It was 7:15 a.m. I had just received report on my ICU patient with the nurse that I was assigned to for the day. She wandered off to receive report on the other patient that would be in her care for the day. The ICU was filled to capacity, and the four bed rooms had become six bed rooms with stretchers and beds too close to each other. Free standing portable curtains were being used in an attempt to provide privacy. Decisions would need to be made, as there were too many patients and ventilators were getting scarce due to the high acuity level of the patients.
It was 1975, and I was half way through my senior year in nursing school. The patient assigned to my care was named Rick, and he was 3 months younger than me. The day before, he had been involved in an automobile accident. He suffered a flail chest with multiple fractured ribs. Two chest tubes exited his left lung and were connected to a chest tube drainage system at the bottom of the bed. Blood oscillated back and forth in the tubing with each breath the ventilator delivered. A tracheostomy was visible just below his chin and connected him to life support. It was placed the day before to allow his bruised lungs and rib fractures to heal.
His long dark hair cascaded over the pillow. As I approached his bedside he opened his eyes and attempted to speak — -‘help me — -I can’t breathe — -it hurts’. It would be the first time I would experience the value of knowing how to lip read for patients whose voice has been silenced by having an tracheostomy. At the same time, his eyes blinked rapidly with panic on his face. He violently yanked his arms and kicked his legs in frustration and terror. The left leg had a cast from groin to toes. His arms were tethered to the base of the bed to prevent him from pulling out his tracheostomy and invasive tubes. I took his hand and whispered to him and explained why he was tied. He repeatedly said ‘pain-pain-pain.’
I looked at the MA-1 ventilator that hissed with every delivered breath. I felt totally helpless to help him. The nurse I was assigned to shadow entered the room, and she came to the bedside. The best I could do was to tell her that he told me he was in pain. She told me she would be back with pain medication, and that I was doing a good job by staying with him.
A few minutes later, the physician in charge of the unit entered the room followed by the charge nurse. They went to the bed of the patient beside my patient, and I heard the nurse give a synopsis of the events of the previous shift. The patient had suffered a severe head injury, and had been on life support a few days with no improvement. The doctor listened to the nurse’s report. I watched him with his head bowed, and his jaw visibly clenched. A long sigh echoed from his mouth. He walked to the other side of the bed, and opened the man’s eyes to check his pupils. He moved his head left to right several times, checking for the function of the man’s brain stem. He mumbled ‘No brainstem function’. I watched as he disconnected the ventilator from the endotracheal tube, the alarm wailing immediately. For what seemed like an eternity, we waited for the man to take a breath. Finally, the doctor reached across the bed and turned the machine off.
‘He’s brain dead. He has no hope for survival.’ And he walked out of the room without looking back.
That would be my first introduction to life and death in the ICU. 45 years later I can still remember the hot tears that ran down my face.
In the time that the nurse I was shadowing went to get pain medication for Rick, a decision was made about the viability of a human life. She returned and saw me crying in the middle of the room, and then looked at the patient in the next bed. She placed her medication tray with the syringe of pain medication on the over bed table and motioned me to help her lift the portable screen from across the room to place around the deceased man’s bed.
We returned to Rick’s bed, and turned him on his side to give his injection. In those days, mostly all pain medication were given in the muscle, so it took a few minutes longer to work. I turned my head away so that Rick wouldn’t see my red eyes. It wouldn’t be the last time a patient would see me crying.
I waited till Rick fell asleep, holding his hand until I saw him relax and allow the machine do all the work. The nurse pulled me aside and put her arm around me. “You will have many tough days like this one in your career. Never let it harden your heart. I know you won’t forget this day.”
I took care of Rick for much of my ICU rotation. He healed and was eventually discharged. He sent me a card thanking me for holding his hand and talking with him through many terrifying situations. Years later, when I graduated and moved to another town we went out to dinner. He eventually married and had two children. In May 2017, I found out that Rick died when I searched his name and his obituary appeared.
My rotation in ICU solidified where I wanted to be.
I knew that I wanted to be an ICU nurse. I could not know at that time where that choice would lead me. I did not recognize that I had much to learn about life and death, despite the fact that I was surrounded by it on a daily basis. I had yet to make peace with the circumstances of my father’s death.
Making choices about who should live or die is not new in the medical world. However, we never thought that we would come upon these grave times where an algorithm would be needed to decide who gets priority for a ventilator.
We never thought we would be faced with choices such as these, but as a profession, there have always been plans in place. Having to think about these choices is absolutely gut wrenching.
Of one thing I am sure. I have never allowed the tough days to harden my heart. I’m sure that nurse will never know the impact she left on me. I’ve carried her words forward, and shared her words with those who needed them. It’s how we survive together in our world.
We hold space for each other. We know of the joys in celebrating life, and the desperation of losing a life to death. We carry these memories in our hearts, and although time softens the details of the loss, the collective feeling lingers forever.
For all those who remain in the front line of this distressing time, I hold you in my heart.
