Other Side of the Room
by: Chelsea Epling
June 20, 2021, I received my hardest patient to date, the one that will stick with me for the rest of my life.
The report we received was of a 61-year-old male who underwent cardiac arrest at home, without CPR for approximately 20 minutes. When EMS arrived, they were able to secure an airway and obtain ROSC. They transported the patient to the closest facility, a stand-alone ER. Once he arrived at the ER, the patient arrested for a second time.
After one round of CPR and one dose of epinephrine, ROSC was again achieved. The patient was not reported to be sick or feeling ill that day. Per the patient’s girlfriend, he was actually walking to his vehicle to go see his dad for Father’s Day when he collapsed in his driveway.
We prepare his room. Call respiratory to obtain a ventilator. Set up suction. Neurology was consulted. The arctic sun was placed in the room for targeted temperature management. Everything was ready and the only thing left to do was wait for the arrival of the local HEMS agency.
The patient arrives and the flight crew states that about ten minutes out from our facility the patient started seizing and they had to deliver two doses of Ativan in order to halt the episode.
As the patient was moved to the hospital bed and connected to the ventilator and hospital monitoring equipment. He sat straight up, his eyes were wide open, and staring directly at me. For a second, I believed that this man had gained consciousness, that he had a fighting chance. As quickly as he sat up, he laid back down. I catch my breath, he does it again.
His deep brown eyes gleaming into mine, I call his name – he does not answer. Then I recognized the rhythmic motions. Myoclonus had overtaken this poor man. Immediately I knew his chances of ever making a meaningful recovery were practically non-existent.
We placed him on the artic sun and set it to cool. In the back of my mind, I knew these efforts were futile. We drew all the routine labs and placed all the routine orders for a patient of this nature. His pressure dropped rapidly, an arterial line and central line were placed, vasopressors were initiated. Death seemed imminent. The neurologist came, a continuous EEG was ordered as well as a CT scan.
After we returned from the scanner, the EEG was placed. I take in everything in the room. I note everything about this patient. His face tells me that he has been through much in his lifetime, his hands are rough and calloused from his work. His hair retains the smell of cigarettes. I note his urine output, CRRT is to be started within the hour. His legs are swollen. I comb over his vent settings; he hasn’t exceeded the set rate once since arrival. I examine all his drips, ensure all his lines are labeled and untangled. His vitals are stable – for now.
I pull up a chair. I take his hand in mine and squeeze. “It’s okay, Dad. I’m here now. Happy Father’s Day.”
I was no longer a nurse but a family member from that point on, a family member that knows way too much. It was difficult in many facets. I didn’t know how to be on the other side of the room. To be staring at the inside of the wooden door. To be the one being “informed” instead of being the informer.
How do I just sit here and stare at him and do NOTHING? After connecting the EEG, the neurologist even turned the monitor screen off so I couldn’t watch it. My coworkers were forcing me to be a family member, to spend time with my dad, and watch his face instead of the tracings on a screen. I resented them, and I loved them for doing this.
On the opposite spectrum, I felt helpless. In all my training, with all the extra certifications I hold, there was not a single thing that I could do in this situation to change the outcome. So I deserved to sit on the other side of the room. I’m trained to cut a hole in someone’s neck, to stick a needle in their heart, but I can’t do anything to help my own father? Guilt engulfed me.
The intensivist and neurologist recommended that we wait a full 72 hours post-arrest before making any decisions. That’s what we tell all our family members. That’s the standard of care for non-responsive post arrests.
This infuriated me. My dad was gone, and I knew it.
I felt selfish for keeping him “alive.” However, a small part of me was thankful to them for giving me a chance to see if there was any hope at all. I reluctantly agreed. I stayed with him into the night and left to get a shower, a quick nap, and a change of clothes.
Day two: I walk into the room, full nurse mode. The CRRT has clogged twice throughout the night but is back working. The vasopressors are off. He’s maintaining hemostasis independently – if you don’t count the giant ventilator. The EEG screen… it’s on, but all the brain waves are flat. He has no activity.
They will begin rewarming him this evening. One of my close friends has him as a patient today. I know this is difficult for them. I know they don’t want to tell me how bad this is looking. I ask to see his lab work, they comply. They work tirelessly to ensure that my dad has everything he needs and that my family and I have more than everything we need. It’s weird being catered to this way. The sad eyes from each of my coworkers as they come to check on me, as they try not to glance into the room. Do I do this? Can my patient’s family members see the heaviness I carry when they’re losing their loved one?
I speak with the neurologist and beg him to tell me one way or the other. Is there any chance at all that my dad will have a meaningful recovery? If not, he’d be livid if I kept him alive like this. He needs an MRI. I spend the evening into the night reading to him from the Bible. On the promises that God gives to his children. I don’t know if he can hear me, but if he can, I don’t want him to be afraid of what’s to come.
Day three: The arctic sun has been removed. The CRRT has clotted multiple times, and for now, it is being placed on standby. I beg for an MRI. I know in my heart of hearts he is gone. I knew the very first day. His soul left us on Father’s Day, but his poor body is being kept alive by machines. Machines that I have the ability to turn off.
Am I causing him more suffering? Can he feel any of this? Can he hear me? Does he know what I’m doing to him?
Do I keep the Faith, pray harder? Pray for divine intervention to occur because I know medically there’s not a dang thing we can do to reverse what has happened?
An MRI has been scheduled. A giant weight has been lifted from my shoulders. More than anything, I want my dad to make a full, meaningful recovery. The second thing I want, if option one is not available is a widespread anoxic brain injury. Is that weird? Morbid even? To wish for such a thing for the man who still refers to me as “daddy’s angel”? Is that something an angel would wish for?
How do I explain to my family members that if I can’t have option one, I want the worst possible news? My dad was a strong man and a hard worker. If he couldn’t have that life, if he couldn’t care for himself, he would have been miserable. I remind myself of what I tell my new grads and family members in similar situations, “there are worse things than death.”
My dad is finally taken for the MRI. I knew what the results would be. But still, when the intensivist came to deliver the news, I almost didn’t believe him.
He pulled up the images, and sure enough – there it was – complete widespread anoxia.
A part of me was relieved. I didn’t have to make the decision. It was made for me. But the daughter in me – was distraught. My dad was gone. My dad was gone, and all the time I had spent dedicated to being the best clinician I could be, to know how to truly and completely save lives, failed me when it came to my own flesh and blood.
We called the rest of my family in and planned the terminal extubation. A few minutes later, there it came, the death cart. It’s officially called a courtesy cart, but we all know what it means. It means that someone in there is experiencing the worst day of their life, and somehow, we think fruit and a cookie are going to make it all better. It’s weird how these things change when it’s happening to you. I appreciated the cart – don’t get me wrong, but I had never thought of it in this manner before. I made sure all my family members had a chair, that their coffee cups were filled, that they had tissue boxes.
I didn’t know how to NOT be the nurse and to be the daughter. Maybe it was a coping mechanism; perhaps it’s just bred into us to continue to be the health care provider even when it’s us who are suffering.
Respiratory was called, my family stepped out. I stayed in the hallway, I knew his death would be quick, and he wasn’t going to go alone. As soon as the endotracheal tube was removed I grabbed my brother, and we went back in to be with my dad. He didn’t take one breath. It was about one minute before his heart finally ceased to pump. I watched as the color drained from his once rosy cheeks. This was the strongest man I ever met, the one who could conquer anything, lying lifeless before me.
Death has never been so real and yet so non-believable.
This experience changed me. I have a whole new perspective for how families see us when caring for their dying or critically ill loved ones. I have a whole new perspective for the weight that we as healthcare providers carry on the day-to-day when these terrible things happen.
We shrug them off as if they don’t bother us, and some of us (myself included) are so disillusioned that we actually believe that death has no affect on us at all; it’s just part of the job. I also have a new understanding of how difficult it is to take yourself out of the clinician role and into the family role.
In every situation, I try to turn the bad into good. From the day I lost my dad, I vowed to ensure that I would help every health care provider going through this type of loss to the best of my ability. We think differently, we grieve differently if we allow ourselves to grieve at all, and the guilt that follows from being unable to change the outcome lasts for a while.
To any of you who have made it through to the end of this, if you need help – please reach out.
If you feel alone, please know that you’re not. And if you find yourself fighting demons in the middle of the night that you should have never put on yourself in the first place, know that it is not your fault and just as we tell all our families, everyone has their time.
Most importantly, it’s okay not to be okay.
We try to put on this hard exterior because we couldn’t do the jobs we do without it – but it is okay to ask for help. To ask for someone to listen who has been there, and even though it’s via blog, I’m throwing my hand out to you – it’s up to you to grab it.
If you are struggling in a similar way and need someone to talk to please know that we are here. There are so many amazing healthcare professional-specific resources available, and you can always message me directly at firstname.lastname@example.org as well.