Lament of the Non-Nurse

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Healthcare is all about nursing. I understand this. With 77% of non-physician roles in U.S. healthcare being those of the nursing variety, I can understand. They are the backbone of our hospitals. I am not a nurse. I had the option years ago, and I decided that, with poop being my Kryptonite and all, it would not be a wise career choice for me. I opted, instead, to help people breathe for a living. Thus I became the respiratory therapist. That choice has come back to haunt me in several ways.

The first of these started when I wanted somewhere to go from here. Nurses have so many avenues they can take to do this: become an instructor, a case manager, management at their facility, become an NP. What can the respiratory therapist do? Well, aside from becoming a Registered Respiratory Therapist from the entry-level Certified Respiratory Therapist, which I did the month after I graduated from respiratory school, there is nothing. Bachelors programs in respiratory are just starting to emerge, but a BS in respiratory gets us no more job perks, no more pay. You just get to say you have it. The majority of my bachelors-having coworkers got theirs in “health sciences”. Whatever that means. So instead, I opted to finish my BS in business administration with the added concentration of healthcare management. But then what? If there are only a handful of BS programs, there certainly are no masters programs. But my BS is in business anyway, so the MBA was a no-brainer.

So here I am. I am one of the more educated in my department, even in the hospital. My MBA is complete. I did well. I did it. So now what? Now I find a job.

I thought this part would be easy. Well, not really easy, but not this difficult, either. Let’s discuss my situation: I have spent the past eight years of my life working in the toughest in my field–adult critical care, and eventually NICU. To the layperson, let me explain further: I am a member of a critical care team who responds the emergencies in the hospital. We are called in when you or your loved one is at their sickest. We bring our skills, experience, and knowledge to you, make recommendations to the physician based on all of the above. We communicate with other members of the team, with family members, with patients. We assess and decide, then act. Repeat as often as necessary to the point that it is second nature to us.

So what does this tell you about me? Well, it tells you I can effectively communicate with anyone. I have non-English-speaking patients, when I am most certainly unilingual. I have deaf patients, blind patients, patients who are intubated and cannot talk, trached and cannot talk. My job is to find out what is going on with them rapidly enough to act. I have become, over the years, a master lip-reader. But that’s not all. The people with whom I interact each and every day have been anyone from a PhD-holding professor who was ill, down to a man whose education was limited to elementary school before he was put to work out in his family’s fields. On our professional team, we have everyone from housekeepers and registration clerks, who may only have a high school education, all the way up to senior management and physicians with advanced degrees. I. Can. Effectively. Communicate. With . Anyone.

Now for my work. It may involve looking at lab values that seem to others to have nothing to do with the lungs, but actually do. Watching vitals. Seeing how the patient breathes. Assessing vital signs. Looking at patient history to see what clues I can find. Listening to family members who may not speak the same lingo I speak. Look at x-rays, watch for clues. And I look at all of this, and since the physician is not there, I have to decide when we need to be concerned, when to call for more help, what I can do to help. So in a split-second, I have to take in this information from multiple sources–complex information at that, compare it to the knowledge stored in my brain, and formulate a plan on how best to proceed.

And under stress. The patient is either having trouble breathing, or even has stopped breathing, when I have to do all of this. Maybe their heart has stopped. Maybe their oxygen saturation is low. Regardless, I don’t often have the luxury of being able to take my time. I need to make a decision and act now, now, now. And while nurses have anywhere from 2 to 6 patients to care for, when I go into work, I have the respiratory histories of at least a few floors’ worth of patients in the back of my mind or in notes in the margins of my printed work assignment. If you figure the average respiratory rate is 10-20 breaths per minute, and there are usually 30 patients per unit, that it 36,000 breaths for which I am responsible in one hour of work on just one floor of the hospital. And I May have three or four floors. That’s a lot of responsibility and a lot of stress.

And I have done this for years of my life.

And then I got an MBA. So I understand finance and strategy, management and business law, marketing and accounting. I have been educated thoroughly in all of the above from a nationally-ranked program at a well-respected university. Add that to the ability to communicate with anyone, the ability to work under stress, the ability to extract complex information from multiple sources to formulate a plan….Nothing should stop me, right?

Wrong.

Because I am looking through these jobs, and seeing that many of the leadership opportunities are asking for someone with a nursing background. Why? No idea. We respiratory therapists go everywhere. A nurse may be hired to work in one specific unit. I can go anywhere in a single night, giving me intimate knowledge of the work flow of every patient care area of the facility, from behavioral health up to the ICUs. And I know healthcare. And I know business. At first, I noticed this trend, and I was a little discouraged, but I figured that I would find the right role  But today, I came across a posting for a pulmonary unit. They need a director. Perfect. Except, as I scrolled down reading the job posting, toward the end, it listed a RN as one of the qualifications. They want someone with my clinical experience, an MBA….and a RN.

It is what we all deal with everyday–we non-nursing patient care staff. We are skilled, we are experienced, we are valuable to patient outcomes, but this is the hand we are dealt, and frankly, it sucks. Part of me wants to just go to nursing school for a couple of years so I can say I did. But I shouldn’t have to do this. I have worked hard. I have done well, completing all three degrees with academic honors. I have the experience under my belt. This is just ridiculous.

Nursing is the backbone of healthcare, but I have yet to see a backbone accomplish anything without limbs, without muscle to hold it upright, support it and ensure it can move and flex in the ways needed. And it’s high time that the rest of the body gets some respect.

I’m Having a Heart Attack or I May Just Be Bat-Sh*t Crazy

Okay, so given John’s recent fiasco where my perfectly fine husband’s heart ended up being most definitely not fine, we are pretty sensitive to anything in our house that could indicate impending death. Call us oversensitive.

10 days ago, I started having this chest pressure. It kind of comes and goes with no logical pattern at all, really. So I hemmed and hawed and mulled it over before finally just going to the ER, since it was a Sunday.

Normal EKG. Negative troponin. Negative d-dimer. Normal chest x-ray. It was deemed muscular in nature, and I was freed with a script for muscle relaxers.

Except for one problem: I am incaple on any form of consciousness on those damned things. So I have taken 2 of them in 10 days. And still, the pressure/pain comes and goes. It isn’t severe, but instead just there. Occasionally it will get bad enough that I have to stop and focus on my breathing.

So today I go to my family doctor, simply because it got bad enough that I couldn’t catch my breath and it felt bad enough that I couldn’t even focus on anything. Honestly, it reminded me of the massive squeezing done about 40 times a minute by my dysfunctional uterus just a few years back. Only not really, because it didn’t stop. And it was in my chest, just left of center.

But my tests were normal, so I have to be fine. Maybe it’s just stress. But it won’t go away. But I am under a lot of stress. But then again, I live in stress and have for my entire adult life.

But, but, but….

So the doctor asked me how I would like to proceed. And I don’t know, because the logical side of me who spent years studying all things cardiopulmonary knows it isn’t likely to be my heart. But then there is the part of me that doesn’t know what the hell it is and wants to be sure. So I told her I didn’t know, to jyst do what she feels is best.

I ended up on a proton pump inhibitor to ensure it isn’t something GI-related, a steroid to ensure it isn’t inflammation, and a stress echocardiogram just to be sure.

I’ve never had anxiety issues unless it involves John behind the wheel of the car. Now, I am questioning my sanity.

Bitchypants

It’s What I Do

Ya’ know, when I was 19 years old, my mom passed away. At her funeral, there were these strange women there, crying along with the family. None of my brothers and sisters knew a single one of them. It turned out that they were from the respiratory therapy department at the hospital mom always went to when sick. It was a little hospital. And I remember thinking “how awesome is that to be able to be that invested in your work?”. I guess it stuck wih me. And then later, John talked me into going back to school. I was too smart to not finish my degree, according to him. And so I did. I just wanted something that would support my family. I was going to try nursing, but I couldn’t handle the poop part of it. And I found out my college had a respiratory therapy department. I applied for admission into it. I didn’t think about the times mom’s cough would be productive and I would gag when she would cough into a tissue. I just remembered her funeral, her life, her demise. Along with my interest in medicine.

I became a respiratoty therapist. I never gave any thought to it. I had straight A’s, so how could they deny me admission into the program?

I finished my degree and I ran with it. My first resuscitation after graduating was a 6-month-old baby boy. They found him submerged headfirst in a bucket of mop water that had been left by a bed. We had no idea how long he was submerged. He was supposed to be taking a nap at the babysitter’s house. Of course we didn’t get him back, and I came home from work that day and told John that I had made a horrible mistake, that there was no way I could do this job. Nobody with a heart could. But I went back to work the next day. And the next. And somehow, I stopped being able to keep track of the resuscitations in which I have participated, except for a select few that hit particularly hard. Like the mom who died in childbirth and almost took her baby with her. We were successful at saving the baby, but not the mom. My last picture of that was the NICU door closing on the new widower cradling his new baby girl with a bewildered look as he sobbed for his dead wife. And then there was the little boy who was 3 days older than Evan, who tried to help his stressed Daddy out by taking his ADHD meds himself. Only he took the whole bottle and his heart stopped. And his mother wailed as I stood at the head of the bed, breathing for him until they told me to stop. Or the 35-year-old breast cancer patient who had contracted necrotizing fasciitis after having her lymph nodes removed. Someone thought it was a good idea to let her daughter come back and say good-bye before we called it. Her daughter was Evan’s age, and I can still hear her wailing, “Mommy, don’t leave me.” Those? Those I kept right here with me. They have never left.

It’s interesting isn’t it? For every one we couldn’t help, there were probably 2 that we did help. I don’t remember those. Their faces blur together and disappear into this infinite mosaic of faces that have wafted into and out of my life. My work. Evidence? The grandmother who ran into me and remembered my face as one that did CPR on her newborn grandson. Or the lady who ran into me at the grocery store and remembers me as one who responded to a code on her father. I was just standing there in the produce aisle with my family, with this blank smile on my face because I couldn’t very well come out and say, “I’m sorry, but I haven’t the foggiest who you are.” The successful ones become the equivalent as another Big Mac sold by the McDonald’s worker: I did my job. I’m so sorry I do not remember, and I never dreamed when I started this career that I would reach this point. Pretty much the best I can do is assure you that while I was there, I cared deeply. I still do. But when you are standing there sobbing while we do CPR, I have to block you out. I have to concentrate on my job. And when it was over, I don’t want to remember your sobs because then they stay in my head as a constant reminder of how fragile we all truly are. That it could’ve been my husband, one of my children, me.  And while I am sorry that it is happening to you, to your loved one, I’m truly appreciative that it is not one of mine. I can be selfish like that. I’m sorry. I’m so, so sorry.

But I am not the only one. There is a whole profession out there of people who do what I do. And this week? Well, this is our week. National Respiratory Care Week. The hospital and the physicians, the drug reps and vendors, will shower us with food and freebies. And they’ll say thanks for what we do. And we will pat each other on the back for this week. But next Monday, it will be business as usual. People will live. We’ll help them. And some won’t make it. I’ll see an obituary with a familiar name and it will drive me crazy, serve as evidence of our failure. And then I’ll hate my job, but I’ll still go in the next day. And the next.  And the next.

Somewhere along the way, I became a respiratory therapist.

It’s what I do.

It’s who I am.

Sometimes It’s the Little Things

We cannot fix everything. People have asked me what I thought was the most difficult aspect of my career in healthcare. It isn’t the 12-hour shifts anything else about my work hours. Yes, I work a lot, but my family understands that when I am not here, I am taking care of sick people, and that someone has to do the job. It isn’t that I have yet to find a good, comfortable pair of shoes that can hold up to what it is I do to them all night. It isn’t the blips on monitors or the screeching alarms of a ventilator.

It is simply this: We cannot fix everything. And sometimes, the things we cannot fix are the ones that will completely rip my heart out. I cannot cure cancer. I cannot take home an abused baby. I cannot expain why it is that a loved one has to die outside of the realm of the logistics of science and pathophysiology. And it sucks. And so, while not all of us do, most of us focus our working hours on what it is that we can do. Sometimes, that just isn’t much. It may mean I can hold a hand. Or tell you I understand. Or get you a warm blanket when you’re cold, or ice water when you are thirsty. I always ask when I leave a patient’s room if there is anything I can do to make them and their loved ones more comfortable. Most of the time there is nothing, and this just makes them smile to know someone cares enough to ask. Sometimes they come up with something frivolous. Sometimes I don’t get an answer and I make it my job to anticipate. Little things.

It was a standard night in the emergency room. I was at the more urban campus in a poor neighborhood instead of the large suburban campus where the median income in the area is well into the six figures. No. The majority of the patients that night were on Medicaid. And drugs. They were inmates arrested and awaiting jail clearance to be taken off in handcuffs. They were young girls in with STD’s or pregnancy tests. They were drunkards found in a parking lot, completely passed out. And you would think all of this would break my heart, but you really do grow cold to this stuff. You can tell the people who are having a rough time from the people who are in that situation by dumbass choices.

Here came this patient one night. He appeared to be no different than the others at first. We was downtrodden and dirt-caked. He was wheeling a grungy suitcase like he expected to be admitted. I heard a nurse ask what was up with the suitcase as he was escorted from the waiting room to his room in the back, to which he weakly smiled through grimy, decaying teeth and replied that he takes it everywhere. He was assigned to Craig, a tough-talking RN who really can be an asshole if the situation calls for it. In fact, Craig is the one we intentionally put with the assholes. The beligerent drunks who curse and yell at us. The idots who tried to get high and overdosed to a point that they have depleted their respiratory drive, then get angry at us for giving them a reversing agent because we ruined their high. Those are the ones for Craig simply because he will respond to their abuse by getting back in their faces and speaking to them in the same way they talk to us. And I heard this patient from my desk. He was out of his anxiety medication and wanted more. A refill on one of the most comonly abused drugs. Yeah. Like we haven’t seen that one before.

But the night wore on. The board went from being filled with drug seekers wanting prescriptions to get their weekend started right, to twenty-somethings who had sore throats and wouldn’t go to a family doctor like a normal person would, to the wee hours where the ones who come in are the drug overdoses, the arrests, the beligerent drunks with head lacerations from bar fights. And this man was still there. I heard a young guy yell and curse because he had been there a long time for his earache because we were treating true emergencies before we would get to his non-urgent complaint. I heard a drunk guy in one of the psych rooms yell at the doctor because he would give him narcotics. I heard laughter from a group of 14-year-old girls who all came  in for an STD check, as if this was a social function. I never heard a peep from this man. And Craig seldom had to go into the room.

Finally, at around 3 AM, the great asshole Craig had the papers to discharge the man. The man who looked like so many of the others, but behaved so differently. Polite, quiet, respectful, appreciative…Craig went into the room, discharge papers in hand. And I heard him ask the guy if he had somewhere to go for the rest of the night, to which the man replied that he did not. And Craig told him that, so long as he continued behaving the way he was, he could have the room for the night. The tough-talking nurse emerged from behind the curtain and promptly went to the fridge to take the man a boxed lunch. It wasn’t much: a ham sandwhich, chips, and an apple. But Craig showed his soft side. He gave the man a bed for the night and a meal to fill his belly. Without being asked, he sensed this from the patient. That he needed this, and Craig responded without request to do so. As the night faded to dawn, and the clock ticked closer to dayshift, the man had to go. Craig went in and woke him. Escorted him to the restroom with soap, a washcloth, toothbrush and toothpaste, deodorant, clean socks. Allowed him to clean himself up. Gave him numbers to local shelters and other social service organization in the area who may be able to provide more long-term assistance. And as the man left, he smiled and thanked us all with eyes glistened with tears.

It really is the little things we can do that matter. The tasks may be tiny to us, anyway. I go into a patient’s room in the ICU to withdraw care and allow the patient to die. I am no-nonsense. I perform the taks as if I am doing something menial like folding laundry. One would think, from my demeanor, that I do not care. It isn’t that. I do it because this keeps me from being sucked in. From crying. But if you watch closely, it is there. It’s there in the way I smooth the patient’s hair when I am finished. Or the way I tuck the blankets up around them in the bed as if I am home and tucking in my young child for his nightly slumber. Or the way I place a cool washcloth on thier face. Not much. Little things. Because that is all I can do. I can make them a teensy bit more comfortable as they slip from this world.

But sometimes, I think it can be the little things that mean the most to the patient. And just when I start to have my doubts in humanity after caring for some of the scourge of society in that urban ER, I see what it means to be human. Not in the patients, but in the staff. The people with whom I work day in and day out can do some things that touch me deep into my core. You don’t see it at first, because we have all been doing this long enough to allow ourselves to be encased by this hardened shell. The years add the layers onto this shell to where the softer side of us gets deeper and deeper down. But it is still there. And that night with the homeless man, Craig showed me that.

I love my coworkers. When the world shows me all that is wrong with it, the people with whom I spend my nights come through to show me the very best of humanity.

 

(Please note, as I have stated before, that I abide by all rules governing a patient’s right to privacy. I will NEVER reveal any characteristics that can identify any patient. NEVER! I extend the same courtesy to my coworkers, because, hey, I wouldn’t want stories about me to pop up randomly on the internet. Quite simply, if you are reading this and it sounds familiar, I can assure you it isn’t. You don’t know the patient. You are NOT the patient. Nor are you the nurse. ALL IDENTIFYING CHARACTERISTICS HAVE BEEN OMITTED OR CHANGED. For all you know, I may have just completely made this shit up. So…Peace Out, Homies.)

Life According to Plan

I am not a sci-fi type. I’m not really any type. But tonight, John and I watched The Adjustment Bureau and it has my head reeling. If you haven’t seen this film, starring Matt Damon and Emily Blunt, I highly recommend it.

Now, how can a simple thriller have my head reeling? Well, quite simply, this film is, at its core, the physical embodiment of everything of which I have wondered my entire adult life. If you haven’t seen, I’ll offer up a quick summary so you know what the hell I am speaking of.

David is a politician on the fast track to the presidency. Elise is a contemporary ballerina. They meet in a public restroom by complete chance. (Or is it?) David can’t get her out of his head. Cut to a park after a lost election: David is on his way to his new job when mysterious men in fedoras seem particularly interested in the fact that he is supposed to spill his coffee on his shirt no later than 7:05 AM. But the man overseeing this seemingly random event that is ultimately a part of the master plan for David dozes. David doesn’t spill his coffee. He instead catches a city bus, where he runs into Elise. And so it starts.But it was never supposed to. David was to spill the coffee, thus necessitating a change of clothing, resulting in a missed bus, not seeing Elise, and leaving their knowledge of each other limited to the chance encounter in the restroom. They were not supposed to be together. It was not a part of the plan for either of them. David is supposed to win the next election, and more to come, eventually becoming the President. Elise is planned to become a world-famous dancer and marry her choreographer. Instead, the two fall in love. To be together, there must be a deviation of the plan. And a sort of straying from the dreams they each have for their lives. They simply cannot have it both ways.

I have often thought of this very topic. I’m not insane. I never thought there was a team of men in fedoras following me around to make sure I fulfill my destiny. But like just about everyone I know, I’ve wondered if there is some sort of plan for me. Is this supposed to happen, and what are the events to follow that are a direct result? This is all compounded by the fact that I have lived through some things that would make any normal person’s skin crawl. I’ve made it through when I never dreamed I would. Catastrophic events. And the strange thing about it all is that after the dust settled and the smoke cleared from each of those personal earthquakes, I could honestly see something positive that was a direct result. While I hate the events, I can say that each has left me even more changed than the one before it. I am the person I am because of those earthquakes. If you drop a beautiful vase, you may be able to pick up the pieces and put it back together, but the vase will never be the same. Its very constitution has been changed forever. It doesn’t mean it’s any better or worse. Its justdifferent. Rougher hewn. Was it always the plan for the vase to shatter?

In the film, they refer to the small events that have the capacity to change the course of one’s plan as inflection points. These aren’t the life-altering events, but rather the small ones that can make a difference in where we go. And so I sit here pondering the inflection points of my own life. Laughter on the night of my senior prom. The first feeling of true freedom on my first night away at college. A kiss from a past love. The smell of my newborn son. The first time I got a taste of the medical world and thought it could be for me. Moments where it just could have gone differently and yet didn’t. But what was the moment? Where did the plan change forever?

Flecks of copper. That was it for me. My plan changed with the sight of them. Everything traces back to that. John’s eyes. Flecks of copper in chocolate pools. And suddenly, I can trace the events of my life in relation to that point. My ill mother and her subsequent passing. The events of my life, of which I cannot speak right now, just prior to meeting John. The lost love that broke my heart. The job that led me to a friend that introduced us. The strangest thing is that, while he lived four hours away from me, he dated a girl who grew up in the same tiny rural town of Indiana where I finished high school. And their family moved to Cincinnati at the same time my mom was passing away and I was returning home to Cincinnati by myself. Yet our parallel paths never crossed. Until I saw those flecks of copper. And suddenly the events of my life after that point are the direct result of his presence here in my life: respiratory school, Evan, Zachary.

So when I stop to ponder all of this, the next obvious question is this: what if we never met? If just one tiny thing were to be off just slightly and our paths never crossed? Would I have ever become the physician I always dreamed of becoming? I can’t even think of it. To do so would have the images of our children’s faces dissolve into a mist of the nonexistent. And so I have spent my time since then trying to have both. Two paths converged into one. And every step of the way was a disaster. Finally, Zachary and bedrest came along,nd suddenly the other path seemed to be not so important to me anymore.I could stop trying to blaze a path where there was none before. I could relax just a little. (Those of you who know what it is that I am doing these days will probably laugh at the idea of this being relaxation, but it really is compared to before.)

What if this was it? Maybe this was the plan all along, and all of the events led me here? Or maybe it wasn’t. Sometimes I feel like I missed my chances from pure happenstance. Other times, this is exactly where I should be. I guess the only thing that matters is that even in the times where I feel as if I missed something, I know that this was the better of the two. Because of the copper flecks.

And now I leave you with this quote from the movie as the credits started to roll. (Background note: The Chairman is the God-figure in the film who writes the plan for David.)

“Most people live life on the path we set for them. Too afraid to explore any other. But once in a while people like you come along and knock down all the obstacles we put in your way. People who realize free will is a gift, you’ll never know how to use until you fight for it. I think that’s The Chairman’s real plan. And maybe, one day, we won’t write the plan. You will.”

>Worry and Frustration

>Evan has ADHD. You can spend 10 minutes with him and tell. We tried everything before we go the diagnosis because I believed, and still do, that the diagnosis is completely misused. Is your kid creative and bright and maybe a little bored? Medicate him. Does he not fit into the cookie-cutter image of other kids? Medicate him. It is so frustrating as a parent.

We tried everything. We met with a private psychologist, had meetings with the teacher and the guidance counselor of his school. We were told he was just really gifted and bored. And so we relayed the info to the proper people, and still received the same treatment. Pressure to put him on medication.

And then it got worse. And we took him to our family doctor, who could tell within a few minutes that he did have ADHD. We left that day with a script for ritalin. And it did nothing. Change it to Adderall and it worked. But it worked too well. You can look at the pictures of Evan over the years and tell the exact point where he started the medicine because it is like someone dimmed the light in his face, the spark in his eyes. It breaks my heart. He wouldn’t eat, either. And at 8 years old, he lost so much that he dropped 25% of his weight in 3 months. And the Adderall was stopped immediately. We tried not medicating him and that lasted for about 2 weeks before we were back in the doctor’s office, begging them to find something, anything to help him. The answer was Straterra, which lasted all of 2 days. Enter Concerta, and the kiddo was doin g better in class, but started to have more problems: manipulative, conniving, angry. After a couple of months of this, we said “enough” and didn’t refill the prescription. That lasted about a month.

2 weeks ago, the principal of his school called us in the middle of the day and told us to not bother bringing Evan back to school unless he was medicated. I understood that he was having issues, but some of it was a stretch. For example, he got a behavior notice sent home because he accidentally farted in class. I swear. I know it’s gross and we teach him manners, but he is a young boy. And when I asked him about it, he said he had a belly ache that day and he accidentally farted when he bent over to pick up a dropped pencil. And he said “excuse me”. And he got a behavior notice.

I was angry at being forced to medicate him. Which, if we get down to brass tacks, was really what was happening. But what do I do? So I made an appointment for him and John took him. We asked them to put him back on Adderall because that is the only thing that got him to behave in school. I figured we could avoid the nasty side effects by just adjusting his dose. That was this past Friday. He started the medicine and–Wham!–the side effects started. The last time it at least took a few days for this to start happening. He acts like a Zombie. He won’t eat. He behaves alright. Because he is too depressed and tired to misbehave. Well for the past 3 nights, he has not been sleeping at all. And complaining of a headache. And either vomiting or dry-heaving. I just had to page our family doctor and they called in a prescription for Phenergan so the poor kid can at least try to sleep without vomiting. It’s horrible.
Tomorrow we take him to the doctor. And they are going to do something about this or he is stopping the medicine. I will home-school the child if I have to, though I believe doing so deprives kids of the normal social experiences of childhood. But a mom’s gotta do what a mom’s gotta do.

>First Do No Harm

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Primum non nocere.

Of course we all recognize this as the cardinal rule of any medical practice. Nonmaleficence, meaning that it is entirely possible that the best course of action for me to take in an emergency is to actually do nothing. That doing nothing, and thus not causing further harm, may be better than being wrong in a manner that leaves my patient in worse shape. Now take all of that and combine it and roll it into a big ball and realize that I grapple with this in a split second when my patient has stopped breathing. That instant that truly seems like an eternity. The great void between the realization that your  patient is indeed pulseless and apneic, and the pushing of the big blue button that will trigger the calling of a Code Blue. In my career, I have had situations where I go back and think about  a patient and wonder if me reaching any conclusions sooner would have changed an outcome. And thus far, I have had the luxury of being able to say that I don’t feel as if I have harmed anyone.

Last night, I had to face that possibility when, after some aggressive airway management for a patient who wasn’t ventilating well, I witnessed the spiral. First the oxygen saturation starts to drop. And then the blood pressure is low, followed by the slowing of the heart rate. Finally you reach that chasm where the heart ceases to beat, whether it be a pulseless ventricular rhythm or completely asystolic. The patient is dead. Expired. And you can do all you can and whip out everything you have learned in years of education and professional experience in the hopes that it will help. That the heart will resume beating. (Not so much the breathing because, honey, I can make anyone breathe with the right equipment.) But this happened last night. While I was there with my hands on that patient, taking the opportunity to teach a new ICU nurse about ventilator basics. I have never had that happen to me. And after we got her back not once, but twice, and they finally got the stat chest film for which I kept begging, it was determined my patient had a pneumothorax. And so when the family arrived at the bedside and told us to stop all efforts at resuscitation due to patient wishes, in the blink of an eye, my role switched from caring for the patient to caring for the family. To help them find some peace in her death. I did all I knew to do. I extubated her, washed her face, smoothed her hair, tucked her in, and left the room so they could have those final moments with her on her death bed.

And then I went into my back office in the ICU and I cried. Actually I started crying before I got there, prompting fellow ICU staff to follow me to make sure I was okay. I was. I was still breathing. My patient wasn’t. It was the first time in my career where I was physically working with a patient when they went down, and my instantaneous thought was, “Did I do that? Did I hurt her?” Of course after logically recounting the steps to her demise, it is obvious to me that she suffered the pneumothorax before I did anything that could have caused it, and thus I cannot blame myself. But it just did something to me, and I cannot really explain why.

I love my job. Love it. But I have always had confidence in my professional skills and training. I haven’t really doubted myself before this. Well, I have, but not in the manner that I had to stop and think on whether or not I did damage. I have always said that the most dangerous person in healthcare is the one who will not admit that they don’t know everything. So with that in mind, there has always been a healthy dose of fear. There has to be when you are literally running someone’s life support. But that fear cannot be so great that in inhibits one’s performance, one’s ability to be on their toes when a true life-and-death emergency strikes.

Lately, as a senior therapist, I have been mainly working the critical care units. Once in a blue moon, my boss will give me something else so I don’t go insane, but it isn’t very often. And the thing about this is that I am in a teaching hospital. Meaning when there is an emergency and the code team assembles, it really is a team effort. In other areas of the hospital, this may not necessarily be the case because there are more seasoned physicians running the show. But in the ICU’s, you get residents. And the presence of “MD” behind their names has yet to give them the idea that they know all because of their education level. They know that an experienced ICU nurse or therapist has seen a lot and can help them. I work with them on intubations, on managing pulmonary issues. I give crash courses in blood gas interpretation or ventilator management. And in a code, when we get to the point where we have exhausted all possible causes, or in one where the cause is obviously pulmonary in nature, they look to the therapist. Me.

I don’t know what I’m getting at here. I think it is just that I had to think last night that it was possible that I hurt a patient. And even after coming to the conclusion that I did not, the fact that I could have just seemed to linger. And of course this has made me think of my role in the hospital even more than I have before. The pressure. The weight. The responsibility.

I upheld my ethical commitment last night. I did no harm. But I had to come face to face with the idea that I hold lives in my hands when I go to work and clock in at night. That I very well could hurt someone. I think it just caught up with me.