Road Block

I'm pretty sure I've hit a road block... Well maybe not a road block, but I was taking care of a patient tonight who's been on the unit for a solid 2 or 3 weeks now and really just had a difficult time. He was a younger man (maybe in his late 50's) who had suffered a serious bleed in his hypothalamus and has since been practically braindead and struggling to regulate temperature, etc. What's so deceiving about his current status is his ability to open his eyes and cough, which to the family (who is very religious and is keeping this gentleman alive incase of a 'miracle') means "Well if he can do this he must be getting better and anything is possible... " blah blah blah. I can appreciate their unrelenting sense of hope, but what I can't appreciate is their decision to keep him in the hospital bed for so long... alive. Now I know that last line may have been harsh and I apologize for being so crude, but it has frustrated me over the past few weeks to have to watch this father/brother/son/ husband waste away in a hospital bed while his family can not understand that this man is a living vegetable and no, he will not get better.

At first, I also almost had a difficult time believing that he would be like this forever. After it had sunk in though, I sat back for quite a few days wondering when it would click for the family like it had for me. I wanted to know when they were going to see past any potential for miracles and accept the reality of the situation. After a while they finally decided to make him a DNR, but for now he remains in our CCU bed waiting to be transfered to a near by rehab center/nursing home where he will go to die.

Tonight I really had such a tough time being with this patient. This man, since admission, has been bleeding from practically every available site, hes been seriously third spacing, he's developing cataracts... He's just a mess.

I think what I am struggling the most with about this situation is just the general well being of the patient. Granted I know that he's got very little brain function and he's been given ativan and what not, but it kills me to turn him and watch tears swell up in the corners of his eyes. Or even to stand next to him and watch him struggle for air while his lungs fill up with blood. I think lately we've been shipping so many success stories out that this particular case is difficult bc it breaks the current trend. I just keep putting myself in the shoes of his family members and can't get past how terrible it would be to watch a patient fade away in such a miserable fashion. This is no wearing out process, this man is straight deteriorating in to nothing and it's heartbreaking to watch. I can't understand how people can keep their love one's alive like that, I really can't.

I had mentioned to a nurse my feeling regarding this situation and she responded with her remembering how it felt to be where I was and she agreed that yes it was a difficult time. But she said it in a way that was reassuring I would get past it. I'm curious... do I ever want to get past that? I mean yes to some degree, but in this moment it seems like it shouldn't be alright I can be ok with a patient existing like this. He's off our unit soon and from there I can only hope the best for him and his family in such a trying time.

Just a Quick Addition...

I wanted to tag a quick story on to the last post that is somewhat related to the idea of "family members with limited understanding," but I thought it would be more appropriate to seperate it from the other. This situation occured during my last rotation in the ICU up in a hospital at school. I was taking care of a patient who had undergone his second AAA repair. I can't recall exactly what had happened (and now it's going to drive me nuts trying to remember), but during the second surgery, the patients abdominal aorta was clamped for too long, causing his bowel to become ischemic (which led to an ostomy) and his lower extremeties to lose significant circulation, resulting in a severe lack of perfusion and progressive necroses of his feet and calves. I came to know him while he was sedated and on a vent in the ICU and my role as a student nurse came in to play at a crucial time in the patients care.

The doctors and nurses were trying to decide whether or not to amputate the leg or begin this treatment or treat this problem before this one or blah blah blah.... but the biggest problem for them that I think they overlooked didn't even concern the patient. It really had to do with his DPOA, the son. Because the father was unable to make his own decisions due to the heavily sedated state he was in, the decision making burden now rested on the shoulder's of the son.

I had the opportunity to meet him one morning while I was in doing my assessment. He was kind of a punkish, bushy unkempt bearded kid, probably around my age, who wasn't very well educated, but had an incredible heart. He came in kind of quickly, awkward, and flustered. Because I was in the room he assumed I was the nurse and immediately started up with the "how's my dad?" questions. Making every effort to keep the son optomistic, I tried to explain that his father was doing slightly better, but the condition of his legs caused a great deal of concern for the doctors and staff. I really tried to keep the terminology simple and stick to what I knew, but despite my efforts to remain in a medical conversation, the son just kept directing me off that path.

What I can remember most vividly was the son coming back to this one assumption "... yeah but when he's down to (say 50%) the doctor said that's when he'll wake up and be able to make his own decisions... he's at 65% O2 he's almost there!" (this was all followed by a nervous smile and a complete lack of regard for any statement disproving his assumption) I kept trying to explain to him that his father coming to it was really conditional on how he would be able to tolerate weaning and there was no magic number that would bring him back. During the rest of that day I felt like no matter what I said or how I said it, that kid was not going to believe anything but what was in his own head.

What I had come to find during my conversation with the son was why he was so eager for his father to wake up, besides the fact his dad would be better (This was also something no other nurse had taken the time to find out. Not one nurse had sat down with him and just let him talk). The two lived together out in the woods and his father was the type of man who drank the night before to help ease the pain of surgery and spent the day up until that chopping wood (this is no lie). The son tried to explain that the father did not want to get the 2nd AAA, even after he very well understood he would, in fact, die if he were to leave it be. The son I guess had convinced him to get it fixed, so he went in and a few days later was next to me in the bed in the ICU. The son couldn't even begin to imagine the reaction the father was going to have waking up to a bag attatched to his intestines, let alone the reaction he would have if one of his legs was gone. The son couldn't make the decision for the father and was feeling a tremendous amount of guilt for making the dad get the surgery in the first place. It was just a terribly sad situation that I knew could not be swayed by myself or anyone else but the father.

One of the greatest things the son owned became one of his greatest weaknesses, and that was his immense respect and love for his father. He truly cared but he was unable to get past his emotions and fears in order to think clearly for his father in his worsening medical condition. You can't blame him, though, he's young and completely unexperienced with such critical decision making. But his lack of understanding of what was happening with his dad was causing him to drag his feet and hold out for his dad to wake up, which I knew wasn't happening any time soon. My rotation ended before any decision was every made by the son.

In situations like these you almost want to shake that family member and say, "look, you've gotta do this, you've got to make a decision..." But who am I to put my two cents in and tell someone to stop feeling and start thinking? We're only human.

Time for a New Post...

Well it's late night but I've got some of that second wind energy left to burn... I just got off shift and I've been itching to put up a new post, but to be honest I just haven't had the time to sit down and let it all out. I feel like so much has happened in these few short weeks I've been working on the hospital, that when I try and recall a memory to put down I'm drawing blanks. I did experience the loss of my first patient a little while back, but I'd like to save that blog for a later time when I'm able to sink in to the emotions and really go back to that night. For now I think I'm going to stick to a little less solemn topic which we all feel the pain of on a daily basis... family members with limited understanding...



It's a difficult role playing the family member of a patient who is incapacitated or severely ill, I will admit, but it's especially difficult for you as a nurse, or even a human being, to interact with a family member who just won't seem to go away, or just doesn't get it. You know the one's who don't leave the bedside and if they do, pace just inches outside the curtan while you're in the room trying to turn the patient. Or how about the one's who nervously call every hour or so to check on the unchanged progress of their loved one? If you don't know them then beware... they're out there! And they're harmless, but don't they just seem to make your job that much difficult to do? I feel like I'm still green enough, and maybe even naive enough, to say that I haven't quite developed those calus's the older nurses might have in response to these certain people. And by calus's I mean an ability to tend to the families needs with enough compassion to keep them content, but also enough distance to keep your own sanity. It's almost in our job description to posess the ability to get close enough to really care for a patient and their family, but remain detatched just enough so as not to be drained emotionally with every new face. It's tough. It's truly tough to know when you've given enough, and when you're being cold, and being able to distinguish between the two is not something they teach you in nursing school. But it truly is a talent learning to deal with these people, because often we find that their lack of understanding or constant tampering with the patient and their healing is hindering the progress of that patient.

I've actually got two stories related to this similar type of topic, one happening tonight. General rundown... patient came in a few days ago because of a twisted bowel which was eventually resectioned. Pt was intubated, A line in, etc. etc... She really is a lovely person, but has a son no better than a gnat. He's just always around, which is great because it's so rare to find a family member so caring and supportive of their loved one, but he's difficult to deal with... he's just that typical "uh it's the patient in bed 4's son calling again" kind of family member. So much to the point that we had to ask him to stop being so physically affectionate because his holding her hand all the time was misplacing the location of the transducer of her A line. He needs to know every drug, needs to know exactly when this happened and why this happened, and if the head of her bed is elevated 3 degrees lower than it should be, he'll let you know about it.

How he made our job tough though, is because of something that happened today. The patient was in need of blood because of a low H and H, but was not willing to sign consent for the blood (nor was the daughter) and would not make the decision because only the son could. Now to me that seems strange considering it's her body (Hell if it was my body, I would have had them hanging the bag while I was searching my purse for a pen). But the son was just so up in his mother's business I almost felt like calling LDRP to come cut the umbilical cord. I thought the nurse I was working with handled him very well as she was inviting but very "this is how things are, you can't be doing this." I was really impressed... and her response to him is why I'm typing about the situation. The people on my floor have been incredible with family members, so much sometimes I'm surprised, but in my teachings I have encountered quite a few who fell very short of this standard.

I think it's extremely important to keep the perspective of that family member in mind, which is sometimes hard to do when our job requires us to be sympathetic, not empathetic. The way they teach us to practice almost sets us up for contradiction because we can't really embody the emotions of that family member at that time. We can't get tied up in the anxiety or the fear or the sadness, we need to be the people who keep it together for them and keep the medical perspective a reality. We can, however, keep that brief glimpse of what they're feeling in mind, and I know that when that person comes in through the door that's your dads age or your brothers age, you can't help but get a little bent out of shape thinking "what if it was them?" Maybe I don't have much of a point, but if anything try and take from this the reality that we can become cold and detatched at times and we can forget what it's like to be that family member. One of the most incredible things I experienced was when my preceptor cried with the death of our patient because of the recent loss of her father.

I can't tell you how to react to these people who unknowingly crawl under our skin because I'm not even sure how I'm going to handle them some day. But if you feel like maybe nursing has got the best of you and you're running with the crabby crowd, then reevaluate how you're dealing with these certain situations, and if it's not how you would want to be treated, then fix it. Worry about the things you can control.