The hardest extubation

Sometimes people go to a hospital, and we cannot save them.

That is one of the worst parts of my job. The toughest thing is when it is one of your people. This story is one that I have hesitated to write, but I think it is time. My biggest fear is that I will be unable to fully convey what this woman meant to me.

In May, 2011 I am graduating from graduate school. (Well, we were walking then, we still had a summer session of clinical work to do.) I have a great weekend. Angela comes from California, My friend Aneta, who I had not seen in years comes from New Mexico, and we all have a great time. Angela and I stay up all night after my party Saturday night talking. So, the next day after I take her to the airport I am in dire need of sleep.

I did not realize that I had never turned my phone ringer back on. When I woke up later that day, I have missed several missed calls and voicemail from my friend Stacy. She sounds confused and lethargic (encephalopathy sucks.) Then, the last two messages are the worst. Steve (her husband) and Christopher (her son that is a year younger than my son,) have left messages asking me where I am, and that there is something wrong with her. I call their house and get the answering machine. I figure that she is either okay, or that they have taken her to the hospital. I have to be at the hospital early on Monday for clinical time, so I jokingly tell myself, “Worst case scenario, she will be in my unit in the morning.”

The next morning, I walk into the unit, look at the patient assignment sheet, and there is the worst thing I can imagine. Stacy’s name. I am instantly pissed. What is this all about? I look at the monitors, she is stable, so I wait to go talk to her. I am confused and hurt. I do not understand what is going on.

We meet at the opposite end of the unit for rounds. We methodically go through the unit until we are at Stacy’s room. I stand back out of the group. I am not sure of what my place is here. Am I her friend? Am I a nurse? Am I a student? What the hell is my role?

Finally after rounds, I go in to talk to her. I ask her what on earth is going on. She says she did not take anything. She had been complaining of vague stomach pain for several weeks. Nothing too serious. Steve has brought her medicine, and there is the proper amount in the bottles. This was not an overdose or suicide attempt. Now, she is in liver failure. I feel guilty that I did not know that immediately. I just assumed the admitting diagnosis was accurate.

Unfortunately, there is not a lot to do for this. We consult specialists, and they come and offer their best advice. I am not aware of how sick she is. I tell the nurses to please call me if anything changes. I tell them that she is one of my best friends, and that she is like family to me. I go home, do some homework, and fall into bed exhausted. I leave my phone right next to bed, with the ringer on high.

The next morning, I walk into the unit and she is on a ventilator. Things have gotten so much worse. She was having seizures, and was not able to protect her airway. I am furious that no one called me. I cannot say anything for fear that I will make people mad. After all, I still work with these people. I spend a lot of time biting my tongue. Stacy’s friends and family are crowded into the waiting room. I am struggling to maintain a professional demeanor.

These people have known me since I was a (for lack of a better word,) troubled teenage punk. Now, I am updating them on the condition of our friend, My “Momma Stace.” I am confused and desperately hurting. At one point, I go into the break room and have a minor meltdown. This is one of the most stressful events of my life. I am terrified.

I go home and I am sick. I have rarely felt so helpless. That night I do not sleep. Finally, I give up and get dressed in jeans and a baseball cap. I go to the hospital. Every one is gathered outside her room. She is desperately unstable, she is no longer breathing over the ventilator. Her blood pressure is being supported with high doses of vasopressors (and still falling.) It is my worst nightmare. Once again, no one called me. I only got there by chance.

I am frantically trying to ascertain what is happening, and I am trying to wrap my brain around the situation. I knew this was a possibility. Fulminant liver failure is serious. There is not much you can do once the liver is that sick. She had every major organ system failing. We are losing her.

Now, Stacy had been my confidant many times. We had an understanding. She said she would never want to be in the situation that she was in. She would never want to be kept on machines if she was not going to survive. Her death is imminent. Her husband and her family are at her bedside. I have to be honest with them. I have to tell them that she is dying. It is hard enough to admit it to myself. I know she would want the tube out of throat before she dies.

Her husband asks me what happens now. I tell him that we can wait for her heart to stop, and start CPR, and do the horrendous code blue that has no chance of saving her. We can leave her on the ventilator, but make her a DNR- which means we will not do CPR. The last option, the one that I know Stacy prefers, is to stop the machines, and let her go naturally. This option is the scariest one to choose. It feels so final. It means that you are accepting the inevitability of losing your loved one.

After he and I talk in the quiet waiting room, I go back into the unit to stand guard. I feel responsible. I feel like if I loved her, I would do something to save her. There is absolutely nothing to do. We are doing everything, and she is still dying.

Steve tells me his decision. We have to call the physician, and get orders to change her code status, and remove the machines that she is hooked up to. I am reeling at this point. I want to run away and go home. I never want to step foot in this building again. I am seriously considering switching careers. When it is time to remove the tube, I go to head of the bed. Just like I have done so many times as a nurse. She is wearing sunglasses that we bought in the gift shop to hide the scleral edema  that comes with this kind of devastating illness. I do not take them off.

She is no longer here. She has no brain function. She has no reflexes. Her pupils are fixed and dilated. I am still so careful when I pull on the tape that secures her ET tube in her airway. I do not want to pull her hair, or rip her swollen skin. Once the tape is loose, I lean over and whisper in her ear. I am telling her goodbye, I love you, and I am so sorry I could not save you. Once the tubes are out, and I see that she is not going to breathe, I walk outside the door, and Jamie immediately hugs me and I start sobbing.

It does not take long for her heart to stop. She never takes a single breath and she was already hypoxic due to the ARDS that prevented us from oxygenating her. Once she is gone, someone hugs me and tells me that she is in a better place. I am incensed. No, she is not. THIS is the place she wants to be. She wants to be here for her son. She wants to be here for her husband. She wants to be here for me. However, I say nothing. I go downstairs and sit on the curb. I am crushed. I do not know what to do.

One of my favorite cardiologists pulls up, and he knows that it must be bad. He knows her condition was grave,  because I had asked him questions earlier that day. He gives me a hug, and I am undone all over again. I tell him that I hate people, and that they are assholes. He just agrees with me, and offers that perhaps they are just trying to provide the only comfort they can.

After a while, I go back upstairs. Her family is gone. I walk into her room and shut the door. I sit beside her bed, and don’t move. I do not know how long I sit there. I am not leaving. I know what happens next. We prepare the body to go to the morgue. I hate that part. I will spare you the details.

I do not want any of this to happen to Stacy. So, I sit there. Finally, Tracy walks in and convinces me that it is time to go. She promises to take care of her. I finally go home. I take several days off that week, and stay home until after her funeral. Several of us spoke. I agonized over what to say, and if I had it to over again, I would do it better. My mother helped me arrange for flowers, and I had a ribbon placed on it that said, “My Friend.” She was MY friend. I was bereft and inconsolable. My life had a huge gaping hole. I did not think I would ever feel joy again.

I have struggled with this situation for years. I have read about liver failure and I have experienced regret and sadness. I have grieved for my dear friend a lot. Whenever I have a patient with this condition, I feel sick to my stomach, and I am bombarded by the grief all over again.

You see, Stacy was a very important person in my life. She had been a high school english teacher, and she was helping me get through some of the books that I had missed by not finishing high school. She would discuss them with me, and she helped me process what it was that made the book “important.” She and I had been close for many years. She and Debbie were two of the small number of friends that I had to come to my baby shower. She was very much a mentor, and a confidant. She had seen me grow from an obstinate, rebellious teenager into a responsible (mostly) professional.

She was one of my closest friends. We talked almost every single day. She was the one person I wanted to talk to about my grief and she was gone. I was also hurt that my coworkers had not called me when she started to do worse. They had promised me that they would, and I felt betrayed. It took me a long time to forgive them. Her friends and family assumed that I had been called.

I finally realized that the nurses were busy trying to take care of her. I had no justifiable reason to be angry. So, I forgave them.

To this day, I still tremble a little when I am removing the tape that is securing someone’s life support. My heart races, and I have to take a deep breath and banish the thoughts of that night. I have to focus on the task at hand, and not allow it to be about my grief. That is my responsibility, and it is the best way I can honor her memory.

Writing is the other way I pay homage to Stacy. I imagine that she would have been one of my biggest supporters, and likely would have been willing to offer grammar advice and maybe even some editing. She invested a lot of time and effort in my growth with language. She listened to me prattle on and on about whatever paper I was writing. She wanted me to succeed.

It took a while, but I think it is getting better. I am no longer a student, and I work in the same unit I worked in when she was my patient. Stacy would not have wanted me to give up on my dream of this position. She would have wanted me to be every thing I ever dreamed of and more. I owe it to our friendship to be the best person I can.

I have managed to find joy. I am very happy in my life. There are so many things that I still get excited about. I love a great many people, and I have a group of wonderful friends. I have a family that loves and supports me unconditionally. I have a job that I love. I am learning to write, and I am obsessed with it. I love the process. I want to do more. I want to live my life to the fullest. I cannot allow myself to become bitter and unhappy just because I am sad that my friend died. That would be selfish.

This is one of the reasons that my profession is so difficult. We eventually run into a situation that is personal. One that we cannot escape. We know the course that these situations often take, and we are facing a helplessness that is brutally painful. It can cause you to question your worth. It can make you doubt your abilities. It takes effort, time, and patience to work through all those feelings.

If you are lucky, you find peace on the other side of grief, even if it is after the hardest extubation.