basric | lLJIDOL WEEK 17 "OPEN TOPIC"

WARNING: Please DO NOT read if you or someone close to you has cystic fibrous. Also Death scene for those who are squeamish.

To understand better how I got into this situation I want to explain the difference between Vandy and the other Middle Tennessee and Southern Kentucky Hospitals (The area we usually service.) Most hospitals nationwide have an ER and an ICU unit to serve their hospital. Sometimes they will also have a CCU for cardiac patients if they specialize in bypass surgery like St. Thomas Hospital.

Vanderbilt has and ER for the run of the mill walk ins, ambulance patients with minor and major medical problems. A Trauma unit that is serviced by four LifeFlight Helicopters. They have a MIC-U-medical Intensive Care patients, SIC-U for surgical ICU, CT-ICU for cardio-thoracic patients (Heart/lungs), NIC-U for Neuro patients (There is also a NICU for premies in the women's section of the hospital. Then there is the Trauma Unit. We are self contained. While the other services have a step-down floor and a regular floor Trauma is self contained, TIC-U, step-down, regular beds. We have our own radiology dept and laboratory and nuclear facility on sight along with triage.

Let me explain about diversion. When a hospital reaches maximum capacity or does not have enough staff they are forced to divert ambulances and LifeFlight is grounded. This upsets the administration beyond belief. So when an area has overflow, let's say Medical, they put these patients on other floors until beds become available. Of course, if all the ICU's reach maximum capacity and no one can be step-downed then we divert. ICU patients can't go down the chain, but the regular beds can end up in an ICU bed. Trauma is the last one they fill because of LifeFlight; therefore two beds are held no matter what.

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I was on-call on a Wednesday a usually slow night for trauma so I was surprised to be called in. Paula and I rode in together-speculating.

I had one medical patient my other bed free. From reading the chart she was a 26 year old female with late stage cystic fibrosis. Married with two children. She'd had a lung transplant three years ago but they were failing and her veins and arteries feeding and leaving the lungs were too week to endure another. The anti-rejection drugs had caused the bone loss most transplant people receive and she'd undergone two hip replacements. She should have been on Medical ICU but--full.

She also should have been a DNR (do not resuscitate) but she refused to sign. I walked in on (my lucky night-since you can't HEAR my tone that was said with extreme sarcasm) the resident--Dr. Idiot. He was trying to get her to sign the DNR since she was terminal, but she was insisting all be done and leave it up to her husband, Michael, to take her off the machines when he deemed it was time. Dr. Idiot pushed--he figured he wouldn't be called on to do anything if she signed to form. She pushed back until he threw up his arms and stormed out shooting a glare at me as he passed.

Her husband looked exhausted and I had them say their goodbyes and sent him home. After I assessed her and spoke with respiratory, I knew she was not going to make it through the night.

Then I sat down with her and talked straight-she was dying--she knew it, she'd already lived well past the age of most people born with her condition. She had a husband who loved her and two girls. I asked her if it was fair to Michael, who would be in deep grief when she passed and going to have to be the emotional support for those girls over her loss--to make him disconnect her life support. She was then going to leave him not only with survivor grief but the knowledge he killed her. Yes, he actually did not ACTUALLY but I had seen this many times before. Was that what she wanted. She signed the DNR form for me. (There was a much longer conversation but that was the gist of it.)

She was coughing but it was under control with the R.T. and Valium.

My new admission was a woman who was bitten on the abdomen by a brown recluse spider six months earlier. All the skin on her abdomen had necrosed (blackened and died). All that held her insides-inside was an abdominal binder with six-in wide by 14-inch long Velcro closure; then a binder with laces, pulled tight and laced at the top and bottom over that. She was also a psych patient with some control issues and apparently an expert manipulator. Oh, how I hate psych patients (Bless those that can deal with them).

Around midnight Mary began the deep severe coughing, with some blood spray. I called the resident. He stood reading the chart. I told him "Don't leave her."

Spider-woman (what the nurses in medical had dubbed her) called for me. I made a quick peek into her room, and I knew Mary was in first stages of dying and alone with Dr. Idiot.

Spider-woman said her bed was scratchy and wanted it changed. I explained that all the Care Partners were tied up but would be with her in about thirty minutes.

"But I've been sitting in this chair for forty-five minutes and I'm not supposed to sit over an hour," she wheedled, "Why can't you do it, think your too good to change a bed?" S*I*G*H)

"I have a critical patient right now or I would. Just lay on the bed until they can get to you. Changing your bed is not critical, but we will get it done.

I SWEAR she stood, took her water pitcher and dumped it upside down spilling the contents into the middle of her bed. "Critical enough now, bitch" she sneered at me." (GOD! I HATE PSYCH patients).

I could hear Mary, now--louder and harsher coughs with gagging.

"Now, you can sit in the chair until we can get to you."

"HEY, COME BACK HERE, BITCH, AND TAKE CARE OF ME, THAT'S YOUR FUCKING JOB."

I asked the charge to let the C.P. know the bed needed changing. And the patient would be screaming. I also let her know Mary was dying.

I returned to Mary, Dr Idiot stood wringing his hands and pacing. Mary was sitting up bent over mists of blood all over her sheet. I gowned up and threw one at HIM and sat on the bed beside her, "Mary, try to relax and take slower breaths." I wrapped my arms tightly around her to try and give her some control and human touch. Coaxing her through each bout.

They grew worse the next round of coughing after a gasp for air brought copious amounts of blood, she'd burst a vein or artery in her fragile lungs. I thought Dr. Idiot was going to pass out.

"She needs 10 of Valium IV, stat."

Dr Idiot pulled himself together enough to get that superior look and order 2mg of Ativan which was going to do nothing. Frowning at his misplaced timing to show his authority, "COME, sit beside her hold her around the shoulders tightly it makes is somewhat easier for her."

"But the blood?"

"DR. R., NOW. So I can go get her Ativan. Another burst of coughing and blood had him doing as I asked.

I hurried to the machine that dispenses the patient's meds and over-rode her list of medications; she didn't have it ordered so I used my charge nurse code to verify the order.

I pushed the Ativan in her IV and it did nothing. He quickly gave her back to me, I held her as the spasm grew worse, then she began coughing blackened lung tissue up with the blood. It became worse and worse. My heart bled for her. I looked at Dr. Idiot for support; but he just looked traumatized.

"Go out to the Charge nurse, sign the order for the Ativan you ordered and order 10mg of morphine stat. Have the charge nurse give it to you and bring it to me."

For once he ran--an excuse to escape, my guess. Mary never stopped coughing there was more and more tissue with the blood each time the spams wracked her body she coughed the tissue bright pink and red as her lungs shredded inside her. She was having trouble drawing a breath back into her destroyed lungs and what trickled in came back as a gagging, crouping gush. Dr. Idiot returned with the syringe. We are on a needleless IV system but I broke protocol and used the needle. I pushed it directly into her port. Almost immediately her eyes glazed over but the coughing continued. I knew now she was in a calmer place mentally and her end would not be as horrific for her.

Dr Idiot stood hands dangling; white as a ghost as it became worse and worse. So much blood.

"Should I trach her?" (Like he could.)

"No she is a DNR."

"You got her to sign?"

"Read the chart."

Mary had one more horrific blast from her lungs with a gush of the last of her life's blood, gagging on a chunk of lung tissue, then she seized and went limp. DEAFENING SILENCE.

"It's over?'

"There's no apical pulse (stethoscope directly over the heart). You can call TOD."

Which he did. "Do I call the husband?"

"No, I want to clean her up and the room before he comes. And I have to call the Coroner."

"But she's a DNR?"

"All patients who die within a twenty-four hour admittance have to have the coroner called."

Luckily Vandy has autopsy rooms (for the medical school), so he can come here. But he saw no reason and released her. Also we have to call Tennessee Organ Donors, she wasn't a candidate there either.

Paula came and helped me get her ready for her family to view her. I just couldn't allow anyone else to touch her. It just wouldn't have been right.

When Michael came, he asked if she passed easily and I lied right through my teeth, looking him straight in the eyes. He didn't need to carry that. I would carry it for him.

Meanwhile, Spider-woman was not happy with me. Told me I was the most incompetent nurse she'd ever had and she'd be reporting me. She lay on her clean sheets eating ice cream. "Do you need anything?"

"Not now."

An hour later a Care Partner came for me, "Hurry, hurry."

I walked into the room and there she lay both binders open and intestines spilled out over her and onto the bed. "I turned over and they just popped open."

How I kept from strangling her I will never know. Called Dr. Idiot who nearly passed out, AGAIN. I had to hold him up, literally.

"You push them in and put the binders back on."

"Oh no. I'm not a doctor. I'm not going to be blamed for causing a crimp in her bowel and a bowel obstruction."

"I can't, I'm gonna be a plastics. I'll never need this kind of stuff."

"Well, to get there, you have to do this."

He walked out on me, "No, I can't"

Covered her intestines with sterile towels soaked in sterile water. Called for the GI Resident who came and did the work. Binders secured again, he apparently knew her. "Marta this is twice you've done this. The next tine I'm using duck tape. No, don't try to tell me it came open by itself."

"That bitch ignored me." It was my punishment for not making her bed. Her nerve ending were destroyed with her skin, so she felt no pain--a perfect way to manipulate the medical staff.

The remainder of the night was peaceful. I have seen hundreds of people die; some easy in their sleep others fighting till the end, but this one I carry with me as the worst. It was difficult to suffer with her and difficult to write--so much I left since it lasted over thirty endless minutes and to spare the reader the gorier details. She was a sweet girl. No one deserves to die like that.

Much of my writing I go back and read my journal entries, but this one, even though it was years ago, I remember every moment. Every word, every cough, even Dr. Idiot who did go on to become a Plastic Surgeon in Miami.

Makes me a believer in right to death with dignity. 30mg of morphine and it would have been peacefully over. But we follow the law, though if they had sat through her suffering I think the laws might change.

I was happy to see 7 a.m. Paula threw and arm around me, "Wanna go to Wynona's (A 24 underground bar.)"

"Yeah, but I already have to drive home sleepy facing the sun. A couple of drinks and I'd kill myself or someone else."

"I.H.O.P. it is; Rooty Tooty Fresh and Fruity or steak omelet? And we'll flirt with that hot new nurse from Surgery." She can always make me laugh.

Give me a M.V.A, G.S.W. or a nice knifing any day.

I'm going back to the Stargate and maybe I'll take John Sheppard with me.

Current Mood: morose
Current Music: AMBROSIA