Out

Today was my last day at Sinai.

Neurology isn't what I want to do forever and so I'm excited to move on to the next adventure. For me, this means oncology, something I've wanted to do since my last semester of nursing school.

It seems so long ago that I felt like I was mindlessly clicking buttons and writing the same but slightly different cover letters over and over and hoping for someone to say SOMETHING, even if it was rejection. After six months, I finally had a job. At the time, I had no interest in pulmonary and infectious disease but if they were willing to give me a pay check, I was willing to work for one.

The idea of me being able to move on because I decided I wanted to do something else was unfathomable.

Nursing school friends, it gets better.

On Death and Dying - The Distraught Niece

Recently, I've had a few patients pass away on my shift. We are not a hospice unit; the majority of our patents are admitted for some kind of neurological issue. But we do get other types of patients on occasions. This is one of them.

All of our patients have some kind of order set put in by their physicians. They dictate the frequency and type of vital signs to be taken, when and what labs are to be drawn and what the patient is allowed to eat, if anything. There are other orders, but these are the most common ones.

All patients are required to have a code status, which is perhaps the most important one. At any moment, a patient could stop breathing and we need to know what to do. If we have no information, the default is full code and all appropriate interventions are used as necessary. This may include CPR, oxygen therapy (intubation or an external mask), medications, etc.

For patients who want no interventions in the event that they stop breathing, our facility uses AND - Allow Natural Death. A more common term used at many other facilities is DNR - Do Not Resuscitate, but the meaning is the same.

The first of these patients came to our unit from the ICU as AND. She was elderly and non-responsive. The orders for her were comfort care only. This means that, among other things, no vital signs are ordered. Many times, as was the case for this patient, pain assessments were ordered at regular intervals and a constant morphine drip was running. When she arrived, the charge nurse, tech and I went into the room to set her up but unlike other patients, there wasn't much to do. We set her up comfortably in the bed and left her to rest.

The charge nurse didn't say it, but he didn't have to - take care of the patient and let him know when it was over.

There were no family members in the room for most of her time there so my hourly rounding was uneventful. The patient arrived with a breathing pattern that is called Kussmaul. It describes a breathing pattern that is one sign that death is near. It's a shallow kind of breathing that sometimes will skip a breath. You learn about it in nursing school and it's hard to describe but when you finally hear it, it's very distinct and you know what it is.

Eventually, some family did arrive. Her niece came along with her husband. The niece was in tears over the bedside, while her husband stood a foot or so away from the bedside and calmly introduce himself to me. I left the room and not half an hour later, I was told there was an emergency in that room.

Now the only irregular breathing pattern belonged to my patient's niece. In tears, she asked me if I was absolutely sure there was no pulse. As a nurse, I'm not allowed to pronounce someone dead; that responsibility belongs to the physician. At her request, I hooked up a vital signs machine. The error messages on the screen seemed both comforting and frightening to this woman.

The physician arrived and shortly thereafter told the family she had passed. He asked me to do an EKG (also known as an ECG - electrocardiogram. EKG is its German abbreviation and is sometimes used to differentiate it from similar-sounding procedures like EEGs). The print-out showed the expected straight lines where a heartbeat would have been a few hours ago. Was an EKG necessary? In theory, no, absolutely not. There was not even the slightest indication that this woman might be alive.

But one thing they often fail to address in school is that you don't have just one patient. If there are family members or friends at the bedside - they are just as much your patients. This niece needed that visual to give her some closure.

For her, yes, the EKG was absolutely necessary.