Dr. Y took a straight blade (a metal tool that looked like an old fashioned tent peg) from the towel around Posey’s head, and a #8 ET tube (The #8 referred to the size of the plastic tube, the ET was short for endo-tracheal tube.) Now that Posey was sedated, I took an ambu bag, with its mask connected, and gave breaths of oxygen to him as I waited for Dr. Y to do his thing.
He placed the blade on a handle with a grip—I stopped bagging as he opened Mr. Posey’s mouth and slide the blade down his throat. Peering down the length of the blade, looking for the white of the vocal cords as a landmark, he slid the ET tube past the cords and into the lungs. I assisted him by using a small suction catheter to remove the mucous and secretions that lined the blade on its trip down. When Dr. Y. was sure the tube was in the right place, he inflated a balloon located at the tip of it with a small amount of air from a syringe.
After the tube placement, we both checked again with our stethoscopes to make sure air was going into both lungs. Dr. Y wrapped up his tools and stepped away from the bed. I went to the door and requested a portable x-ray, for tube placement, from the ward secretary
When Dr. Y placed the tube down Mr. Posey’s throat, things abruptly transitioned from one level to another, we were now plateau’ed on a new level of care, and doing it in a faster rate of time. No longer was Posey a person with feelings and expressions, he was now meat to be machined and optimized. The time when he got to think or plan for his future had ended, we were in a new phase, a phase of logic, progression and inevitability—the true land of cause and effect.
The respiratory therapist taped the ET tube securely-- the tube was not a thing anyone would like to see dislodged. A ventilator was attached to the end of the tube, as breathing parameters were shouted out by the Anesthesiologist. With the increase in oxygen provided by the machine, Mr. Posey’s heart rate returned to a still elevated, but stable, rate.
Mr. Posey’s eyes opened and he became a little agitated. I spent a few minutes with him explaining his recent past and then gave him a fast push of morphine through his IV. His eyes rolled back a bit and he relaxed—the pushing of the morphine worked quickly.
Our routine in ICU was to use soft restraints to secure any intubated patient—just in case. Since I planned to be in the room most of the time, I wrapped them loosely around the bed frame—technically meeting the rule. I asked Dr. Y to keep an eye on Mr. Posey and walked to the waiting room to update his wife.
Mrs. Posey was standing alone outside the double doors of the ICU. Holding a Kleenex with most of her makeup on it, but no longer crying, she looked hyper alert, as if waiting for a last minute call from the Governor. As the automatic doors opened, she walked towards me.
Before she could ask, I told her that her husband was stable and comfortable and that it was OK for her to come back in to see him. I explained that the heart muscle had become too weak to pump enough oxygen to keep him alive without support and that the breathing machine would, hopefully, help him until the heart had a chance to heal.
On the day that Mr. Posey entered the hospital I knew that he would die. I knew it with certainty, and without any doubt. On that day I had detachment and the ability to stand to the side and make observations without the closeness of attachments.
I had become too close. Like a woman thinking that love could change a man; like a gambler thinking his luck would change with one more --I began to tell myself that this situation was different, and that if I just did everything right, and put into practice all that I’d learned—Mr. Posey could get through this.
And the promise of medicine was, that it could happen, because it had happened—and I had been there when it happened. I had seen impossible things happen before, real miracles that defied any rational explanation I could conceive of.
I’ve been there when people have recover from impossible injuries--- a little girl with a head smashed flat from a falling desk; an automobile accident victim found torn and broken in a crunched place smaller than a suitcase; an aneurysm survivor whose initial CT scan showed only the white reflection of blood throughout her entire skull—I have been there when each of them woke up and walked out of the hospital.
All of these miracles, these outcomes outside of cause and effect, these things that I would have bet my life couldn’t happen—I was there; I saw them and they were real. And I told myself that Mr. Posey would be one of those people—if I worked hard enough and made it so.
In my lifetime, I have occasionally known the future—small paths or directions of surety that I would walk into blindfolded without any hesitation. Knowing that a thing was true and certain always gave me a type of determination and motivation. If I know a thing can be done, it’s just a matter of banging and manipulating it until it happens. It’s never been about faith, only about belief.
As I walked with Mrs. Posey to her husband’s room, I believed I had the power to save him.
I also believe that in a hospital a Doctor can make you sick, but that only a nurse can kill you. Doctors write orders, then leave and trust, nurses to do the orders. When a doctor orders something stupid, or at odds with another aspect of their care, it’s up to the nurse to catch it—it’s a written responsibility for the nurse—a job requirement, and part of the secret nurses code.
The nurse is like the senior enlisted man on a ship at sea—accountable for everything, but still having to figure out a way to get the Captain to turn the boat away from the iceberg in time.
Nurses function as gatekeepers in ICU—they are the point that information flows through. They control the patient record—the common meetings place that all the other functions of the hospital eventually converge on.
Because the unit has so many specialists, all of who get paid to handle just their specialty, often times, no one gets assigned the whole person—and that’s where Nurses come in.
Specialists, because their focus is so narrow, come to a patient convinced that they can handle the disease process they were hired to treat. And, if each disease or process were seen in isolation, they would be correct, cures would be relatively simple for a good specialist dealing only with the one problem.
That’s not how it works-- two diseases aren’t two problems-- just one big, connected problem. When you start adding more problems, the complexity gets increased and the prognosis gets fuzzier.
Diseases and treatments collide with each other like waves. At times they reinforce each other and get bigger, at other times they cancel each other out and get smaller.
A cardiologist wants to get a better picture of the heart so he orders an angiography. At the same time, a nephrologist is trying to keep the kidneys working. With an angiography, a dye is used in the IV solution to show the heart better, but the side effect of this is, additional work on the kidneys, and sometimes this additional work leads to the kidneys dying.
Meanwhile, the breathing doctor is trying to stabilize the patient on a mechanical ventilator, and transporting the patient to the x-ray department will require that he be off the breathing machine for an hour while the test is being done.
And, in the Unit, others nurses, already staffed to the edge of collapse, will need to cover for the nurse and respiratory technician as they leave the floor for an hour.
Tests will have to be rearranged, orders will be missed, physicians will have their schedules delayed, and the patient will suffer from less than ideal care, all while being shuffled, folded and spindled on a gurney tour of distant parts of the hospital.
To the cardiologist requesting the angiography, it’s just a test, a simple request for more information. It’s just a thing he needs to have done to do his job, and, her thinks, isolated from everything else, how hard could it be?
Imagine the complexity when the five specialists taking care of your patient all think the same way.
After talking with Mrs. Posey, I called Dr. Kanada to get to give an update, and to get the new ventilator orders, and then I returned to the room.
Posey was still on his back and the bed was flat. To the right side of the bed, the ventilator was pumping air into him. I went around the bed to it and made the changes in the rate and depth of the mechanical breaths that Dr. Kanada had ordered. His arterial line was also on the right side; I gave it a flush to keep it open, with a small rubber pigtail that poked out from below the stopcock. He had two IV’s, both on his left side, I checked the set rates of each controller, and increased the amount of Dopamine going into the lower one.
Sedated, and no longer working hard to breath, Posey looked comfortably numb and slightly obtunded. His heart rate had settled to 110 beats per minute, and his blood pressure, while still low at 92/45, seemed adequate for just laying around. His urine output was minimal; I gave him some additional Lasix that Dr. Kanada had ordered when I spoke to him earlier. Things looked as settled as they were going to get, so I took a break and went to find Mrs. Posy again.
“It was the soup,” she said, as we returned to the unit from the waiting room, “I met him over a huge barrel of soup.”
She was telling me a story.
She met her husband when she was working as an administrator for a teaching program at the airbase where he was working. Her job was to supervise contract teachers who had been hired by the air force to get “category four” enlistees a little more functional (this was the lowest educational class of recruits —according to her, you had to “just fill in the bubbles on the multiple choice test at random to be considered dumb enough to fit this category.”) Mostly a paperwork job, and it allowed her to use the base facilities (Base exchange, Commissary, movies, gym) and to eat at the mess hall with the regular air force personal.
She met him while standing in line for food. She noticed him, it was hard not too, he was a big guy in a chef’s uniform, supervising—“just standing around and looking at everything all at once,” according to her. She thought she was ignoring him, yet was aware that she still had to look away when she felt his eyes on her. He walked towards here, lifted a lid from a new gigantic container of soup and told asked her if she wanted some. She lifted her eyes in response, and swears that she saw a “twinkle of light” in his eyes that shocked her, and the twinkle made here suddenly pay attention to him.
“You know how sometimes you’re just going through the motions and wandering around on auto pilot,” she said, “and then something pulls you back in an instant, and you wonder where you are and what you are doing there?”
“It was like that.”
She said that it was as if an internal threshold of loneliness had been maxed out by the sudden jerk of him, and she realized in that exact moment that she wasn’t alone anymore. She compared it to walking down a hill with the sun at her back and only seeing shadows, until she turned around and noticed the brightness of the sun and the sharpness of the colors—it was the moment of the turn for her.
She looked for his nametag and said, eyes now locked on the prize, said, “Thank you, Sergeant Posey, you are too kind.” Those were her first words, and she was proud of their exact placement. As she put it, “I noticed him, took it a step further and noticed his name tag and then that he was the guy for me, I tagged him, and from the moment I first met him, I knew he was mine.”
“He courted me for a month in a really formal way, and then asked me to marry him,” she said, “and I did, but I already knew I would from the first moment we met.”