I tell him he can't right now because we're concerned that he's going to be intubated he says "whatever you think is best".

Agree to Intubation

I confirm that he would agree to intubation, and we discuss the process. I explain that he would be asleep the whole time, he would be strongly medicated, we would tie his hands to keep him from accidentally removing the tube. He asks some questions, is a little embarrassed to ask me how he would pee, would he have any pain, and would he be aware of everything that goes on around him. I ask him if he would like to speak with his son. I call the son and let him know that we will probably be putting his father on a ventilator soon so he can speak with him by phone now but after that his father wouldn't be able to speak, only hear. The call is transferred into the room. I can't understand since they're not speaking English, but the conversation is heart-breakingly short. He's hung up before I can tell him he should tell his son anything really important that he wants him to know.  I've heard too many of these conversations in the past year and a half. Trying to convey to people that they need to say the important things, give them some closure. Almost none of them have anything other than a meaningless conversation, unsure how to sum up a lifetime synopsis for those that love them. Many not truly grasping that they are unlikely to speak with their loved ones again. After he hangs up the phone, he looks at me and says "thank you for everything you have done. I should have taken better care of things". I tell him I'll be leaving the room to gather supplies and I'll be back when the anesthesiologist arrives to intubate. 

Sadness in His Eyes, He says ...

We've only had about half an hour of total interaction to this point. My pulmonologist is standing outside the glass doors, pointing out that he hasn't recovered enough after the transfer and we can't wait much longer before we intubate. I let her know we discuss it, he's spoken with his family and I'm just about ready so she calls the anesthesiologist. We are in the room about 10 minutes later. Ventilator, A line set up, IV kit, Foley, OG tube, restraints, he surveys the items on the table and seems to really register that these are some of the last things he might consciously remember. He thanks me for taking care of him, says that I have been very nice to him and he's sorry that he can't help more as we get him repositioned and settled. I ask him if there's anything else I can do for him and he says no. Just before the propofol and roc are pushed he looks at me with fear and sadness in his eyes and says "I won't ever see you again, will I?" I squeeze his hand and look into his eyes. Now is not the time to remind him of his mortality and the unlikely chance we will meet again. I say "You rest now, We'll take it from here and I'll see you in a few days." I admit there's a small lump in my throat and it's there for most of the next 14 hours as I recall what I truly hope will not be the final words he's every spoken. I'm so tired of hearing final words. 

I'm in the room for a couple hours completing all the associated tasks. We prone him a bit later in the evening. Between the head turns every two hours it takes me almost an hour to work the snarls out of his hair, and braid it and twist it into a bun. The room is mostly silent other than the inhuman drone of the ventilator, the click of the intermittent suction canister, the non-urgent beep of an alarm here or there. I make small conversation at times, but we've barely had time to get to know one another before our relationship is reduced to tasks. Placing IV lines, a catheter, temperature probe, etc. I narrate the events of the night as they happen inside his room and out. Including a storm that brings flooding and totals the cars of about 40 of us working at the hospital. I have coworkers crying, some of their cars are worth significantly more than mine with over 200,000 miles. It's not going to be worth much in insurance, and replacing it will cost us far more than I had budgeted right now. But I can't really muster up all that much concern for a hunk of soggy metal and rubber. My parents come and pick me up because my husband's responsible for clean up at his own work after the storm and I'm reminded of how lucky I am to have family that love me. I'm going home, to healthy kids, a good life and I have a job I really love. But I'm really getting tired of some of it, and I hope with all of my being that I didn't hear another patient's last words.

Sorry for the novel, sometimes the aftermath of a 16 hour shift includes a brain dump that just swirls in my head and I really needed to get this one out so I don't dwell on it. Thanks for reading. 

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JBMmom

About JBMmom, MSN, NP

JBMmom has 9 years of experience as a MSN, NP and specializes in Long term care; med-surg; critical care.

4 Articles   2,537 Posts

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Specializes in retired LTC.

JB - you wrote your post so eloquently. And emotionally.

Please take care of yourself. You earned it.

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Specializes in CMSRN, hospice.

This was so well written. It's the moments like these that we will still be working through months and years from now. It is already scary imaging what could be coming this Winter. I don't even know what to say, so I'll just send you hugs. You are doing a great job.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

wow so eloquent.

Thank you.

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Specializes in Community Health, Med/Surg, ICU Stepdown.

You are an excellent writer! I felt like I was there in the room. I really hope your patient survives. Thank you for sharing. 

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Specializes in Pediatrics, Pediatric Float, PICU, NICU.

Hugs. All the hugs to you. That’s all.

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Specializes in Psychiatric, hospice, rehab.

Your heartbreakingly beautifully written narrative touched me. It shows a nurse who, despite seeing the constant illness and often death, still holds on to compassion. I thankfully retired just before the pandemic hit but I am proud of colleagues like you. Take care of yourself as much as you possibly can.

 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.

Thank you all so much for your kind words. I'm flattered that you found my writing to be something that spoke to you in some way. 

I'm cautiously optimistic that I will speak with my patient again, there is hope in his current course of treatment and response. 

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Specializes in Infusion Nursing, Home Health Infusion.

Please keep that beatiful heart of yours, as you will be able to help so many patients.Some nurses get so focused on completing tasks they forget there is often a frightened human being on the other end.

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Specializes in Critical Care.

What occurred to be today are the things have become a dialed-in routine that really shouldn't be.

I always used to have  hard time getting a body bag underneath a patient with the patient centered in bag, the creases on the side were always askew.  And there was always more stool to come out after getting them in the bag, no matter how long you waited.  I can now get a patient into a bag with them centered within an inch or so, and have gotten really good at where and in what order to press on the abdomen to get all the stool out before you try and put them in the bag, it occurred to me the other day that it's a problem this has become such a well-honed skill.  

The other is the pre-intubation zoom call to family.  During the last wave the vast majority of our patients were older (60+).  We had one patient a year younger than me, otherwise healthy and impressively fit.  It had seemed as though intubation wasn't something he'd ever need, until suddenly there weren't other options.  I think we all assumed it was a bummer he'd have to spend some time on the vent but he'd certainly get extubated, the worst case scenario was some residual lung or other organ dysfunction.  

I frantically set up a zoom call to his family while we were setting up to intubate, thinking it would be a while before he got to talk to them again, but that he would of course eventually see them again.  One of his kids was not only in the same grade, but had been in the same class as one of mine (8 year old daughter).  He never made it off the vent, he died despite ECMO.  The rushed goodbyes with his little girl is one of the few things it's hard to shake despite many years in critical care.  

Now though the routine of it isn't something we even have to discuss. The majority of our patients now are in their 30's and 40's, most have young kids.  Breaks are planned around when a nurse is expecting to have to set up that zoom call, with a common understanding that you take your break immediately following the call.  For one thing, you're a mess, and if your nursing spidey-sense was correct you'll be intubating the patient in an hour or two so get your break before that.

 

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
13 hours ago, MunoRN said:

it occurred to me the other day that it's a problem this has become such a well-honed skill

I agree that we've developed a precision in so many skills because of this pandemic. Proning your 400 lb patient? No sweat. Q2 hour head turns, got it. CPR on intubated covid patients, check. 

The zooms/facetime are still a challenge as you mentioned. Our equipment isn't always up and running so I've had to run facetime on my personal phone with the phone in a biohazard bag and then asked the family to delete my number. And then navigating the whole situation, trying to help families maybe say goodbye, but not having them lose all hope, it's a tricky balance. 

And yes, the younger, sicker patients this time around is an unpleasant change. I also find the patient population has been more challenging. We had a patient with his oxygen level in the 70s (which he could see on a monitor) tell us that his covid wasn't that bad, nurses just prefer to put patients on ventilators. And patients arguing with us about why they can't have something to eat while maxed on high flow oxygen. One guy said if he died it was going to be because we starved him, not because of covid. Not that I expect any patients to thank me for taking care of them, but not swearing at me would be nice. 

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Specializes in Community Health, Med/Surg, ICU Stepdown.

Wow! That sounds so tough. When I worked with covid patients our pt population was almost 100% undocumented Latino men who got covid at work and were extremely grateful and cooperative. It was really, really sad when they got intubated, conversations with family, and all the other aspects you mentioned above. 

I can't imagine dealing with that and now also people with severe covid who don't believe in covid, verbal abuse, and seeing so many preventable deaths in unvaccinated young, healthy patients. I really admire your strength and I hope you are able to take care of yourself outside of work. Please keep sharing your experiences as long as it is not traumatic to talk about. 

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