"You people don't have a clue"

I always enjoy meeting my patients for the first time, especially after I've been taking care of them for awhile. That, on face value, may not sound like it makes sense. Many of my patients, however, spend their first many days unconscious and on a ventilator, so in a sense, I haven't really met them. Sometimes I never get to meet them. On many occasions I've taken care of someone for 3 nights in a row, and then my work week is over. I leave for 2 or 3 days (sometimes 4 or 5) and when I come back, the patient has either died or been discharged to the regular hospital floor. Many times I've told myself that I'll go out to their new hospital room and say hi...but I never have. I always think that it's a little creepy that I've been taking care of their most intimate needs and they don't even know me. They couldn't pick me out of a line up. I think if I was in their place, I would feel that way. I'm sure they would not, but I don't go and visit, anyway.
Not on this night though. On this night, I took care of this guy all night. In the morning, the doctors asked me to wake him up and get him ready for extubation, so I turned off the sedation. This apparently did not please him. Shortly thereafter he began gesturing wildly at me, and slamming his fist into the side of the bed.
"What!?" I exclaimed, "Are you in pain?"
He shook his head "no."
"Do you know where you are?" Sometimes confusion can lead to a lot of pre-extubation stress.
He shook his head "yes" and began wildly gesturing at the air again.
"I have no idea what you're trying to tell me," I said, "Calm down and I'll find you some paper."
I return almost instantly with some paper from the printer, a clipboard, and a marker (often people on ventilators don't press hard enough to use pens...I'm not sure why this is, but it's a universal fact, ask any nurse.)
I begin giving report to the next nurse while he writes his all-important message on the paper. When done, he tosses the sharpie at me.
"You people don't have a clue," I read aloud. I raise an eyebrow, "That's neither useful nor helpful." I told him. He begins angrily gesturing again, so I give him back his flung sharpie and the paper. This time he writes something else...but I can't make out most of it (the other universal truth among nurses is that being on a ventilator gives you crappy hand writing.)
"Have fun with this one," I tell the next nurse.
"You should have left him sedated," he said. "Some people are just too mean to be conscious."
Ok, so they're all not so much fun to meet.
The other thing I love is sharing a happy moment in their lives with them. That one is pretty rare. Just by meeting me, it's likely the most unhappy time in their lives. The one exception is our 1A heart transplant patients. 1A means top of the list, sickest of the sick needing hearts. The reality is that 1A doesn't necessarily mean number one on the list. There's another transplant center less than 30 minutes away who probably also has a few 1A patients, as well as many other transplant centers within radius. Add that to the lack of donors, some patients sit on our ICU and wait a long time. They aren't as sick as a lot of our patients (usually.) They're well enough to get out of bed and sit in a chair, go for short trips outside (on a monitor and accompanied by at least one RN and another health-care worker), and they're definately well enough to miss being able to take a shower.
A few nights ago, we hear the rumor that there's a 20 year old in the Neuro ICU that has been pronounced dead after a closed head injury, and his blood type is a match to one of our patients. This is usually how the sequence of events leading up to a transplant begins...with a rumor. The organ donation people are very secretive. They don't want anyone knowing anything until they themselves are absolutely sure. This process involves first obtaining permission from the family to harvest the donors organs. Since the patient is still on life support, they can take days. This is especially true when the particularly young die, or when the family dynamics are dysfunctional.

Then the donor is tested for...well, pretty much everything. These tests can take hours. Very rarely is the heart considered good enough to be a donor heart. You would think that for these patients ANY heart is better than what they have, and this is probably true, but heart transplant surgery is no walk in the park. The heart has to be strong enough to survive the insult of being pulled out of one person, stored in a cooler (often for a few hours) and then put into a new body which isn't always welcoming. The immune system begins to attack the new heart almost immediately. We give the patients drugs to slow it down, but it's very difficult to completely stop the process. The best hearts are young and large. Teenage/young 20's boys make the perfect donors.

Once the heart is found to be of high enough quality for transplantation, the organ donor people step in again. They begin going down the list in an outward circle to figure out who is going to get the heart. Preference is given to distance, and how ill the recipient is. After a certain point, however, a recipient can be considered too ill, making them less likely to get the heart. During this phase, the nurse often gets a phone call, asking about the most recent cardiac numbers on a particular patient. That's often the first clue that a nurse gets that her patient may be getting a heart.
It also starts a flurry of activity. Every nurse has to look at the last waveforms obtained from the patients heart catheter and give his or her opinion. These waveforms have to be interpreted absolutely perfectly. No one wants to make a mistake on a patient's numbers when a new life is on the line. No matter how excited we are, nurses do not reveal to ANYONE what's going on. We do not even tell the doctors on our unit at this point.

Even if your patient is chosen, it's still many hours before it's time for surgery. This process has to be repeated for every other organ being donated. Liver, kidneys, lungs, all have to be removed while the heart still beats. Those recipients have to be identified, notified, and everyone has to be put in place. Helicopters have to be ready to fly the organs out that aren't being transplanted in house, some organ recipients sit at home with pagers, and they have to be brought to the hospital and prepped for surgery as well.

If your patient is chosen, it's pretty much the happiest moment of your life, too. Sometimes the nurse is happier than the patient. That may sound exaggerated, but many patients have emotional issues, and doubts related to getting a heart. They know too well that this heart came at the cost of someone else's life. Probably someone young and vital. Their happiness at their new chance at life, also comes with the dark cloud that someone died for this gift.

For the nurse though, death is familiar. People die all the time, and we know it all too well. Grandmas and Grandpas die, moms and dads die, but so do young adults, teenagers, and even toddlers and babies. Everyone dies. It's easy for us to realize that there was nothing that could be done about the teenager driving off the road into a tree, or the snowmobile accident fueled by alcohol, or the occasional random lotteries that are brain aneurysms. We're just grateful that at least a new life can be lived out of senseless tragedy. We're about 10 steps removed from the process, for us it's an easy thing.

Telling your patient isn't your job. It's the doctors (damn bastards, they get everything!) It is your job however to tag along and then deal with the emotional aftermath. There's going to be screaming and hugging and crying. The more family that happens to be in the room at the time, the more emotion there will be.

Despite all this, we try to keep the whole thing quiet. There's usually more than one patient on the unit awaiting transplant. We do not allow them to know that someone else is getting one. Once or twice it has even happened that two patients on our ICU were being considered for the same heart. It's hard then to walk out of a happy room and into another patients room and pretend like it's just another day of waiting for you, as well.

On this occasion, after my patient had been told and whisked off to the ICU specializing in thoracic surgery to prep for the OR. I sat by myself in the break room. Another patient would fill the empty bed soon enough, but for now I had a chance to sit down. I was contemplating how downstairs the donor was also being prepped for surgery. That part was a little strange. Our hearts usually come from other hospitals, not our own. The donor was always this far off person, not really a person at all. It was strange to think that I could hop on the elevator and go look at them for myself, could meet their grieving family, could hold their hand while it was still warm. The happy crowd that had just poured out of my ICU including the donor, and all of his family, friends and even a few of his doctors was a sharp contrast to the sobbing family that I knew I'd find downstairs. It's strange how much happiness can be born out of tragedy.