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.