Letting death in the room.

Taken by the author. Mukwonago, WI. Oct 2016.

One of the most heart-wrenching things I witness at work is people saying goodbye to their loved ones. Today I watched a husband say goodbye to his wife of 31 years, with their son also present at bedside, weeping as his mother died.

I stay in the room for all terminal extubations, along with the ICU nurse and the respiratory therapist. It's always an emotional thing to witness; I think we all find some kind of unspoken moral support in having each other present, besides the obvious practical needs to be there (RN to give meds, I provide orders/ explain things to the family/pronounce/ask for autopsy, RT weans ventilator and removes the endotracheal tube).

I stood in the room and watched the RN bolus morphine and midazolam...I watched the patient's respiratory rate. I watched her face for signs of struggle, her body for signs of stress. There were none, so we were ready to let her go. I gave the final "ok" to the RT to remove the woman's endotracheal tube, as I thought her respiratory rate and sedation level were adequate so that she would not struggle without the ventilator's assistance (pressure and oxygen). Her sats dropped to the 60s immediately once she was on room air, she developed circumoral cyanosis, and her heart rate was dropping. The medical staff all left the room so the family could alone be with her. She lived for about one hour after extubation, deeply sedated, and died without any struggle. I returned later to pronounce her death (1250) and obtain autopsy consent from her husband. He readily consented and said she would've been an organ donor, if her cancer hadn't prevented her from doing so. He asked "What will your team learn from doing an autopsy?" and I explained the top clinical questions that I thought could likely obtained only via autopsy.


In the moments before the medical team goes into a patient's room to do a terminal extubation, there's often a collective "let's do this" sobriety. As in "This is hard. But, we will do it, and we will do it well." And we do, our team always does. Unfortunately in an oncology/BMT ICU, we are all skilled at helping people die well. And at this point in my career, I'm skilled at that part of my job and proud of it. Not proud in a perverse way, but proud to be able to palliate symptoms of pain, anxiety, and breathlessness in one's last moments of life. Proud that I can help guide families through the emotional agony of watching their person die. Proud that the last images they see of their loved one are peaceful, quiet, calm, well-choreographed. Respectful. Clean. I am grateful that we have the ability to allow people to die without suffering, to serve our patients in this way, to calmly let death into the room after beating it back for so long with our various medications, procedures, life support. We spend hours trying to corral irrational forces (life and death) with rational means (science)--it's almost absurd at times.

But as we let the dying person leave the earth, as their suffering ends, the survivors' suffering begins. Their love wasn't free; now they grieve. All of this had me thinking this afternoon--about love. Whenever we love someone we do it knowing (somewhere in ourselves) that someday one of us will say goodbye to the other. It's an overwhelming thought to ponder for too long. You'd think this would hold us back sometimes, but no. We throw ourselves wholeheartedly into love--loving our partners, friends, children, pets...while knowing that it is all temporary and that this will hurt eventually. Talk about optimism! Humans crave love and connection, we cannot resist it (can we live without it?) even though we know that eventually it is 100% guaranteed to come crashing down around us. Every time.

After every winter, spring...

always comes.

Always.

But my life's progression to "spring" was blocked by an awful behemoth in my path--and I could see glimpses of this thing titled "spring", but I couldn't get there. So it has been a long, long winter, and I have been away from here for a long time. This thing, divorce, loomed in my life for a while, sat in my way, blocked my life and taunted my psyche. It was this big, ugly, hulking, ill-defined beast that sat defiantly between me, peace, happiness, future. It blocked the path between who I was and who I wanted to be...who I had the capacity to be. And avoiding it was causing me to become a person I increasingly disliked. So I introduced myself to it, squared up my shoulders, battled with it, and took it down. I ran, leaped, tripped, yelled, triumphed, paid (tears, money, frustration, adrenaline, fear) and then, officially---it was....over. The ink was dry. And truth be told, the marriage was over long before the divorce was--just as a piece of paper doesn't make you truly married, a piece of paper doesn't make you truly divorced. These pieces of paper simply symbolize what has already taken place in your heart, I believe. And they exist for the protection of property and children. That is all.

The initial months after my ex-wife moved out were a blur of pure relief, loneliness, freedom, calm, financial stress, happiness, and much needed solitude. I never looked back. I never doubted my decision to leave, not one time. I knew I'd done the right thing, as hard as it was to enact. As time passed, I dated a few women, but no one in particular really struck my fancy. I never found anyone who I thought was really special. Nice, kind, smart, attractive? Sure. But that wasn't enough to keep my interest in anyone in particular, and after a while the dating world was....tiresome. I had no real connection with anyone, no real chemistry. The thrill of being single, being free, being wanted, flirting was...getting dull. There I was wandering aimlessly around a romantic virtual world, without any real destination in mind. So I'd delete the app for a bit, roll my eyes, and drink/hang with friends. Onward....maybe someday I'd find someone again, but I sure wasn't in ANY rush--the very last thing I wanted was A Real Girlfriend. I didn't want to be anyone's person--I didn't want the obligations, the expectations, none of that. I wasn't sure I could do that again. Been there, done that, and in some ways----I'd failed miserably. It had been such a tall order before and I'd not measured up....right?

While I dated casually, I also worked to heal myself from the damage that our marriage had caused.  I was in therapy, and I fought to delete the list of ways that my ex-wife had said I'd failed her, failed our marriage, failed our children--all by initiating the divorce, which was the only way to a better life that I knew (after thousands of dollars in marital therapy and two separations). I realized that I had recreated my self-image according to her feedback, not my self-knowledge (or the knowledge of others who really know me)--and I was angry and disappointed in myself for having done so. I had actually believed all of the things she'd told me about me--things she'd said over the years out of anger/need/frustration/hurt, time and time again, as I repeatedly failed to meet myriad unspoken and seemingly mysterious and randomly presented expectations and needs.

I didn't know what was true anymore, and it was terrifying. Was I Person A or Person B? I fought to redefine (rediscover, really) myself for myself, to believe my voice about myself instead of her voice/story about me--and it was impossibly hard at times, and I did not always succeed. Some days were interminably long and painful,  and I worked to feel valuable, attractive, intelligent, worthy of anything--love, respect.  I worked to make eye contact with another human, some days. I worked to summon the energy to go to work, to engage with my patients beyond lab data and physical exam findings. My therapist was my reality check, when I wasn't sure which way was up some days, when I wasn't sure who I was anymore.  She was my mirror through all of this--she showed me the little tiny bit of myself that was still there, that was unchanged, the essence of ME, that was going to be ok--that had always been ok and that always would be--no matter what. Her unwavering belief that I would be ok was steadfast and solid; some days I counted on her belief in me far more than I ever believed in my own ability to be ok. I had to take her word for it. And I did. And some days, it saved me.

Fast forward a few months. The dust had firmly settled. I could see the good in life again. I realized that I am an ok person. I was in a new routine with life, work schedule, kids. I was single. Spring was ...here.. I think? I felt pretty good in my body, my mind, my heart. I'd dated a bit, and it'd been fun. I I was happy, and not seeing my therapist as much. The worst of things was over...life was looking good again. So I opened a dating app, while I was standing in the middle of my kitchen--and I don't know what made me do it, I just... opened it. And there was one of the most handsomely gorgeous women that I'd ever laid my eyes on--my inner dialogue was "Oh my goodness....!", I had a run of a-fib, and I sent her a message. And I wasn't so sure I'd hear back...I mean, she was so damn cute and...I'm just..me. But something about her simply took my breath away. Something.

Well, I heard back. And back. And back some more. And now we're heading into our sixth month of dating and I love her in a way that I didn't think my heart was capable of loving. Nor did I think my heard was capable of receiving such love. I have loved before, and she has loved before--we've been on the planet too long to not have, and the loves we have had have helped craft us into the humans we are today--and for that I am thankful for us both. But I've never loved like this before. It's different; it's more complicated. It's more complete. And I didn't know that this kind of love, this kind of seemingly unconditional love and non-transactional love--the kind of love where someone loves you simply for who you are--not what you do for them, the money you make, what you say or what you look like or what you provide now or could provide or anything else---could ever be a part of my life-I assumed it would forever be beyond my reach, that it wouldn't happen in my lifetime. Thankfully, I was wrong. "BB" suddenly landed in my orbit and I knew that spring had definitely arrived.

To be continued...

ZebraARNP

Not everything that ends is a failure.

I’ve been gone for a while. A lot has changed in my life and some of the more peripheral activities within it (like writing for this blog) have necessarily been on pause. But I’m returning to this space now that I have the time and energy for it. In the past many months, our one family has morphed into two families --my marriage of 12 years ended. This was after a couple years of marital therapy, a trial separation (in which we lived in separate homes) a few years ago, and a lot of tears, gut wrenching atrocious fights, heart ache, issues within ourselves, issues between us, commitment, recommitment, more therapy and then…our marriage needed to be over. I truly feel that we turned over every rock looking for a solution to it all, and one could not be found.

We are recasting ourselves in our roles as co-parents only, and perhaps someday we will recast ourselves as friends. I firmly believe that a marriage that ends is not a failure, that the standard of “forever or failure” is just…ridiculous.  Does a marriage have to be life-long to be considered a success? No, it doesn’t.  We did not fail. We had a successful 12 year relationship in which we raised 3 awesome kids, bought a house, overall had a damn good time-- and I’m proud of all of that. And I'm grateful for the years we had together and I wouldn't change anything--life unfolded as it did.

But after much soul searching and countless tears, I realized that despite every good intention (on my part and on hers), and despite every effort (from us as individuals, as a couple, and by those in our families/community supporting us), I could no longer be the person that I wanted to be in my marriage any more—and even worse than that, I was becoming someone I did not want to be because I was so unhappy. This affected me more and more, and it was time for a change. I cannot speak to her unhappiness other than to say I think it was profound. And all of our combined unhappiness affected our children, without a doubt. And that was not tenable. 

In the meantime, she has moved out (and lives nearby), and the kids have started living in two homes. There have been bumps in the road, of various sizes—of course there have been. But I have every confidence that we will survive and we will all thrive, as we find a more peaceful existence. Families have survived far greater challenges than this, and our three children have two parents who love them immensely (and grandparents, and friends) and who will support them in whatever ways necessary. I am hopeful. 

ZebraARNP

"Why didn't you just go to medical school?"

I'm guessing this is a common question posed to ARNPs/PAs, and one I figured I'd take a moment to answer personally, because I find it irksome. Well, I didn't go (or even apply) because....I didn't want to be a doctor!  I don't think it's a compliment to ask an RN/NP/PA that question, but I'm thinking it's meant to be one (i.e. you're really smart, you could've learned more/done more). But the question presumes that becoming a doctor is The Best Option for those interested in a professional graduate level healthcare career (and that the smartest people in medicine are always the doctors).  But becoming a doctor is one of several medical career options out there, and it's not always The Best One for everyone. So for this post I'm going to recount how I got to ARNPLand, given other possible paths-and how a key factor in going to ARNPLand was motherhood. Doctors are awesome (duh), but not all of us are destined for DoctorLand--for a variety of reasons.

My undergrad education was in liberal arts, which was interesting but frankly not very useful at all (a classic tale). I worked in social work right after I got my degree, and worked in social work/corrections for a while...but I wanted a job where I could DO things, and PROBLEM solve and really FIX things. And not be stuck at a desk all day long shoving paper around.

I knew that I wanted a job where I could do the following:

• Be a big nerd, and be in an environment where nerdiness was celebrated 

  

  What a cute ARNP!

• Fix things or people (or both)
• Make a good living, i.e. to support a family of at least two kids. Oh crap, we have three now; we've debated selling one but the kid market is in a slump. And yes, the third pregnancy was planned. And yes, we had an OB ask us this. We changed doctors. Think about that question for a moment...Anyway, my goal wasn't to be rich but to have enough. Comfortable enough to be like the Cleavers (well, the interracial lesbian family suburban version). Ah, but "enough" is so subjective, isn't it?

The Cleavers, "then"..

The Cleavers, "now"

• Be a mom who could go to choir performances, be home for dinner most nights, have dinner with my mom, go out to dinner with my wife, walk my kids to school sometimes,  have time to email my twins' teacher about schoolwork (and kvetch about common core math, that is a whole different post...), cook dinner on my off days, and so on. 
• Be able to have kids closer to 30, not 35 or 40 (I had twins at 29--overachiever!!). 
• Completely gross out my kids and wife with graphic descriptions of medical procedures, bodily fluids, and so on. 
• I wanted to be able to say nonchalantly, "It's just a flesh wound!" (please click HERE if you understand that allusion...you're welcome!)
• Pay $800 in student loans per month. Actually, this is a heck of a deal-ask a physician (or a lawyer). Gotta pay to play, right?
• Crap my pants as I mumble  confidently say the the words "Call a FREAKING code !!!" as I run to the room, after the RN calls me and I hear the words "EKG changes" and I see the heart rate go from 120--100--90--70--50 in 5 seconds on the tele monitor, while my amygdala fires repeatedly and my brain says "ARGHHHHH!! You totally know what to do, breathe...". Begin CPR....
• Have an unlimited supply of graham crackers to sneak from the nutrition room when the charge nurses aren't around to notice (and peanut butter, oh MAN, that stuff is good).

I also took into consideration how much I'd be able to see my kids, day to day--it was important to me to be around as much as possible...consistency. In some subspecialties (that involve years upon years of fellowship), fellows put in so many hours that it's a real challenge to balance the demands of motherhood and work--and year after year they face these dueling demands--and hats off to these women for taking it on! I see fellows in particular who FaceTime their kids nightly, because they're rarely home in time to say goodnight--especially those with young preschoolers. And sure, it's temporary--because kids grow up, stay up later, and so on--and fellows finish their programs. And fellows do have days off, of course, during which they can love their kids (in person) to pieces. But for me, I wanted more of the day to day mom stuff. The stuff that makes me crazy and the stuff I love.

My point is---to each her own. I have as much respect for the mother who is a general surgeon as I do for the mother who stays home full time. And really, it's great that those of us in medicine can FaceTime now to say goodnight to our kids so that we can maintain the daily connection despite our wacky schedules; I used to do it frequently when my twins were toddlers--I'd leave for work before they were up and get home after they were asleep. It was hard, we missed each other a lot. And it was a lot of extra work for my wife when I was gone, as she'd get through multiple 13-14 hr days on her own. So for any woman who is embarking on a medical career it's incredibly important to consider how one's choice of career will affect one's ability to parent in a way that works best for you, for years.  It's a huge, huge consideration. It's a years long balancing act--how on earth are you going to mix these two awesome things (motherhood and medicine) together successfully and keep your kids alive (and your patients)?! 

I needed the work:life balance that I thought an ARNP career could best provide, and I was concerned that I wouldn't have been able to find had I chosen medical school. Or, I suppose that I could have found it eventually, but I would have had to put off having kids for several years--and I didn't want to do that, for many reasons. I couldn't be the kind of mom that I want/wanted to be had I chosen a different career path. And what about the difference in salary, you might ask? The money is great, I think. The starting ARNP salary in outpatient oncology around here is about 100k. Inpatient oncology at private hospitals around here? Around 130k. That's enough for me, enough for my family to live well. So I'll never be The Boss, I'll never be famous, but it's enough--I'm home over half the month (I work 10-12 12hr days a month), I often pick up the kids from school, I have the time to make dinner frequently (and lunches for school, ugh), I have a challenging/brain stretching/ emotionally taxing job and it's all enough. Score.

So this is my corner in the medical world, and I'm happy in it. And frankly, ALL of us are awesome for making our lives work-however we get it done. So here's a toast to getting by with FaceTime, nannies, dads, moms, friends, support groups, childcare centers, vodka martinis, grandparents, Munchery/Pizza Hut/Whole Foods/Amazon Fresh--we're getting it done--mothering AND medicine.


Later,

ZebraARNP

think zebras, not horses

Hi MiM aficionados,

I'm ZebraARNP, and I'm so pleased to be the first non-physician contributor here! I'm a nurse practitioner in a big hospital in a big city. I've been an ARNP for about 8 years now, and I've spent all of those years in oncology. I can't imagine doing anything else, to be honest. I live in the 'burbs with my wife, to be known here as The Wife, and our three kids, to be known here as Jaybird, Hedgehog, and Egret. More about the family in my next post.

The other day on rounds, as my team was heading out to see our first patient, we encountered a large group of petite Filipina women, dressed in the green environmental services uniform provided by the hospital. Our team greeted the group then as we passed them my (tall, white) attending said to me "They're so cute, they're all so short!" At the same time in my mind I was thinking "Dammit, they're all people of color..." and I felt a wave of...disappointment? Sadness? Irritation? Hard to find a word to describe the exact feeling. I'm not even sure that the two (white) MDs with me even noticed that the ENTIRE group of custodial staff we encountered was Filipina. All that my attending appeared to notice was that they were "cute." Sigh.

The flip side of the above experience is when I see another African-American/multiracial ARNP/PA/MD in the hospital. In those moments, time slows down, music starts to play...(Chariots of Fire, in case you're wondering. It's ok to click on it..) I want to run up to them to see if they're actually real!! Should we hi-five? Cheer? OK, no. Maybe next time...

For such a big city (although <10% African-American), and such a big hospital (>300 beds), there is a dearth of African-American professional staff. Over the years I have been mistaken for kitchen staff, janitorial staff, nursing staff, but more than that people have often looked genuinely surprised when I explain my role on their healthcare team and what I actually do on our team (admissions, write orders, take first calls from the RNs re patient issues, etc). And my point is not that any of the above mentioned jobs lack importance at all; my point is that no one assumes that I have the job that I have and mostly that they express surprise at my actual position. Food for thought. That surprise? It doesn't feel very good on my end.

Always check your assumptions....because we all have 'em. Women as surgeons. Men as nurses. Someday I hope that female surgeons, African-American physicians, male nurses, etc--I hope none of that even raises an eyebrow.

More about me, since I'm a newbie-->
**********************************
ZebraARNP is an oncology ICU ARNP with three children- school aged twins (girl, boy) and a preschooler (girl). That brief sentence vastly oversimplifies the amount of joy/pain/money /insanity/Band-Aids/love/maniacal laughter it requires to raise three human beings; it’s a doozy sometimes. Anyway, this is ZebraARNP's first public/non-academic/not Facebook writing experience, or writing that isn’t a daily progress note of a critically ill oncology patient. ZebraARNP is married to a pediatric SLP who isn’t in fact really that interested in oncology but who has acquiesced to the fact that she will indeed continue to learn about it (or at least listen to random factoids) year after year simply out of love for Zebra. Dinner time conversation in our demographically complicated yet still shockingly quotidian suburban home (interracial lesbian marriage, anyone? Can someone say “intersectionality” ten times fast?!) may or may not include how much CPR was done that day, palliative care conferences, cdiff vs VRE, who did well on his/her math test (or who did not), who will go grocery shopping next, what MRSA is, what exactly IS pus made of, what actually happens when you die, arguing over who gets the last muffin/cookie/etc, reviewing hematopoiesis, and questioning whether kid # 1, 2, or 3 really did wash their hands after using the bathroom. When ZebraARNP isn’t at work or with kids, she enjoys gardening, chicken keeping, reading books (or the NY Times), and wasting time on her iPhone (oh the Amazon app…)…and not being at work or with the kids.