If you work in an ICU for long enough, you will come to realize that you are hanging out with a lot of very smart people who don’t have a clue as to what’s really going on -- the big picture. Maybe they feel that if they acknowledged it, they’d have to then change their behavior to continue living with themselves. Maybe they are just clueless, but clueless like foxes -- there’s not much money in observing the rituals of death or attending to the dignity of the dying and it’s easy enough to paper over reality with the good intentions of mixed motivations.
Life may more about subtraction than addition, but it’s not reductionist, it’s more about the stripping away of distractions to uncover the relationships of one thing to another, and in these relationships, tying together the whole that is us to the things that are around us and of us. All this is complicated, time consuming and difficult to get Medicare to pay for, but if you take it and break it down to parts, it becomes easier to get it on a spreadsheet, and then all you have to do is mix proprietary science words into a liturgy, add strange smells and put it all into a massive building to have a new religion for those not so inclined, but still needy in their desperation.
God knows it’s not easy, but taking something complicated and breaking it down into parts only makes it easier to explain in pretty words, not to make whole or put it together again.
Patients in critical care usually end up with 5 or 6 specialists, all of them brilliant and well paid. Each of the doctors will do anything they can to fix the problem they were consulted on to fix. Respiratory will fix the lungs, endocrine the kidneys, a cardiologist the heart and the surgeon will remove whatever breaks and then smells like it needs removing. Finding someone to see the patient, as a whole of interacting parts, with thoughts and wishes that are intellectually unknowable, but at the same time real and strongly felt, is almost impossible. If you think it’s going to be a doctor doing the finding, think better.
In an ICU you need a quarterback. If you are lucky, you might get a nurse who understands this role, and then chooses to act like a well-informed, non-sick version of you. If unlucky, you might end up with a mom in the worst sense of the word.
When you are sick, having a mom to take care of you is a great thing, if you didn’t get a dud from the mom pool, so having a nurse who thinks her role is to be a mom is not always a bad thing -- it depends on the mom.
What you get, is what they got -- and sometimes the worst of what they got. You get: a mom with power, fixed rules, surrounded by authoritative men who are clueless. You see this a lot in nursing, stylized moms for whom patients are wards or chattel and all rules for everyone but them are fixed and unchanging. The patient exists to be the physical acknowledgement of their status, and the sickness that their patients were going through gets extended to themselves and elevated to the holy grail of give me more – they take onto themselves all the pain that their patients are going through, but do it in the form of sympathy, not empathy, so they don’t have to actually suffer. Like the doctors they emulate, they haven’t a clue about what it feels to be dying; to be alone in a church that speaks in a foreign tongue and feeds you wafers and drinks of bitter poison. They take responsibility for you without blame, and worship reflections of the cross without the feeling of the bindings of the nails. They stand on unstable pedestals; illuminated by the suffering of those they see reaching up for help.
Sometimes you get a different nurse, one that looks at you and says, “You are my brother, and I will do for you what you would do for me.” But, it’s the luck of the draw.
The Anesthesiologist arrived on the unit and talked with Dr. Kanada briefly. Dr. Kanada left quickly, and the anesthesiologist scooted over to me in a rolling chair and asked for the latest blood gas, which he reviewed dismissively, and complained that it was too old to do him any good.
“This is old crap,” he said, “give me something that tells me what he looks like now.”
Tempted to point to Mr. Posey’s room and saying, “the thing speaks for itself,” I instead ordered a new ABG and gave him a quick summary of things too knew to have been placed in the chart.
After Dr. Y confirmed that the intubation supplies were in the room and that the ventilator ready to be plugged in, he jumped up from his chair and headed to Posey’s room.
Anesthesiologists are like pathologists with an attitude— they are seldom known for their bubbly personalities. Dr. Y. was no exception, and there was no way I was going to let him explain anything to Mr. Posey with me being there to interpret things. I followed him into the room.
Dr. Y. ordered me to raise the level of the bed and to remove the headboard. I explained to Posey that this was the doctor that would be putting a tube down his throat to breath.
Dr. Y. pushed the bed out from the wall with his knees and squished his way around to the head of the bed. He didn’t say a word until he had put his hands in Posey’s mouth and said, “Is this a partial?”
Posey looked up at me, as if to ask, who the hell is this guy? I quickly injected 4mg of Valium into an IV line to dope him up and not have to answer the question. I had my own notion of who this guy was, but I didn’t want to share it.
Anesthesiologists are like regular doctors in that they tend to quietly appear out of nowhere—suddenly you just feel like someone is watching you and, as you jerk your head up to respond to the feeling, they are just there. Anesthesiologists take it a step further than most; they slink around without feeling the need to waste facial expressions on people they plan to knock out anyway. Known to carry large, unlabeled syringes of various uncolored liquids, they are mythic, scary and the ultimate in non-verbal. Their job is to not make you talk because talking just means trouble, and is an indication to them that their work is only half finished.
The way I see it—at least Pathologists don’t pretend.
Intubations involve the placing of a plastic tube, with an interior diameter of about a small finger, down a person’s throat and into their trachea. After insertion, a small balloon is then filled with air to provide an anchor for the tube, and then the tube is taped securely to the face with an elaborate taping scheme – a scheme so secure it often rips off the skin if not removed carefully.
After the tube is inserted and secure, it is connected to a machine that mechanically attempts to mimic the actions of your lungs. It is not as passive or as gentle as your own lungs, however—it’s mechanical, with all the baggage that word implies.
Normal inhalation occurs when the diaphragmatic muscle stops contracting--like a bellows being closed—imagine the type of tool used to build up fires in old English manors. It’s passive in the sense that air just falls into the lungs as the muscle moves to make more space available.
Mechanical ventilation, although improving all the time, consists of a machine pushing air into the lungs—it’s active, and tends to be rougher and more damaging than relaxation involved in normal breathing.
What mechanical ventilation can do is: provide a more regular depth and rate of respiration, and a much higher concentration of oxygen than any other method of delivery. The normal percentage of oxygen is air is 12; a ventilator can deliver a concentration of 100 percent. As we have seen earlier- the energy the body needs to power itself primarily comes from oxygen. Up to a point, more is better.
Dr. Y and I have history together, primarily through his son, Mark, a fellow nurse who had been working with me in the ICU for the last few years.
Mark and I met years ago, when he came out from Texas for a summer vacation. His Dad got him a job in the operating room as an orderly, where I was also working part time between semesters at school.
Dr. Y had left Mark’s mother for a younger woman when Mark was a baby. Raised by a single mother, Mark had poor male modeling—which I thought was fairly obvious when he latched on to me as a mentor.
I was a little different human being when Mark met me—a little off. I had hair down to my waist, and came to work at three in the morning in shorts—only shorts-- no shoes, no shirt, no underwear—and the shorts were kind of flimsy. I changed into scrubs every morning and used 4 pairs of paper “booties” for shoes (slip cover type coverings to help keep the OR clean) and tucked my hair up under a paper cap.
My morning routine consisted of: a cup of coffee, a joint, and a brisk walk to work. I was a walking, willful ball of self without any insight or reflection. Evidently, that appealed to Mark.
I came to work at three AM to shave people before surgery; I thought of my self as an artist -- my razor a brush and the patient my canvas.
I met Mark after lunch on his first day at work (my lunch-- two joints, a hamburger with four catsup's, extra onions- I don’t know what he had) He seemed a little tightly wrapped and uncomfortable, but cleanly earnest in an out-of state sense. He had that bouncy dog type of attitude—you could almost hear him panting with anticipation over the newness of his situation. Though taller than me, he appeared to physically look up to me as I explained the job, the politics and the angles.
At the end of the day, as I changed in the locker room, and took off my scrubs, hat and “shoes” I noticed Mark staring at me. I finished by putting my shorts on and walked out. As I left I could see Mark rapidly revising his opinion of me. I was pretty sure that the new opinion wasn’t going to be any better than the original.
Over years of observation, I’ve come to the conclusion that people see in me what they want to see – I’m a screen for their projections. Half the people I meet love me on first meeting, and the other half don’t. Six months later, after they get to know me, it’s reversed – the people that hated me have come to accept me, and the people who loved me are disappointed in how the whole thing turned out. Evidentially, it’s not me, it’s what they think I am, and that’s strange, because I’m very consistent.
I got to know Mark well over the summer. After work we would go down to his father’s house, smoke dope and watch the golfers tee off outside a large picture window. I taught him everything I knew-- which mostly consisted of scams and tricks, all things necessary to get along, in what I thought, a smoothish and internally consistent manner.
As Marks dad became more comfortable having him around he started buying dope from him as the summer progressed—I think the good Dr. had a history of giving up alcohol “in the past” and he used pot to “take the edge off.”
Mark was too nice a person to hate his dad in a straightforward manner, for past sins, so he jacked up the price on the dope he sold him, to help begin to heal the pain and to finance more dope purchases. I’ve never thought about selling dope to my dad, it was something Mark brought to our relationship that freaked me out a little.
By default that summer, I found myself hanging with the Anesthesiologists, in a sort of low-tiered posse position. I suppose it’s important to know a little bit about how the bastards work.