in practice
Time to Breathe by Aimee Milliken
I
t was Thanksgiving. There’s always a certain dread that accompanies working during the holidays: knowing that your family is already gathered, celebrating and indulging, you feel a pit in your stomach while you mentally prepare for twelve hours in the intensive care unit. Hoping for an uneventful day, I walked in to the intensive care unit and read the assignment board. Bed six. “He’s sick,” the overnight charge nurse told me. “It’s going to be a busy day.” “He” was a young man who had been in our unit for months, admitted with a mysterious illness. We had been unable to control or even isolate a cause for his constellation of symptoms, and he was rapidly progressing into multisystem organ failure. His course was complicated, confusing, and heartbreaking. His parents had taken up residence at his bedside; they had learned the lingo of the ICU, learned what the waveforms on his bedside monitor meant, and knew the ins and outs of every medication and treatment plan we had suggested for their son. They had become staples in our unit. They knew us all; they greeted us by name; they asked about our families. As I walked into his room that day, I looked at my patient, a ghost of his former self, with taxicab-yellow skin, sunken cheeks and eyes, and swollen, oozing extremities. Ventilator tubing jutted from the tracheostomy in his throat. Bags hung from the bed, draining bodily fluids. The room was filled with the symphony of the ICU: the pneumatic boot machine pumping rhythmically, the warming blanket 8 HASTIN G S C E N T E R R E P ORT
filtering hot air over his body, the dialysis machine whirring. He looked nothing like the dozens of photos that his family had plastered around the room. The windows had words of support taped to them and posters his friends and family all over the country had made for him. Everywhere you looked, his smiling face stared back. I struggled, as I do with patients’ families every holiday, with how to address his parents. I offered a cheerful “Happy Thanksgiving” at the risk of sounding insensitive. We exchanged pleasantries: they asked about my family’s plans for the day, and I asked about their kids. I tiptoed along the fine line of wishing them a joyful day while simultaneously acknowledging the tragedy unfolding in the room: their son’s decline toward death. My day had barely begun when his blood pressure began to precipitously drop. The continuous dialysis machine was not sufficiently filtering his blood, despite my best efforts, and the levels of acid in his body were in very dangerous ranges. His lab values were quickly worsening. His heart went into a rapid, irregular rhythm. Before 8:00 am, my room was crowded with doctors and fellow nurses from the ICU team. We drew labs, pushed medications, titrated drips, and ran ultrasounds of his heart and belly. His terrified parents sat in the corner, silently observing the organized chaos at their son’s bedside. Caring for a dying person is never easy. It doesn’t get easier over time, with repeated exposure, or even with the hardened shell that we develop over the
years in the ICU. As a nurse, I have responsibility for the person in the bed— he or she is my patient—but we are taught to think holistically. The whole person is a son or daughter, a brother or sister, and a friend. The whole person has a loving support system that needs help navigating the tragedy evolving in front of their eyes. I could not take care of my patient, of this patient, as a whole person, without also supporting his family. My job was, as it always is, to keep my patient alive, but I would have been remiss if I had not reached out to his parents at the same time. Hours passed. Empty IV bags, syringe wrappers, and bloody linens accumulated on the floor; new lines were placed; and no progress was made. Our social worker did her best to narrate the scene for the parents. Eventually, two critical care attendings and I sat down with them and told them that the situation was grave. They cried, and I felt my own cheeks become hot and wet. I brushed my tears away and flushed, embarrassed at my display. I had never cried in front of a family before. As health care providers, we become all too familiar with suppressing our emotions, putting on a brave face, and going through the necessary motions at the bedside. We power through these emotionally charged scenarios day after day, patient after patient. We try to remain serene, to appear calm, and to exude confidence, competence, and professionalism. We deliver life-altering news to devastated families; we sit at dying patients’ bedsides and hold their hands as their hearts stop; we deplete ourselves physically and emotionally when a healthy patient takes a turn for the worse. We skillfully manage the natural process of another person’s body decompensating while we hold back our tears, sadness, or sense of defeat. And then we take a deep breath and walk into the next room to see the next patient. We betray our inner turmoil by putting on a smiling face, by focusing on facts, by completing necessary tasks. At the end of the day, I gave a report to the oncoming nurse. My patient certainly hadn’t improved, but he was alive. “Happy Thanksgiving,” she said May-June 2014
cheerfully. This time I was on the receiving end of the uncomfortable greeting. I laughed. I had forgotten that it was a holiday at all. My lunch of turkey and stuffing, prepared by my concerned and compassionate coworkers, sat cold in the break room, untouched. When I got to my car that night, I cried. I cried about my family, whom I missed and who missed me during the holiday. I cried about the Thanksgiving lunch that I didn’t share with my coworkers. I cried from exhaustion. I cried because my back hurt and because my feet hurt. Mostly, though, I cried for my patient and for his family. I cried for his mom, with her furrowed brow and gentle hands. I cried for his dad, with his soft-spoken voice, his patience, and his determination to solve the puzzle that was his son’s illness. While we may become well versed at hiding distress at the bedside, these
May-June 2014
situations still follow us home. How do you explain your day to your parents, when they call to say they missed you at Thanksgiving dinner? How do you convey your catatonic state to your partner, when you get home at night and don’t feel like talking? What can you explain to them, without betraying patient privacy? These situations may not always happen on Thanksgiving, and they may not even be life-or-death scenarios. It may be a treatment decision that elicits disagreement among the team members, between the patient and providers, or between the patient and family. It may be a lingering feeling that you are not doing what is best for the patient or what the patient would have wanted. It may be a negative interaction with a coworker or supervisor. It may be a mistake or a forgotten task, even if no patients were harmed.
We are humans, caring for other humans. These intense emotions need to be felt and processed. In addition to supporting our patients and our patients’ families, we need to support each other. We need to offer care providers time away from the bedside to debrief, to express their concerns, to talk about what went wrong, what went right, and what we are feeling. When we don’t do this, when there isn’t ample time to breathe, it’s no wonder that people burn out and leave the medical profession. These challenging cases are rich with information that we can use to improve care for the next patient, for the next difficult case, and for the next distressed provider at the bedside. We are experts at caring for our patients, but we are not always experts at caring for each other and for ourselves. DOI: 10.1002/hast.306
H AS TI N GS C E N TE R RE P O RT
9
Time to Breathe by Aimee Milliken
I
t was Thanksgiving. There’s always a certain dread that accompanies working during the holidays: knowing that your family is already gathered, celebrating and indulging, you feel a pit in your stomach while you mentally prepare for twelve hours in the intensive care unit. Hoping for an uneventful day, I walked in to the intensive care unit and read the assignment board. Bed six. “He’s sick,” the overnight charge nurse told me. “It’s going to be a busy day.” “He” was a young man who had been in our unit for months, admitted with a mysterious illness. We had been unable to control or even isolate a cause for his constellation of symptoms, and he was rapidly progressing into multisystem organ failure. His course was complicated, confusing, and heartbreaking. His parents had taken up residence at his bedside; they had learned the lingo of the ICU, learned what the waveforms on his bedside monitor meant, and knew the ins and outs of every medication and treatment plan we had suggested for their son. They had become staples in our unit. They knew us all; they greeted us by name; they asked about our families. As I walked into his room that day, I looked at my patient, a ghost of his former self, with taxicab-yellow skin, sunken cheeks and eyes, and swollen, oozing extremities. Ventilator tubing jutted from the tracheostomy in his throat. Bags hung from the bed, draining bodily fluids. The room was filled with the symphony of the ICU: the pneumatic boot machine pumping rhythmically, the warming blanket 8 HASTIN G S C E N T E R R E P ORT
filtering hot air over his body, the dialysis machine whirring. He looked nothing like the dozens of photos that his family had plastered around the room. The windows had words of support taped to them and posters his friends and family all over the country had made for him. Everywhere you looked, his smiling face stared back. I struggled, as I do with patients’ families every holiday, with how to address his parents. I offered a cheerful “Happy Thanksgiving” at the risk of sounding insensitive. We exchanged pleasantries: they asked about my family’s plans for the day, and I asked about their kids. I tiptoed along the fine line of wishing them a joyful day while simultaneously acknowledging the tragedy unfolding in the room: their son’s decline toward death. My day had barely begun when his blood pressure began to precipitously drop. The continuous dialysis machine was not sufficiently filtering his blood, despite my best efforts, and the levels of acid in his body were in very dangerous ranges. His lab values were quickly worsening. His heart went into a rapid, irregular rhythm. Before 8:00 am, my room was crowded with doctors and fellow nurses from the ICU team. We drew labs, pushed medications, titrated drips, and ran ultrasounds of his heart and belly. His terrified parents sat in the corner, silently observing the organized chaos at their son’s bedside. Caring for a dying person is never easy. It doesn’t get easier over time, with repeated exposure, or even with the hardened shell that we develop over the
years in the ICU. As a nurse, I have responsibility for the person in the bed— he or she is my patient—but we are taught to think holistically. The whole person is a son or daughter, a brother or sister, and a friend. The whole person has a loving support system that needs help navigating the tragedy evolving in front of their eyes. I could not take care of my patient, of this patient, as a whole person, without also supporting his family. My job was, as it always is, to keep my patient alive, but I would have been remiss if I had not reached out to his parents at the same time. Hours passed. Empty IV bags, syringe wrappers, and bloody linens accumulated on the floor; new lines were placed; and no progress was made. Our social worker did her best to narrate the scene for the parents. Eventually, two critical care attendings and I sat down with them and told them that the situation was grave. They cried, and I felt my own cheeks become hot and wet. I brushed my tears away and flushed, embarrassed at my display. I had never cried in front of a family before. As health care providers, we become all too familiar with suppressing our emotions, putting on a brave face, and going through the necessary motions at the bedside. We power through these emotionally charged scenarios day after day, patient after patient. We try to remain serene, to appear calm, and to exude confidence, competence, and professionalism. We deliver life-altering news to devastated families; we sit at dying patients’ bedsides and hold their hands as their hearts stop; we deplete ourselves physically and emotionally when a healthy patient takes a turn for the worse. We skillfully manage the natural process of another person’s body decompensating while we hold back our tears, sadness, or sense of defeat. And then we take a deep breath and walk into the next room to see the next patient. We betray our inner turmoil by putting on a smiling face, by focusing on facts, by completing necessary tasks. At the end of the day, I gave a report to the oncoming nurse. My patient certainly hadn’t improved, but he was alive. “Happy Thanksgiving,” she said May-June 2014
cheerfully. This time I was on the receiving end of the uncomfortable greeting. I laughed. I had forgotten that it was a holiday at all. My lunch of turkey and stuffing, prepared by my concerned and compassionate coworkers, sat cold in the break room, untouched. When I got to my car that night, I cried. I cried about my family, whom I missed and who missed me during the holiday. I cried about the Thanksgiving lunch that I didn’t share with my coworkers. I cried from exhaustion. I cried because my back hurt and because my feet hurt. Mostly, though, I cried for my patient and for his family. I cried for his mom, with her furrowed brow and gentle hands. I cried for his dad, with his soft-spoken voice, his patience, and his determination to solve the puzzle that was his son’s illness. While we may become well versed at hiding distress at the bedside, these
May-June 2014
situations still follow us home. How do you explain your day to your parents, when they call to say they missed you at Thanksgiving dinner? How do you convey your catatonic state to your partner, when you get home at night and don’t feel like talking? What can you explain to them, without betraying patient privacy? These situations may not always happen on Thanksgiving, and they may not even be life-or-death scenarios. It may be a treatment decision that elicits disagreement among the team members, between the patient and providers, or between the patient and family. It may be a lingering feeling that you are not doing what is best for the patient or what the patient would have wanted. It may be a negative interaction with a coworker or supervisor. It may be a mistake or a forgotten task, even if no patients were harmed.
We are humans, caring for other humans. These intense emotions need to be felt and processed. In addition to supporting our patients and our patients’ families, we need to support each other. We need to offer care providers time away from the bedside to debrief, to express their concerns, to talk about what went wrong, what went right, and what we are feeling. When we don’t do this, when there isn’t ample time to breathe, it’s no wonder that people burn out and leave the medical profession. These challenging cases are rich with information that we can use to improve care for the next patient, for the next difficult case, and for the next distressed provider at the bedside. We are experts at caring for our patients, but we are not always experts at caring for each other and for ourselves. DOI: 10.1002/hast.306
H AS TI N GS C E N TE R RE P O RT
9
