The Yearly Visitor

I often find myself with writer's block, especially when I stop to think that people are actually reading what I write. I have to remind myself that blogging is not a performance art, it is a (hopefully) creative outlet for emotions, opinions and commentary.

I often find myself blocked from adressing a specific topic because I'm only minimally anonymous on this blog, if at all. I worry about HIPPA regulations and patient confidentiality.
Sometimes it's easy to change the sex, age and chief complaint of a patient and not affect the story or its outcome. But what happens when you can't do that; when the details ARE the story? How can I describe what was the most tragic, gut-wrenching shift of my career with a patient I can't forget..... because she returns every Fall?

I have decided to tell this story in the form of a letter to my patient, covering up the details to the best of my ability. Who knows, I may just delete the whole thing when I'm done, but it is Fall again, and she does come around.

"Dear Melissa,

It's been many, many years since our meeting in the emergency department late that holiday night. The evening you told your mom that you would join the family over at Grandpa's as soon as your headache improved. You didn't show, and your mom came home later to find you unresponsive on the den couch. She called 911. We met around midnight.

The paramedics gave you some medication en route and you responded to one of those medicatons. By the time you arrived, to have called you agitated would have been an understatement. This was a different kind of agitation. Your eyes were open but they did not see. You thrashed and writhed but not because of any particular stimuli. You screamed a scream we could not understand but could not seem to hear when we tried to speak. You looked right through us. I'd never seen that stare before. I will never forget it.

We noticed that you were oozing blood from a nasal airway attempt en route. And you were dripping from both IV attempts the medics made. The entire department and half the hosptial met the ambulance that brought you to us and many things were occuring simulaneously. The nurses inserted a foley that returned red urine. Every place you hit while thrashing turned ecchymotic. You leaked around the IV insertion sites we put in. Somehow the ED doc managed to do an ENT evaluation. Blood behind both tympanic membranes.

Disseminated Intravascular Coagulation (DIC). All I knew at the time was that it was 60% fatal. The lab confirmed it. The question was why? The specialists started arriving. Internal Medicine. Hematology. Respiratory. An ABG was done; pressure was held. You didn't stop bleeding. Blood cultures done. More bleeding. You continued to thrash against the barriers we had put up. We tried sedating you but nothing worked; your respirations remained sixty and deep for hours.

Your mother stayed in the room with you after the majority of the procedures had been done.
I stayed calm and conversant even though I knew you were critically sick. I told her to try and talk to you because you could probably hear her. I told her you were the same age as my daughter. I learned you were taking college classes and happy with a part-time-job. I learned you had a recent break-up but seemed to be getting over it. I learned you had sisters. Your mom wondered if she should have your father called and get your sisters to the hospital.

I said yes.

The rest of the hours are a blur after so many years. No time to chart so I kept grabbing paper towels and putting my notes on them. By now, the other two nurses had to go back to taking care of the other patients in the totally full ER. You were nowhere near stable enough to transfer to ICU, although we had had the room for awhile now. I ran with IVs and medications and clotting factors and FFP and blood and reinforcing dressings and a million other things that needed to be done.

Then it got very quiet. I looked over to find that you had laid back down on the pillow. You became unresponsive except to painful stimuli. It happened that fast. I told the ER doctor that your breathing had suddenly dropped to 20 per minute and that you were no longer thrashing.
He intubated you without any response except a ET tube full of blood. An NG tube also was passed. No response. More blood.

The family came back in, this time it was your dad and your sisters. I explained what each tube was for, what we were waiting for. Your dad asked if this was bad.

I said yes. It was very serious.

More hours flew as I worked with you with your family at the bedside. By now we knew that your tox screen showed the presence of some pain medications and that your acetaminophen level was normal. Mom remembered some complaints of an upset stomach during the week.
I wish I could remember all the details and technicalities that went into my non-stop 7 hours of caring for you, but my memory is fading where the technical stuff is concerned. It has never faded where you are concerned.

At 0700, you were stable enough to go for a CT scan of your head. It looked like a pristine scan. No bleed. No swelling. Your mom joked about telling you she saw your brain. After the scan we went up to ICU where the new nurses took over and settled you into their unit. I heard them say to start Dopamine. I said good-bye to your parents and to you and returned to the ER.

I had seven-and-one-half hours of nursing care to account for when I sat down with a cup of coffee to do your chart. And I'm obsessive with my charting so it was a little after 0930 when I went back up to the ICU to give them the missing nurse's notes. I walked in just in time to see your agonal rhythm on the monitor. My heart sank. I was told they had decided to take you off the ventilator.

You were no longer breathing. I saw your heart stop beating. Your father fell into my arms, sobbing. Your mother cried and hugged me and thanked me. I touched your hand and said good-bye and held myself together as best I could.

Until I got to the ER, where I made it into the bathroom, shut the door. The sobs came. Hard. I leaned up against the cold tile wall in a fetal position sobbing so hard I ached. Half-an-hour I did that. I pulled myself together enough to get in the car where it started again. All I could say was "Oh God, Melissa, I'm so sorry" over and over. I couldn't come back to work the next night. Or the next night.

They said you died of an overdose of acetaminophen. Only you know the whole story.

I'm so sorry Melissa. I'm so sorry we couldn't save you. I will always wonder if there was something more I could have done. Something I missed. Something that would have stopped that cascade of death that overpowered us all that night. Sometimes, as we tug-of-war with God over a patient he lets us win. He won that night and Heaven is richer for it. We are the poorer.

I think of you often, but mostly this time of year. I wonder how your family is doing, I think of how old you would be now. And every time my family bows their head to say grace over Thanksgiving dinner, I say a prayer for you and your family. Put in a good word for us, too, okay?

Thanks for visiting me again this year, Melissa.
See you next November.

Your Nurse,
Kim