ACT II: It's Okay

“He gets down to the end of his life, and he looks back and decides that all those years he suffered, Those were the best years of his life, ’cause they made him who he was. All those years he was happy? You know, total waste. Didn’t learn a thing. So, if you sleep until you’re 18… Ah, think of the suffering you’re gonna miss. I mean high school? High school-those are your prime suffering years. You don’t get better suffering than that.”
-Frank, Little Miss Sunshine

The tears began to stream from my eyes, uncontrollably. I was sobbing like a baby. I have never broke down in front of a patient before. I cried. My face shield began to fog. My duck mask looked like a brown paper bag— inflating and deflating, as I cried in it. I could feel the tears ruining my PPE. The patient, a 63 year-old Caucasian male, had been trached and pegged. He was unable to successfully wean from the vent and had undergone a procedure (a tracheostomy) to create a surgical, artificial airway. So, the ventilator was now connected to his throat. This allowed him to mouth words. He grabbed my hand and mouthed,

“it’s okay.”

But it wasn’t okay. This was not how I liked to nurse. I was trained to turn my patient every two hours. I was trained to round on my patient hourly.

This brought me great distress. The day was so hectic. My other patient had required all my attention since the moment I walked into the COVID unit that day. The patient had just been paralyzed with a one time dose of Rocuronium— a paralytic, at shift change. The thought was she would synchronize with the ventilator and oxygenate better, but her chest X-ray was completely white. Her lungs were moving little to no air: stiff from COVID. I had seen end-stage COVID before and this was no surprise to me, but the family wanted us to do everything we could for the 46 year-old AA, female, and so I laced up my sneakers, because I knew it would be a long day.

The breakdown I had in my patient’s room was a result of deep shame and guilt; two of my dark traits that I have surrounding my worth.

When he held my hand, I almost forgot who the patient was— me or him? This was something I had been working on following my trauma last year. It was one of the reasons I had left the ICU briefly for outpatient PACU. The guilt I have from my sexual assault has permeated every aspect of my life. I have tried to unload my guilt and shame— my disgust from that event, by continuously performing good deeds. In my subconscious, I suppose, this is a way to atone for that trauma.

My hands were trembling when the patient held mine. He was covered in urine. I felt so bad. I felt so guilty. I looked around for someone to help me clean him, but no one was there. The hospital had no techs on the COVID- ICU.

There was no help to turn your patient, to clean your patient, or to even check a blood sugar. The patient was probably twice my size. He had no foley catheter to collect his urine. His condom catheter had fallen off again, and he was saturated. I had cleaned him earlier in the day with the help of another nurse, but now everyone was preoccupied in their own rooms. I hadn’t even charted an assessment for the day.

I looked him in the eyes, unable to wipe my own tears, “we can do this together. I’m going to clean you now.” I tried to stop myself from crying, but I just ended up blubbering. I kept repeating over and over,

“I’m so sorry. I’m so sorry.”

He patted my hand. Later after he was cleaned, he would tell me he just wanted to go home. I needed to hear that. I needed to know that I had somewhere to go. While my suffering would end after twelve hours, his would remain. He was a father, a husband, a grandfather times three, and he still had a long recovery to go. I was being selfish and ungrateful.

I stopped crying after that realization. This wasn’t about me proving I was a good nurse. This wasn’t about me atoning for my sexual assault or trying to undo an event (subconsciously); this was about the patient— a person, who unlike me, was unable to go home and hold the ones he loved. When this realization occurred, I knew I had to find the strength to finish the day, no matter what happened throughout the day that prevented me from giving the level of care I pride myself on. That was in the past. Right now, in that moment, the patient was forgiving and extending his grace to me. So, I did what I do best and I pushed. I pushed through the last two hours of my shift. This was the difference maker.

The shift began in chaos.

When I got my assignment, I automatically knew what unit I would be sent to as a traveler. The travelers are always offered up as a sacrifice, but I enjoyed working with COVID patients, and I had successfully cared for many COVID patients in the ICU setting. What I was most nervous about wasn’t the patient load, but the things that were unknown to me: the charting system, hospital policies, the medication delivery pumps— those things that were foreign.

I entered the unit and circled by the patients I had cared for my previous shift. I had only looked after them for four hours of orientation, but I was emotionally invested in their wellbeing. My heart sank when I discovered the male patient, who was previously talking two days ago, and breathing on highflow, had now been intubated. He came from a family of physicians. They worked at the hospital and were very immersed in his care. The shift before I had given him IV Remdesivir. There was also an order for convalescent plasma. I thought all these factors would change his clinical progression, but sadly they did not. He was such a pleasant man. The shift before he just wanted a cup of tea, which I gladly obliged to. When you look at COVID patients, on the outside they look so stable, but on the inside the virus is creating chaos in a multitude of organ systems.

I left his room and found my assignment. It was shift change, but all the nurses were still in their rooms— no one to be found at the nursing stations. I peered into my room. That’s when I found the night nurse paralyzing my patient. She explained to me that the patient had began to breath out of rhythm with the vent and was previously paralyzed on a drip, Nimbex, but the drip had been discontinued. The doctors had ordered a one time push of the paralytic. I assessed the room. The patient’s O2 sat was only 87% and we were giving the patient 100% oxygen. Her vent settings were nearly maxed for a patient of her size. Anymore PEEP, the forced pressure that opposes passive emptying of the lung, and she could suffer from barotrauma— a condition that can over-distend alveoli and cause her lungs to collapse.

The situation was dire. The nurse informed me that her oxygen levels would range between the low 70’s to 80’s. The patient also needed a unit of blood. I knew from my cardiovascular ICU experience how important the role of hemoglobin was to carry bound oxygen, and so I made it a priority to ensure the blood was given timely, but I had no idea about their blood release process. I also had no access to the medication delivery machine yet, and my patient was on several critical drips: Fentanyl, Versed, Propofol, and Levophed. You never want to be in a position as a nurse where your critical drips run dry. This is one of the dangers of being a traveler. Your first day is spent getting acclimated to the system, and that takes up precious time.

The charge nurse was in shift change. I told her in passing I needed access to pass meds and that I also needed to be walked through the process of requesting blood. She waved me off and said she would be back after shift change to show me. This was unnerving. My fears of not being able to have the autonomy to practice independently began to creep up. My patient’s sats were also dropping again, but the night shift nurse had assured me the team was well aware.

I knew in my heart from my previous experience on two COVID units, that the patient was dying, but I had to try for her family. I decided with this free time I would see my other patient. I couldn’t give her blood now, and I had already assessed her, so I had to move onto my next task. A nurse had graciously put my trached patient on the bed pan. I went into introduce myself, assess him, and clean him. He had a huge bowel movement, but when I looked around for help, there was no one to be found. At this time it was about 08:00 am. I decided I could change him on my own this once and I did. He had no drips, and he was at the point in his care where we were just waiting on LTAC placement. He needed two negative COVID tests to move out and minimal vent settings as well. After he was cleaned and assessed, I knew my priority for the day would be the actively dying patient across the hall, and boy did the day start to roll after that.

I finally got access to the Pyxis, the medication dispensary system, around 09:00 am, but my patient’s sats were still dropping, and I felt I needed to prioritize given her blood, so I found the charge nurse and she personally walked me down to the blood bank and helped me retrieve the blood. It was so reassuring to finally have that presence and help, but the charge nurse was managing forty ICU beds. Forty! I was lucky she even had a moment to talk to me. I started the blood, but the patient’s sats had began to drop after I briefly repositioned her. She got as low as 69% (normal is 90-100%). This was the moment that defined my day. From the time her sat dropped after moving her (something I was hesitant to do from experience with acute respiratory distress patients) my day was sealed. It only got harder after that.

The respiratory therapist arrived. She had been among the first responders in New York. We chatted about her experience: the enormous amount of responsibility she had taken on. She disclosed that she hadn’t been home since March and that day was her last day at that hospital. Our attention turned back to the patient. Palliative care was at the door. They needed an update on the patient’s prognosis. I told them, it wasn’t looking good. Her sats were declining and we had added Levophed— a medication to augment her blood pressure by vasoconstricting her vessels.

I looked at the respiratory therapist,

“what else can we do?”

We shared a moment. We both knew what the outcome would be, but I held onto hope that the blood would help. I hadn’t even been back into my other patients room in a few hours. I decided to check on him.

He was soiled again, but this time I had help. The same nurse that put him on the bed pan earlier, helped me clean him this time. I just kept thinking, 'how great would it be to have a tech right now.' I will forever be grateful to my techs. It was a moment of gratitude I needed to express. We cleaned him and I passed his meds. He didn’t have many. I performed my mouth care, and I thought for the first time that day I would be able to chart.

I left the room and checked on my patient to finish her blood administration. I was also fighting with pharmacy to find her antibiotics. Her sats were worse. Her blood was finished and I had an order to push Lasix to diuresis her after the blood finished. If her lungs were wet, the Lasix would help to offload the extra fluid on her lungs. It was an intervention commonly used in the ICU setting with fluid overload, and with the amount of fluids and blood products she had received, I thought the order was appropriate.

But, I had a nagging feeling. Her O2 sat was now barely above 75% and I had performed all the orders the doctor gave me on rounds. Nothing was improving her status, in fact, she was decompensating. I was also worried that maybe I should have called the physician sooner, but I was so busy trying to carryout the interventions and give the interventions time to work before updating the physician. It was now noon and nothing was working, and the next problem presented itself. How do I page the doctor?

I ran to the secretary and asked her if she could walk me through this process. A few Latina nurses were talking in Spanish. I spoke a little so my ears perked up. I knew they were talking about me. The first one translated, “we were just saying how hard you are working. Most travelers don’t care.”

The other chimed in,

“yeah the patient has been like this for days. Most people just sit here when they come from other hospitals.”

I was mortified! Was I supposed to not perform my duty to save this woman’s life? Granted, they were right. The patient was only 46, but she was HIV positive. She had been ruled out for ECMO, a procedure that oxygenates your blood and organs outside of your body. Additionally, she had been ruled out for transplantation, and she needed new lungs. My acts were futile, but it was my job to care, it was my duty to try, and it was my moral obligation to escalate up the chain of command.

“Can you page the doctor for me?”

I asked the secretary. The secretary asked me where my phone was. I informed her it was dead. She told me where to get a new one, but agreed to page the team for me. I was exhausted at this point and panicking. I have only had two patients to die on me in my 8 years of nursing experience. I have been with patients as we de-escalated care, but I have only had two codes under my watch, and I wasn’t about to lose this patient today.

The resident arrived to my room— no introduction.

He was straight forward. I described to him the situation.

“You should have called me sooner,” he belted.

The shame began to creep in. I could feel my hands trembling. I knew if I didn’t breath deeply, I would burst into tears.

“It’s my first day and I apologize for the delay.”

I explained to him the interventions I had carried out and that the respiratory therapist had also tried to help me troubleshoot, but he wasn’t impressed. He increased her PEEP from 14- 16 and this actually improved her O2 to 81%, the highest it had been in a few hours. Then a Code Blue rang over head. He shushed me before bolting out of the room.

I was alone. I was alone again with my patient. No new orders. I felt like I was practicing with one hand tied behind my back. I didn’t know what else to do.

I went back to the Latina nurses and told them the resident had left me to run to a code on another floor. They told me I should escalate to the attending. I called. No answer. I texted him using SBAR, a communication tool that describes the Situation, Background, Assessment, and Recommendation. I explained that the patient had been previously paralyzed, patient received one unit of packed red blood cells, Lasix, and that their PEEP was increased from 14 to 16. I ended by recommending we restart the Nimbex drip to keep the patient paralyzed.

It was 2:00 pm before I saw or heard from the team again. I struggled for two hours alone. I hadn’t eaten, peed, or sat the entire day. One of the nurses suggested I take a lunch. She offered to watch my patients. I had just gathered my belongings when the team arrived back on the unit. I put my money up.

The patient held my hand, “it’s okay,” he told me as I sat there blubbering like a baby, but it wasn’t okay.

He didn’t understand the day I had prior to entering his room to clean him for the third time that day. I was ashamed. I felt guilty. I did not practice this way. I had worked at public hospitals with limited resources and always made something out of nothing. I felt myself dissociating. I felt my airway compressed by my assailant— someone I had trusted, a friend. I felt his hand smother my mouth. I was gasping. My thoughts were suffocating me. The pat of my patient’s hand brought me back to reality— “it’s okay,” he mouthed again.

I breathed deeply. I practiced my grounding exercises my therapist had taught me. Name five things you can see using your senses. I could feel my patient holding my hand. I could see the monitor, I couldn’t smell anything in my mask, but I could hear the sound of the television. I could see the fog of my breath on my googles. I was safe. I was at work. I grounded myself and completed the task, apologizing to the patient for the last time. I pulled the curtain behind me and exited.

It was 06:00 pm. I sat down to chart for the first time that day. My patient was more stable. Her hemoglobin corrected. Her sat was back to 85%. The family had called back; they wanted everything done for her. I had restarted the Nimbex drip and re-paralyzed her an hour earlier. I mixed my last Fentanyl drip for the day, called pharmacy for another Versed drip, and spiked my final Levophed bag. I looked at her. She was stable again. I could finally chart this hectic day. I just had to learn the system first.

Nursing in this environment is unlike anything I have ever had to tackle in my life. My sensitivity to my patient’s needs and the high standards I place on myself makes it unbearable for me. I handed off my patients to the oncoming nurse. Luckily, the same nurse had the patient again. I told her that the resident told me it was 'game over' for her, and we hung our heads in agreement. These were unprecedented times. The nurse and I were both travelers. We shared our frustrations about the hospital. I was thankful I only had two weeks left. The frustration over the organization of my agency was always in the back of my mind. I had gone through so much just to take this assignment. She explained that her family was currently camping in Savannah, Georgia. I was so lucky to have my family here with me and I empathized deeply with her as she showed me photos of her beautiful children.

“Give me your number,” she told me.

I pulled out my phone and we made the exchange. “We need each other,” she said, and she couldn’t be more right.

People never know what someone is battling. I specifically requested Miami from my agency, so I could return to the place that my sexual assault occurred. With my husband’s encouragement, he told me before I left that I could do this. The month after the trauma, I tried to work with Dade County PD to file a report on the perpetrator, and they informed me it would have to be in person. The local authorities in my area had also confirmed that they were out of jurisdiction, so when I saw the assignment in Miami, I took it as confirmation that now was the time to pull the trigger. I haven’t yet, but I’m trying to build the courage to go through with it. Years of childhood neglect and catering to a mother with mental illness has taught me to blame myself for everything that happens to me, and I’m working diligently to shed this stigma.

Tomorrow, marks the countdown on my stint here in Miami. I know I have to take care of the patients before I file my police report, but I’m trying to stay grounded and focused. I have eight shifts left. Just eight shifts. I know I can do this. I have to approach life one day, one patient, and one meltdown at a time. I’m so much stronger than I know, but I welcome the day when I no longer have to be strong and I can accept that “it’s okay.”

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