Vanilla
"I wab a midshk," he sort of croaked through the oxygen face mask obscuring the bottom half of his face. No matter how many times I adjusted it, it still slipped up too high and pushed a little on his eyes. I knew if I took it off, he would desat to 83% (that's not good).
He wanted a milkshake. It was the first really coherent thing he'd said to me in the two days I'd been taking care of him. He was still in soft restraints because he'd already pulled out his urinary catheter and given himself quite the bleeding prostate lesion requiring the urologist to grudgingly come relieve his 810 ml of bloody urine in his bladder (normal you'd feel about ready to burst at around 300 ml). The nurses had struggled for hours on that task. When they finally called me, he was sprawled out naked on his bed with blood all over his penis and a gowned nurse holding a tube only partially in the opening.
But after that episode, he started to clear mentally. He started to talk to me more. He had this great North Carolina accent. We were going to start a smoothie company together and make our fortunes. Or I was, at least, he said I could go ahead with it. He was too old to take on a new project. He wanted to name it Triple H. We hadn't decided what they all stood for yet, but on of them was "Healthy" and he was working on the graphics in his head.
He lived alone in town. His ex-wife was the only person in town that he knew and she was dying. His brother was worse off than he was. The only family member who could consent for the blood he needed when he hemoglobin dropped below 10 (tranfused for heart failure) was his nephew who still lived in North Carolina. He seemed so alone. No one came to visit him.
He'd been transferred out to our general medicine team--one of the Intensive Care Unit "bombs," who can be total wrecks. He was confused and clouded and altered and had an O2 requirement and bloody urine, and a chronically failing heart. About a week before he'd been going about his business, just made a trip into the hospital to refill his medications. When his heart decided it had had enough. He lived in atrial fibrillation (the top chamber of your heart not beating very effectively), but he suddenly switched into ventricular fibrillation which is much much worse.
He was on the elevator at the time, and one of my fellow interns called a code blue and started compression while trying to keep his foot stretched out in the elevator so the doors wouldn't close him and my patient in there without any other help. In the process of manually pumping his heart through his chest, he broke three of his ribs, but after 15 minutes, they got him back. His heart started beating a bit on it's own and they put a tube down his throat to help him breathe for the next couple days.
Soon after he was extubated (the tube came out), he was transferred out to me. I scoured his records for information as any good intern would do--a "chart biopsy" we dorkily call it. In talking to another of my fellow interns I learned what my patient had been like before he became confused with what we would later determine was probably ICU psychosis (basically being old and confused about all the craziness of the hospital environment and losing your bearings on your life). "People want to write him off," said the other intern, "but he's really a cool old guy. Just think of him as you would your grandfather." He wanted me to see the person behind the tubes and mask and confusion. The vet who had lived a full life.
"I want a milkshake."
"What kind?" I asked as I held his arm and hand to try to hold him in this world.
"Guess."
"Vanilla?"
"You guessed it!" He gave me an eye smile and squeezed my hand.
I later called dietary and they don't make milkshakes at the hospital. I told him I'd pick him up one on my way into work one day.
The next day I was running quite late and didn't have time, but I stayed late and got to know him better. He was well out of restraints by now and I helped him feed himself. He didn't have much of an appetite; his belly was still full of stool despite the suppository we'd tried earlier that day. He liked the canned fruit: peaches and pineapple. We discussed what type would be good in the smoothies we would make together.
I always told him I'd come back to see him. "Good," he would smile, "I enjoy your company," he'd say in his southern gentleman accent.
The next morning I remembered the milkshake. It melted a bit on the way in, and by the time I got there he'd already had a recent dose of morphine (for his broken ribs) and was too sleepy to eat it. I asked the nurses to put it in the freezer with his name on it and would come back to try later.
Throughout that day, I'd pop by whenever I wasn't swamped with other things to do. He seemed to be sleepy that day, like something wasn't right. I tried to help him eat the milkshake a couple more times, he was appreciative, but just didn't feel like having it.
By that evening, when it was time to go home, I was reluctant to leave him. He'd started sundowning by the time I left (getting confused more again at night) and was confused again, "Are you taking me home?" "No, but you're getting better," I held his hand and stoked his hair back. I wanted to believe it when I said it, too. Like maybe saying it outloud would make it true. "Is she taking me home?" He pointed to one of the nurses. "No," I said. And then he looked right in my eyes. The man who must have once been strong as he fought for his country, he looked at me with the pleading eyes of a child, "Am I ever going to go home?"
I wanted to tell him he would. I wanted to believe he would. So I told him he was getting better, that he just had to hang in there with us and we'd get him through this.
I told him goodnight eventually. When I went to sign out to my nighttime cross cover, I warned them that he'd become confused and might need some of the antipsychotic he hadn't needed in a couple days (haldol).
When I came in the next morning, I ran into the ICU intern on the elevator, the one who'd told me to think of him as my grandfather, "We got your guy back last night." What? my mind spun and sank. I must have looked stunned. "He's yours, right? Mr. W?" "Yeah, yeah. What happened?" Not even sure I wanted to know. "We think he got volume overloaded. I just came from intubating him." He had another tube down his throat and another ICU admission. "Not good prognostic signs," my attending would say later that morning.
I was upset. I visited him the next day. He was back in restraints, the tube down his throat, tied in placed with gauze and pulling at the corners of his mouth. He was writhing and fighting to get it out. He looked at me with little recognition, but I calmed him down some, "Just rest and heal. Just rest." I stroked his hair back again. I couldn't bear to stay long. It was too sad and too hard.
That day the team thought he'd come back to me on Monday, today. But today I found out he's still intubated. "It doesn't look good," she said, "He might not make it out." I looked at the intern who'd known him from the beginning, too. "You'd better go visit him," he said. "Go see him."
I try to rationalize it, but I can't. If he hadn't been picking up his medications, he would have died alone at home. But had I messed up? Had I given him too much fluid to keep his pressures up? Had I missed the pneumonia he was brewing? Had I killed him? Had I gotten too close? Had I done too much?
My attending could see I was upset when I first told her where he'd been transferred, "Jeez, what did you do, try to kill your patient?" she teased. I didn't think it was funny. I almost started crying, to tell the truth. "Don't worry, you'll get a thicker skin." Great. That's comforting.
I miss him. I did feel like he was my grandfather in a way. And I felt like he was lonely. And he needed me. And I liked his eye smiles. I guess I needed him, too.
"You're too sensitive!" I would be told a few days later. "I can't even begin to reach your level!" Maybe I'm too sensitive for this job. I don't like it when patients get sick and die. I don't like being there just for the end without knowing the beginning and the middle. I don't like being the one who can't help them hold onto the scraps of life they have left. I don't like being part of the mentality that death is failure. That death is the enemy. And if I can't battle it successfully, I have failed.
I guess I am too sensitive.
He never got to drink his milkshake.
I miss my patient.
I enjoyed his company.
He wanted a milkshake. It was the first really coherent thing he'd said to me in the two days I'd been taking care of him. He was still in soft restraints because he'd already pulled out his urinary catheter and given himself quite the bleeding prostate lesion requiring the urologist to grudgingly come relieve his 810 ml of bloody urine in his bladder (normal you'd feel about ready to burst at around 300 ml). The nurses had struggled for hours on that task. When they finally called me, he was sprawled out naked on his bed with blood all over his penis and a gowned nurse holding a tube only partially in the opening.
But after that episode, he started to clear mentally. He started to talk to me more. He had this great North Carolina accent. We were going to start a smoothie company together and make our fortunes. Or I was, at least, he said I could go ahead with it. He was too old to take on a new project. He wanted to name it Triple H. We hadn't decided what they all stood for yet, but on of them was "Healthy" and he was working on the graphics in his head.
He lived alone in town. His ex-wife was the only person in town that he knew and she was dying. His brother was worse off than he was. The only family member who could consent for the blood he needed when he hemoglobin dropped below 10 (tranfused for heart failure) was his nephew who still lived in North Carolina. He seemed so alone. No one came to visit him.
He'd been transferred out to our general medicine team--one of the Intensive Care Unit "bombs," who can be total wrecks. He was confused and clouded and altered and had an O2 requirement and bloody urine, and a chronically failing heart. About a week before he'd been going about his business, just made a trip into the hospital to refill his medications. When his heart decided it had had enough. He lived in atrial fibrillation (the top chamber of your heart not beating very effectively), but he suddenly switched into ventricular fibrillation which is much much worse.
He was on the elevator at the time, and one of my fellow interns called a code blue and started compression while trying to keep his foot stretched out in the elevator so the doors wouldn't close him and my patient in there without any other help. In the process of manually pumping his heart through his chest, he broke three of his ribs, but after 15 minutes, they got him back. His heart started beating a bit on it's own and they put a tube down his throat to help him breathe for the next couple days.
Soon after he was extubated (the tube came out), he was transferred out to me. I scoured his records for information as any good intern would do--a "chart biopsy" we dorkily call it. In talking to another of my fellow interns I learned what my patient had been like before he became confused with what we would later determine was probably ICU psychosis (basically being old and confused about all the craziness of the hospital environment and losing your bearings on your life). "People want to write him off," said the other intern, "but he's really a cool old guy. Just think of him as you would your grandfather." He wanted me to see the person behind the tubes and mask and confusion. The vet who had lived a full life.
"I want a milkshake."
"What kind?" I asked as I held his arm and hand to try to hold him in this world.
"Guess."
"Vanilla?"
"You guessed it!" He gave me an eye smile and squeezed my hand.
I later called dietary and they don't make milkshakes at the hospital. I told him I'd pick him up one on my way into work one day.
The next day I was running quite late and didn't have time, but I stayed late and got to know him better. He was well out of restraints by now and I helped him feed himself. He didn't have much of an appetite; his belly was still full of stool despite the suppository we'd tried earlier that day. He liked the canned fruit: peaches and pineapple. We discussed what type would be good in the smoothies we would make together.
I always told him I'd come back to see him. "Good," he would smile, "I enjoy your company," he'd say in his southern gentleman accent.
The next morning I remembered the milkshake. It melted a bit on the way in, and by the time I got there he'd already had a recent dose of morphine (for his broken ribs) and was too sleepy to eat it. I asked the nurses to put it in the freezer with his name on it and would come back to try later.
Throughout that day, I'd pop by whenever I wasn't swamped with other things to do. He seemed to be sleepy that day, like something wasn't right. I tried to help him eat the milkshake a couple more times, he was appreciative, but just didn't feel like having it.
By that evening, when it was time to go home, I was reluctant to leave him. He'd started sundowning by the time I left (getting confused more again at night) and was confused again, "Are you taking me home?" "No, but you're getting better," I held his hand and stoked his hair back. I wanted to believe it when I said it, too. Like maybe saying it outloud would make it true. "Is she taking me home?" He pointed to one of the nurses. "No," I said. And then he looked right in my eyes. The man who must have once been strong as he fought for his country, he looked at me with the pleading eyes of a child, "Am I ever going to go home?"
I wanted to tell him he would. I wanted to believe he would. So I told him he was getting better, that he just had to hang in there with us and we'd get him through this.
I told him goodnight eventually. When I went to sign out to my nighttime cross cover, I warned them that he'd become confused and might need some of the antipsychotic he hadn't needed in a couple days (haldol).
When I came in the next morning, I ran into the ICU intern on the elevator, the one who'd told me to think of him as my grandfather, "We got your guy back last night." What? my mind spun and sank. I must have looked stunned. "He's yours, right? Mr. W?" "Yeah, yeah. What happened?" Not even sure I wanted to know. "We think he got volume overloaded. I just came from intubating him." He had another tube down his throat and another ICU admission. "Not good prognostic signs," my attending would say later that morning.
I was upset. I visited him the next day. He was back in restraints, the tube down his throat, tied in placed with gauze and pulling at the corners of his mouth. He was writhing and fighting to get it out. He looked at me with little recognition, but I calmed him down some, "Just rest and heal. Just rest." I stroked his hair back again. I couldn't bear to stay long. It was too sad and too hard.
That day the team thought he'd come back to me on Monday, today. But today I found out he's still intubated. "It doesn't look good," she said, "He might not make it out." I looked at the intern who'd known him from the beginning, too. "You'd better go visit him," he said. "Go see him."
I try to rationalize it, but I can't. If he hadn't been picking up his medications, he would have died alone at home. But had I messed up? Had I given him too much fluid to keep his pressures up? Had I missed the pneumonia he was brewing? Had I killed him? Had I gotten too close? Had I done too much?
My attending could see I was upset when I first told her where he'd been transferred, "Jeez, what did you do, try to kill your patient?" she teased. I didn't think it was funny. I almost started crying, to tell the truth. "Don't worry, you'll get a thicker skin." Great. That's comforting.
I miss him. I did feel like he was my grandfather in a way. And I felt like he was lonely. And he needed me. And I liked his eye smiles. I guess I needed him, too.
"You're too sensitive!" I would be told a few days later. "I can't even begin to reach your level!" Maybe I'm too sensitive for this job. I don't like it when patients get sick and die. I don't like being there just for the end without knowing the beginning and the middle. I don't like being the one who can't help them hold onto the scraps of life they have left. I don't like being part of the mentality that death is failure. That death is the enemy. And if I can't battle it successfully, I have failed.
I guess I am too sensitive.
He never got to drink his milkshake.
I miss my patient.
I enjoyed his company.
posted by S. at 8:41 PM
2 Comments:
No matter how many people I've sent to the ICU or to the morgue, no matter how many train wrecks I've admitted, knowing for a fact that they were going to die on my watch and there was nothing I could do about it, no matter how much I remind myself that metastatic anything means a death sentence, I can still feel the way you feel. Did I miss that PE? Should I have started that heparin? Did I drown him? Or did I make him pass out and aspirate by overdiuresing? I know in the big picture, a lot of it doesn't matter, but I can't help but doubt myself sometimes, even this far along (which is not that much farther than you've gotten.)
When I told my oldest friend that I could never get used to death, even though I've literally seen it a hundred times, he told me that was good, death isn't something you should get used to, something that you can watch and not react to.
But like you said, it isn't the enemy. Death does not mean failure. But, ultimately, there are good ways to die, and there are bad ways, and if I were a patient, I would choose dying with you watching over me, if only for a little while, rather than dying all alone in my apartment face down on the bathroom floor, although it may be selfish because I know it will cause you grief.
But I think that no matter how hopeless the prognosis, we will always serve a purpose, even if it's just to witness the brilliant flame of someone else's life flicker and fade. There is something sacred about being that witness, and of being entrusted with those last few memories, although I know it isn't easy.
Thank you. It is a sacred keeping to be that witness, despite the grief. Thank you for writing and for sharing and for understanding...thank you so very much.
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