Alone Together

Recently I worked what was supposed to be an easy weekend shift. I started off the day with one patient. A nice fellow who through a series of unfortunate events had ended up intubated several times. But here we were, well on the mend, and chipper. The kind of patient I enjoy. I was expecting to transfer him, but the order came though much earlier than planned, leaving me in a precarious position. By 11am I was patient-less and by virtue of the conditions of my contract, I could not be sent home. So I started helping with lunch breaks. Then with another, very complex patient. But the fact of the matter was that I had no patient, so a double admit was a very strong possibility. Not exactly my perfect scenario.

Mid-afternoon rolled around and I finally got the call. A 20 something year old female currently hallucinating in 4 point nylon restraints. Urine positive for opiates and cocaine.

Awesome.

Normally I would be pissed to get the news, but I was having a good day. Charge was nice and my co-workers were chill. For once, I didn’t get my feathers ruffled.

So I got my scant report and soon enough my new patient arrived. She was just as expected. I quickly lost my IV access because she was thrashing around so much. The restraints were helping but she was all over the bed. A security guard stayed in the room with her, which is not normal but I wasn’t going to turn down extra help!

My helpful co-workers were kind enough to place another IV (and another after that one started looking bad) and a quick page to the Doc earned me an order for more Ativan. Things were going rather smoothly.

Around 1700 it became obvious that we had too much staff and that we needed to slim down. Since I couldn’t be sent home, it was decided that I would absorb another patient. I picked up an 80 something year old woman who had coded earlier in the shift. A couple of compressions later she was back and earned a tube. After a phone family conference the decision had been made to make her comfort care. She was started on a Morphine drip and once comfortable, extubated.

So I had just picked up the easiest of patients.

There’s a fine line to walk when administering drugs in dying patient. Morphine can cause hypotension and depress the respiratory drive, two things that can hasten death. I suppose it requires some mental gymnastics when you make the decision to increase the amount of Morphine that you’re giving to your comfort patient. I must believe that I’m keeping them comfortable but not that I’m killing them. So when her respiratory effort increased and I could tell that she was struggling for air, I made the decision to turn up the rate.

Although I don’t necessarily agree with it, I understood it when the family (husband and son) said that they would not come in to be with her as she passed. They just wanted to be notified when it happened.
This lady had been hanging on for hours. I would watch as her oxygen levels plummeted and then, almost through pure force of will, she would take a deep breath and they would bounce right back. At just about 1900, as I was getting my report ready for the oncoming shift, I looked up at the monitor. I could tell by the way the rhythm was changing that the end was near. My other patient had settled down, probably because I had found the therapeutic dose of Ativan and Haldol for her, so I had a few moments.

I pulled up a chair and sat next to her. Taking her hand into mine I watched the monitor. Her hand was already cold and I’m pretty sure that she was not conscious enough to know I was there. She lay there, each breath coming more slowly than the last. I talked to her, letting her know that it was ok. That she was not alone. Her heart slowed, the rhythm changed and I was almost certain that she was in PEA when it started up again. For several minutes her heart struggled to perfuse before it finally stopped. There’s no way to tell the exact moment that she died, but somewhere during that span I went from holding the hand of a person to holding the hand of a corpse.

For 15 minutes or so, two people sat together, touching. Each alone with their own thoughts, oblivious to what the other was thinking and feeling.

Working in the ICU isn’t always about fighting your very hardest to keep somebody around. Sometimes it’s about helping them let go.

Cuba

The human spirit can be a fragile thing.

There’s something that draws an explorer to a place that perfectly showcases the ruins of its glorious past. Last year I headed out to Vietnam, specifically seeking out Hanoi to walk the streets of its Old Quarter with the intention of experiencing the collision of new and old. To view with my own eyes the decay of the frivolity of days gone by and to see how things were changing.

A few weeks ago I boarded a plane headed to Havana with the exact same intentions. For a long time Cuba has enchanted me, a forbidden land locked in time. I landed with high expectations. Met my cabby at the airport and jumped into his Soviet Lada with high hopes, careening through Cuban traffic with a fresh Cuban cigarette hanging from my lips. How else are you expected to explore this new territory?

Freshly dropped off at the new apartment it as time to hit the streets, even though it was late and I was feeling tired. One can’t just fly to another country and be expected to go to bed. So I started off down the Prado until I ran into a nice gentleman who spoke English quite well. He informed me that this weekend was Carnival and extra specially, tonight was the one night a month that members of the cigar Colectivos were allowed to bring cigars home to sell themselves. A sort of bonus day.

Cuba is an exercise in dispensing with predispositions. One walks down streets that would instigate near panic in the US without fear in Cuba, and one learns this quickly. And this is how I found myself in a random kitchen on my first night in Cuba. Surrounded my large men insisting that I purchase cigars of questionable provenience for an apparent discount.

I do wish I could tell you an anecdote here, like from my trip to Thailand where I threw money into the face of a bar manager who was attempting to cheat me. I do. But I don’t. No, I negotiated poorly figuring that whatever I got, it was still Cuban tobacco and got out of there with my shoddily crafted box filled with mystery cigars. Hours into the country it was Cuba: 1 and Me:0.

But travel isn’t about keeping score.

The next few days rolled by with me walking about the city, doing my best to get a feel for the place. I like nice things but I am also quite curious about what life is like for the average citizen, and so I set out to find out.

By the third day I was burdened by a weight. I did not understand this weight, I only knew that I was plagued my a feeling of claustrophobia and I was looking forward to changing locations to the laid back town of Trinidad.

Hanoi is an achingly beautiful city. It is full of crumbling 18th century architecture, harkening to days gone by. An homage, if you will, to its colonial past. It’s also a thriving city full of life and excitement. Vietnam is pulsing with life. With hope. With progress.

It wasn’t until several days later that I realized the difference. Havana is stunning city, almost impossible to take a bad picture of. But the average person, I could not detect much hope from them. Things were dire and they had been for awhile. As opposed to Hanoi, a beehive of a city. Everyone working towards something bigger. Havana felt more like every man for himself. Things were not going well and I could detect little hope for a better life in the near future. As an American, I couldn’t help but feel a bit responsible for this. Compounding this fact was that every single Cuban I met on the street would immediately upon finding out I was an American insist that the average Cuban loved America. That we were all welcome there, and that this diplomatic situation we found ourselves in was merely some misunderstanding between our countries.

I completely agree, but at the same time, I know that it is my country that is almost directly responsible for their current economic situation. I know it’s not be personally, but still, that kind of weight adds up.

It wasn’t until much later that I realized the dire situation that Cuba was in, and has been in for many years. It as the sort of realization that makes one take a step back and question everything that they have been told.