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.

Witnessing sorrow and grief; taking trauma home.

About a week ago, I awoke to the news of the Orlando mass shooting-that 49 people had been murdered in the Pulse nightclub--for no other reason than that they were gay, and most were Latinx. The mass shooting du jour in America. You know the rest of the story, because unfortunately we've all heard these stories repeatedly. But it made me wonder about something else, tangentially related--but related to us in our work.

I came across a Facebook post by Dr. Joshua Korsa, an Orlando resident who described his experience caring for the surviving victims. Check out his story here (original post) or here (short news story)--. The "tangible reminder" he refers to below? His blood soaked Keens. He writes (about the survivors of the shooting):

"They've become a part of me. It's in me. I feel like I have to carry that reminder with me as long as [those patients] are still under my care. So this is a tangible reminder that the work's not done. That there's still a long way to go" 

Later I read the NY Times' "Orlando Medical Examiner: ‘Take a Typical Homicide Scene, Multiply It by 50" which was just amazing (for lack of a better word)--in less than 48 hours they were able to identify all 49 victims and in less than 72 hours autopsies were done on every single one of them. That's a logistical accomplishment and an emotional....quagmire. I cannot imagine being a part of that. I cannot imagine how hard that must have been. What exceptional work-- bringing confirmation to each of the 49 families and countless loved ones involved.

But wow, logistics aside--consider for a moment about the pathologists and technicians who did this work, who painstakingly photographed each victim, prepared them for transport to the morgue, the pathologist/assistants who later performed the autopsies, cleaned the bodies--these are the unrecognized people behind the scenes in such catastrophic events. How are they doing this week? How are the police officers? The crime scene technicians? Are they ok? How do people that witness such awful mass casualties cope? 

So that got me thinking (this is how my ADHD brain works, one topic to another, bouncing along)...WE deal with some really difficult stuff.  Not mass casualties (I don't think most of us do, anyway) but day to day casualties of life. Car accidents. People losing limbs. Diabetes, heart attacks, cancer, strokes. Kids dying. Homicides, suicides, accidents. Alcoholism. Lung cancer. New diagnoses of leukemia (surprise! you didn't just "have the flu"!). Homelessness. Stillbirths. Domestic violence. And so on. It's a lot to deal with.

How do you deal with the anger, death, violence, despair, stress, grief in your job? Sometimes it isn't even the death that's so hard, it's the sorrow, the daily witnessing of human distress. Death is a separate entity, and varies in it's impact on me--some deaths leave me with a sense of calm, some break my heart and I swear I never want to go back to work again (but I keep showing up.). Some don't seem to affect me emotionally much at all, and that's ok too. Every one is different.

As I walked around the oncology ICU recently, several rooms were empty-- and I realized as I walked around that I associate almost every room with a patient I have cared for in that room--and who has since died. I often think of them as I pass by (Oh, that's J's room...oh, that was D's room...etc).

As I walked down the long hallway to grab lunch, I thought:

• M's room-she was my age--she died in that room over there, overlooking the water. She and her husband were avid skiers and mountaineers and he shared incredible pictures of their adventures together. I swallowed back tears during rounds that day; that was the second time I'd cried that day. M died of relapsed leukemia and candidemia. 
• D's room-she coded suddenly, and died before her daughter could make it in. The chaplain put her daughter on speaker phone so she could say goodbye to her mom as her mom underwent CPR ("Tell her she was a good mom....tell her I love her....tell her she was a good grandma"). D died of advanced lung cancer.
• M's room-an older woman with AML, the same age as my mom. Wonderful family, with a toddler grandchild who liked to sit on the bed and who was fascinated by the sat probe on grandma's finger. That boy lit up the room. M died of a disseminated fungal infection. 

And so on. I remember many. 

We carry our patients in our hearts and in our minds--they are with us/in us, year after year. And sometimes memories of them/their deaths are comforting while at times they are heart breaking and hard to revisit--even years later. Some patients/deaths I look back on and I feel peace, and I smile at the memories that surface. Some patients/deaths I think back on and tears still come to my eyes-and the deaths were years ago. Some I look back on and my heart rate increases--because their deaths were so awful that I still have an emotional/visceral response. 

So I wonder. I wonder how the nurses, doctors, EMTs, police, pathologists-how everyone that helped victims of the Orlando massacres is doing. And I hope they're ok. And I'm grateful they were there to face such horror, to run into a scene that hopefully none of us will ever have to face. And I hope now that they've taken care of so many others, that others are taking care of them.

And last but most certainly not least, may we never forget these 49 people, almost entirely queer people of color, murdered en masse for being...themselves. 

ZebraARNP. 

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In Memory.

June 12, 2016.

Stanley Almodovar III, 23 years old

Amanda Alvear, 25 years old

Oscar A Aracena-Montero, 26 years old

Rodolfo Ayala-Ayala, 33 years old

Antonio Davon Brown, 29 years old

Darryl Roman Burt II, 29 years old

Angel L. Candelario-Padro, 28 years old

Juan Chevez-Martinez, 25 years old

Luis Daniel Conde, 39 years old

Cory James Connell, 21 years old

Tevin Eugene Crosby, 25 years old

Deonka Deidra Drayton, 32 years old

Simon Adrian Carrillo Fernandez, 31 years old

Leroy Valentin Fernandez, 25 years old

Mercedez Marisol Flores, 26 years old

Peter O. Gonzalez-Cruz, 22 years old

Juan Ramon Guerrero, 22 years old

Paul Terrell Henry, 41 years old

Frank Hernandez, 27 years old

Miguel Angel Honorato, 30 years old

Javier Jorge-Reyes, 40 years old

Jason Benjamin Josaphat, 19 years old

Eddie Jamoldroy Justice, 30 years old

Anthony Luis Laureanodisla, 25 years old

Christopher Andrew Leinonen, 32 years old

Alejandro Barrios Martinez, 21 years old

Brenda Lee Marquez McCool, 49 years old

Gilberto Ramon Silva Menendez, 25 years old

Kimberly Morris, 37 years old

Akyra Monet Murray, 18 years old

Luis Omar Ocasio-Capo, 20 years old

Geraldo A. Ortiz-Jimenez, 25 years old

Eric Ivan Ortiz-Rivera, 36 years old

Joel Rayon Paniagua, 32 years old

Jean Carlos Mendez Perez, 35 years old

Enrique L. Rios, Jr., 25 years old

Jean C. Nives Rodriguez, 27 years old

Xavier Emmanuel Serrano Rosado, 35 years old

Christopher Joseph Sanfeliz, 24 years old

Yilmary Rodriguez Solivan, 24 years old

Edward Sotomayor Jr., 34 years old

Shane Evan Tomlinson, 33 years old

Martin Benitez Torres, 33 years old

Jonathan Antonio Camuy Vega, 24 years old

Juan P. Rivera Velazquez, 37 years old

Luis S. Vielma, 22 years old

Franky Jimmy Dejesus Velazquez, 50 years old

Luis Daniel Wilson-Leon, 37 years old

Jerald Arthur Wright, 31 years old