"And, when you want something, the entire Universe conspires in helping you to achieve it." -The Alchemist, by Paulo Coehlo

Monday, December 25, 2017

Tales From the Trenches: Christmas Eve in the ICU

*Warning: you will want tissues handy.*

His name was Jerry.

He was one of those cats that arrives at the hospital a terrified spitfire: screaming, yowling, and doing his best to try to kill anyone that touched him. Cats are unique creatures in that they are prey animals first, predators second, and thus when trapped, cornered or restrained, their first instinct is flight. Like a horse. Except that if they are unable to fly, then often have no qualms about resorting to fighting. It is essential that you understand this about cats when handling them in the veterinary hospital, because it is the only way you will keep yourself from getting hurt and will also prepare you to handle the cat in such a way that prevents him from becoming permanently traumatized by the hospital experience. You should never manhandle a cat.

Our shift leader and weekend head tech, Annie, is in charge of directing the chaos that would otherwise reign in our world of emergency and critical care. I live for the critical care aspect, Annie lives for the emergency side of the equation: she loves the adrenaline rush of triages and stabilizing our incoming cases, while I am usually assigned the most critical of our inpatients because I am one of the more experienced ICU techs on the day shift...but also because I adore the intricacy and attention to detail required in keeping alive the patients that are at death's door. I've been told I'm good at it. All that I know is that it is rare for a patient to die on my watch. That's all I care about.

On this particular day, Annie had brought back to the treatment area a carrier full of hissing stripey brown cat. She was able to get Linda, one of our other techs, to help her get an IV catheter in this kitty so that he could be admitted for supportive care. I had my hands full with my hospitalized patients at that moment, so I let Annie and Linda handle the small fierce tiger: Annie is an even bigger diehard cat lover than I am and is one of the best in the hospital at handling fractious cats with minimal stress: she had effectively and carefully wrapped the cat in a thick towel to form a kitty burrito so that Linda could quickly place the IV. Kitty held still, but loudly shouted the equivalent of obscenities across the ICU, letting the world know exactly what he thought about being held against his will. However, in no time the girls were done. He was placed in a cage and started on IV fluids.

I later walked by his cage and there was something about him made me stop. He was totally chill, lying comfortably on the bedding with his front legs with their white toes extended out in front of him like a sphynx, while he calmly stared at the back wall of the cage.

I didn't know his name yet, so I looked at his cage card.

"Jerry," I said softly in a singsong voice.

One ear twitched ever so slightly as he turned his head around and looked at me with widening pupils, "You know my name!" It's cute how patients always seem initially surprised when we call them by name. It's kind of like in their minds it means we can speak their language: their name is their link back to home, to their families, to a world that is predictable and familiar.

"Hi Jerry," I said with a grin, and opened the cage door. The fighting striped fireball from earlier was gone. I introduced myself, giving him the option of sniffing my fingers. He didn't. He just bumped his forehead against my palm. "Awwww..." I thought. I ran my hands along his small thin body and the rumble of his purr immediately reverberated against the cage walls. He flexed his little white toes against the bedding, kneading. Every time I stopped petting him, he'd bump my arm with his head for more, and his purr would rev up louder and louder with each stroke of my hand. I couldn't help grinning. It was hard to tear myself away.

We admitted 4 patients within the next hour. Annie came up to me, "Do you want anyone in particular?" she asked with a grin. Most of the time we don't get to choose our patients; they are assigned based on our skill level as technicians and who has the least patients at a given time, but on this day I was getting to choose.

"I want Jerry," I said without a second thought.

And so he became my fifth patient on that shift. And he rapidly became my favorite: the formerly untouchable cat let me do everything that I needed to do to him by myself. Auscultating his chest, obtaining his blood pressure with the Doppler and its cold wet goo on the probe against his foot, rectal temperatures, checking his gum color: none of it was an issue. He purred throughout his treatments. His one request was that I continue petting him while I did everything: he would bump his head against my arm insistently if I didn't.

He was hanging in there, stable, when I rounded him to the overnight technician. I told her about his medical history but also about his awesomeness so that she would know to look for it in him: when you expect patients to be good, they usually are.

The next morning he looked so much better! His head was up, his eyes were bright, and his overnight tech had fallen as madly in love with him as I had. More patients had been admitted overnight and I now had 6 to call my own, with Jerry being the most stable of them. I kept stopping by his cage whenever I had a spare moment to hang out with him.

Annie helped me get a blood sample from him around noon that day. He was so good for it; didn't even say a peep about being held for the blood draw nor about the quick poke with the tiniest needle I could find. I ran the bloodwork and handed it to his doctor without looking at it: we were slammed with incoming emergencies and I was moving as fast as I could so that I could pitch in and help. I had no reason to think it was worse based on Jerry's appearance and behavior.

A cat carrier was rushed back by one of the receptionists while I was setting up a fluid bolus on one of my other patients who was tachycardic. What is up with all of the sick cats these last two weekends? I wondered, as I heard something about "not sure if he's breathing" and "what do we have permission for?" Normally when you walk into a veterinary ICU, 75% of patients are dogs. Sometimes 100% of them are canine. Cats can get very very sick from an assortment of maladies that are any internist's wet dream to work up, but they tend to happen when cats are ancient. The question of quality of life crops up then, and it is not uncommon for clients to elect to stop. Because how much longer do you expect to prolong a 16-year old kitty's life? Cats are tough, hardy creatures, and you can tell when you look around the ICU and notice their absence. Not on these last two weeks, though: 50% of our patient population last weekend and this one was feline.

I finished setting up my patient's bolus and ran over to the wet table where we run codes as Annie pulled a very limp cat out of the carrier. Two doctors had rushed over as well. I started setting up for an IV catheter while someone else started setting up an endotracheal tube so we could be ready to initiate CPR. One of the doctors found a heart beat. It was confirmed with the EKG. We got an IV catheter into the kitty...his blood pressure was nonexistent, as no blood flashed back from the stylet, but correct venous placement was confirmed by flushing the catheter. Fluids were started. Annie was able to get the tiniest blood sample to check kitty's blood glucose...it ended up being too low to read on the glucometer! IV dextrose was given. By then there were enough people around the cat that I was able to step away when my patient's fluid pump beeped, indicating that the bolus was done. I confirmed that my help wasn't needed anymore and returned to my patients.

Under the head attending doctor's orders, Annie was able to get the kitty reasonably stabilized but stayed with him, because his condition could change at any time.

She later asked me if I could watch him for a minute so she could run to the restroom, and so I did. I leaned against the wet table and watched the kitty's EKG on the monitor across from me: his heart rate was slow for a cat's but the rhythm was normal. I looked down at the small patient. His eyes were open, with golden irises. I had applied ophthalmic lubricant earlier because he wasn't blinking. He still wasn't really blinking, but I saw his eyes moving around, watching the goings-on of the ICU. And for a second, I saw the world as he did: the beeping of the EKG unrecognizable and far, far away, as if heard through a tunnel. A dog whining in a cage in the distance. The people moving around blurry and unfamiliar, in this strange room of bright lights and medical smells. And the question of, "Where am I?" but being too weak to really care.

I slid my hand under the heated Bair Hugger blanket that covered him, my fingers running along his surprisingly soft fur. I could feel every bone, every rib. He was old and guessing by his condition, had been sick for a long time. And he was purring ever so softly: the death purr. Cats will purr when they are happy, but the really, really sick ones will also purr to comfort themselves.

Kitty's expression relaxed and he half closed his eyes as I continued petting him. He stopped purring: since he was being comforted from the outside now, he had no need to continue comforting himself.

His doctor came back from the exam room, where she had been talking to the cat's owners, at the same time as Annie returned.

"They are going to euthanize," Dr. E explained. Kitty had indeed been sick for a very long time. He had seen multiple vets and had had diagnostics performed within reason, but he had continued to deteriorate. It was a fair decision.

Annie took my place so she could scoop the cat up into her arms to take him in to the exam room to spend time with his owners. Kitty looked up right then, turning his head, and making full eye contact with me. His eyes were clear for the first time, focusing. I reached out and stroked his head one last time, and he blinked slowly at me, "Thank you."

I wish more people saw cats the way we do.

At that moment, Dr. S, Jerry's doctor, called me over to her desk. She was very serious.

"Jerry's owners are going to be here in an hour," she said. She had just gotten off of the phone with them. "There is a 50% chance that they are going to choose to stop."

I felt my face fall. I had not been expecting that. "But he looks so good!" I said quietly.

"I know," Dr. S said, "but his bloodwork is worse. And I'm afraid there is something else really wrong with him that we are missing." We went over his long list of undiagnosed problems. The chances of any of it being curable, even if diagnosable, were slim when you took into account that Jerry was also 17 years old. Again, it was fair.

I went back to his cage and ran my hands over him. He nudged them eagerly, and his purr filled the cage once more.

His owners showed up at exactly the time they had said they would arrive. Dr. S went in to speak with them first, and came back to let me know so I could take Jerry into the exam room to visit with his people. They were going to stop.

I looked for a pretty towel in our clean laundry shelves. Jerry let me scoop him out of his cage and curled up against my chest. I wrapped him up in the towel and walked out of the ICU. He was looking straight ahead, the back of his little striped head to me. I could feel his purr soft against my heart. Walking down the hallway to the exam room, I kissed the back of his head and nuzzled him, choking up for just a second. And then pushing it away so I could walk into the room where his family was waiting for him. Dr. S was in there too, talking to them again. I hadn't realized she had returned to the room. I looked around questioningly, wondering whom I should pass him to, and one of the women in the room stood up. Her eyes and nose were red. I passed Jerry to her and she held him against her chest, just like I had, as she sat back down in her chair. Everyone was talking around us, but I heard nothing: I just saw Jerry lay his stripey head against his owner, who kissed him between the ears as he closed his eyes happily.

I walked back to the ICU to continue with my other patients' treatments.

Dr. S brought Jerry back later. Except he wasn't there anymore, it was just his small thin brown and black striped body, the fighting soul gone. Usually Annie or one of the assistants takes care of the bodies: the more experienced techs on the floor often have our hands too full with the more critical inpatients. But all of my patients were stable at that time and so I dropped everything I was doing so I could take him from Dr. S to take care of his remains myself: attaching a label to his paw, to his body bag, filling out his information in the record book in the morgue.

I want to believe that there is some magikal subconscious reason why I decided to choose him, but the truth is that I chose him because he purred when I touched him. It was that simple. I had just wanted to guarantee he would continue to feel that comfortable around the veterinary staff during his hospital stay. That was all. And I had succeeded. He had left this world still purring a real purr of happiness. And that is, ultimately, the best happy ending that one could ask for for a cat.

I furiously wiped my eyes, took a deep breath and walked back to the ICU. There were more happy endings that I needed to guarantee.

The rest of my patients did well. My youngest even went home to spend Christmas with her family, happily wagging her tail at her owners. One client brought us freshly made poptarts from Ted's Bulletin. Others brought us cookies, brownies and cupcakes. Dr. S thanked me for my hard work on her other most critical patient. The doctors had gotten together to get us all cards and gift cards to thank us for our hard work, out of their own pockets. They didn't have to do that, but they did. One of the receptionists squeezed my shoulder lovingly as she walked by, which was unexpected but somehow made my day. We giggled over off-color jokes. I made my favorite doctor laugh. Clients smiled and said "Merry Christmas" and "Happy holidays!" as they took their pets home. The colored lights strung around the ICU glowed brightly, warming up the space we all coexisted in. And we sent another 8 of our 18 inpatients home to spend the holiday with their families. Many of the others would go home on Tuesday, when their owners returned to town after the holiday.

I rounded my patients to the overnight techs that would be taking over their care, and then rushed to help complete our list of shift change chores.

"Go home!" Annie finally said with a grin. "We're good." She just had to finish tying up some loose ends and she would be leaving too.

"Merry Christmas, Annie!" I said, "I hope you get to sleep in tomorrow!" She laughed. She was on call for today, the 25th.

As I walked out with my bags slung over my shoulder, I looked around at this amazing team of people that I have the privilege of working with and thought about how it takes a special kind of person to not just do this job but to stick with it for the long haul. "We are all magical here," I thought with a smile, "And not just because it's a holiday."


  1. I love how strong your heart is . . .

    Every time I read one of these stories, it takes me back to our family members who have walked on while we've held them in our arms.