"Chewy," I whispered into the darkness.
He had been my patient the day prior. I fumbled in the darkness for my phone so I could see the time.
It was 4:00 am.
I lay back down, staring at the ceiling and trying to shake the unwavering certainty that he had just died. It was that knowledge, that feeling of his passing, that had woken me up from a deep, bottomless sleep. "But he was doing so well," I thought. He had finally eaten for his owner and he had been consistently oxygenating well by the end of my shift.
I shut the door on my work-related thoughts and turned onto my side, covering my head with a pillow as if that would keep my brain silent, sliding into a fitful sleep where I drifted in and out of vague dreams of the great Saint Bernard that I had slaved over for 13 hours on Saturday.
I finally flung the covers off 10 minutes before the alarm went off and hit the shower, still unable to shake the feeling of what I knew to be true.
Fridays are my surgery days at a hospital closer to home and it had NOT been a Good Day by any means. I'm not one to stress over Friday the 13ths, especially because my own mother was born on Friday 13: in the family we tend to consider them good luck, just like we love black cats. Which is good because my patient on this day was, actually, a black cat. So there was good luck in the sense that my patient was still alive when I left my shift, but it was bad luck due to the events that happened to her that could have been prevented. I finished the day knowing that I had done everything I could possibly do to the best of my capabilities with the information that I had and the short rein that I was given by my doctor, but sometimes that is not enough, and as a nurse I can only do that which I am given permission to do (see "short rein"). It was one of those days that I can't write about. All you need to know is that the events on this day left me questioning my career choice. I hadn't had one of those in a long time, so I guess I was overdue.
|Not my patient from that day, but still an eye belonging to a mostly-black cat. |
This is an awesome shot by Carlos of none other than Zombie!
It was well worth it. The Universe gifted me with one of the most spectacular afternoons outdoors that I have experienced in a while.
But I still did not sleep well that night.
I walked into my ICU job the next morning, Saturday, already feeling wiped out. I usually know what kind of day we're going to have by the general vibe when I walk in, and it was not the best: everyone was flustered, moving hurriedly. The two baby doctors (as we call our interns. They are full-fledged DVMs, usually recently out of school (but not always), that choose to do rotating internships (unlike in the medical field, internships are NOT a requirement in vet med) at specialty hospitals in order to gain more knowledge so they can move on into residencies in the specialty of their choice or just be above-average general practitioners) that had worked that night were frowning at their computers, their shoulders tense lines as they typed up their notes in a hurry before the senior doctors arrived for rounds. I got smiles hello from the overnight techs I made eye contact with, but I saw the strain behind the smiles.
Usually the ICU is neat and tidy when we arrive in the mornings on the weekends, because the evening rush is normally limited to the hours between 11:00 pm and 1:00 am, so the night techs have time to get caught up on treatments, admits and diagnostics, clean up the area, and relax before their shift ends. This had not been one of those nights.
|Not my hospital. This is actually the University of Pennsylvania's Ryan hospital, which was the first university-based animal hospital to receive the Level 1 designation. Our layout is different but a busy shift can look just like this.|
We each had three patients, which is a reasonable caseload. We rounded with the overnight technicians that had had our patients. Since I was the most experienced tech on this shift, it meant I also had the most critical case in the hospital, which is absolutely 100% fair: I like the critical cases. The more complicated, the better. It's why I do this.
His name was Chewy. He was a two-year old 180 lb Saint Bernard that, at the moment, could not really walk. The dog was bigger than me, with massive paws larger than my hands, and a 45 lb advantage on me weight-wise as well. He was also having trouble with that most basic of things you need to be able to do in order to stay alive: oxygenate. The biggest concern with him right now (among many others) was that he had horrible, horrible pneumonia. He was too big to fit in our oxygen cages so at the moment he was sporting the latest trend in our ICU: bilateral nasal cannulas that delivered the oxygen straight into his nose. In his case, this also meant he was head-shy for administering oral medications, which was not surprising. We have the oxygen cages so that we can avoid this type of situation because the cannulas can be so annoying for the patients, but the largest dog they'll accomodate is maybe 90 lbs. Chewy would have been scrunched in there so tight, we wouldn't have been able to get the cage doors closed.
|Nasal cannula for delivering oxygen in a dog. The cone (E-collar) is a must to keep them from pawing/rubbing the cannulas off. Less sick patients can often get away with just one cannula in one nostril. Chewy was not one of those patients. Photo from here. <- That article explains how it's done. At my hospital it's usually us techs placing these.|
I took all of his vital signs, including his blood pressure: all were normal. The most daunting thing that needed to be done was to get his weight: one of his many complications was edema, so he had to be weighed every 12 hours to keep tabs on if/how much more fluid weight he was gaining.
He had a special double harness with a handle above his shoulders and another above his hips (it's called a Help 'Em Up Harness) that allowed me to help hoist him out of his run. He was able to help, placing his feet while I lifted the brunt of his weight, as we made our way to the scale. Remember that he weighed 180 lbs. I weigh 135. Deadlifting 180 lbs of static iron in the gym is a lot easier than a living, breathing, moving animal of the same weight.
We made it to the scale (thankfully less than 10 steps away), where he lay down with a sigh. His weight remained unchanged.
Now we had to make it back to his run.
I literally deadlifted him by the handles on his harness, hoping that he would place his feet so we could get going, but it was not happening. He didn't even try: he was done. One of the other techs helped me carry him back to his run, where he was promptly hooked back up to his oxygen.
His next treatment was nebulization, which involves placing a vaporizer near the patient's face that emits steam from either water or saline to help loosen the phlegm in his lungs. He was not too keen on the steam, which I had been warned about in rounds, but if I held the vaporizer attachment about a foot from his nose, it still wafted in the general direction it needed to go without bothering him. After 10 minutes of nebulizing, I coupaged him, which involved standing above him and thumping his ribcage on both sides firmly but gently with cupped palms: this is to help continue loosening up the phlegm in this chest in the hopes that he will be able to cough it up. He didn't cough.
Next up was checking his oxygenation with a device called a pulse oximeter.
Pulse oximetry is probably one of the things that I hate the absolute most to do on awake patients. Why? Because most of these devices are meant for people, whom are hairless and tend to have lighter skin on their fingers, which is where pulse oximeter probes are usually attached. There are veterinary-specific ones, of course, but they still don't work well on fur. They are excellent for anesthetized patients, who are not moving and on whom you can just attach the probe to their tongue.
|Pulse oximetry on an anesthetized dog. The 96 indicates the % of oxygen in the dog's hemoglobin. The 102 in this case corresponds to the dog's pulse. Photo from here.|
|Pulse oximetry options for awake patients. Photo from here.|
|It takes a crazy amount of patience and begging to get a patient to be this tolerant of the pulse ox probe. Some patients are just this good to begin with, but it is rare! Photo from here. <- That article has a great explanation of how pulse oximetry works.|
|An adorable puppy demonstrating sternal recumbency. <3|
He had been in the hospital for almost two weeks, with one thing after another, his problems compounding themselves and snowballing into the avalanche that he had become. He had never really been comfortable during his entire stay with us, no matter what the techs and doctors did for him, no matter how the bedding was padded or accommodated for him, no matter how he was positioned, no matter the sedatives or pain medications that were given to him in the hopes that he would finally sleep. Just sleep. Instead he would be awake, panting, shifting uncomfortably, sometimes sitting up for hours at a time unable to find peace.
During my watch, he finally slept. He finally stopped panting all the time.
His owners came to visit, a lovely couple that adored their dog. One of the biggest challenges with him had been getting him to eat: he would not eat and up until he had required intranasal oxygen, he had been receiving a liquid diet through a tube that had been placed through his nose and into his esophagus. His need for oxygen had become greater, so the feeding tube had been removed in order to accommodate the two nasal cannulas for oxygen.
On this day, his owners brought him chicken that they had cooked for him at home. And he ate. He ate for the first time since he had been admitted.
I think that was the moment when I subconsciously stopped worrying about him. When you have a critical case in your care, you move around the hospital but the back of your mind is always tuned into that patient (or patients...sometimes ALL of them are that sick!) You find yourself drifting towards their cage when you're not thinking about it, or looking in their general direction if you realize you've been focused on something else for too long. One of the eeriest things you get to experience as a critical care nurse is when your patient suddenly tanks across the room and you feel it. You know something happened without seeing it, because you felt the change from the other side of the ICU. I can't explain it, but it is the kind of thing that forces you to believe in the unexplainable. It is something that I have seen happen over and over and over again throughout the years, to other techs and to doctors too, and that I have experienced myself with my own patients.
Chewy was still cruising towards the end of the day. I rounded him to Manuel, the overnight technician that had been taking care of him the previous night as well. The giant dog had been sleeping when we walked into the kennel area off of the ICU but he slowly woke up while we were talking. I looked at him and he looked the same as he had all day, but I got a distinct subtle feeling of unease that I couldn't place. His respiratory effort had never been easy, but it had not increased, and just 15 minutes earlier I had checked his vital signs: everything had been fine (for him, given the circumstances). His lungs sounded no worse and he had continued oxygenating great all day as well.
I shook off the feeling and finished rounding my patients. It had been a hectic day, just like I had figured, and we still had a million chores to get done before we could leave. My 13-hour shift turned into 14 hours before I could walk into the break room to grab my stuff to go home.
Walking through the ICU on the way out, I glanced at Chewy one last time in passing, almost as an afterthought. He was sleeping peacefully, his breathing still the same.
I don't remember the drive home, nor showering when I arrived at the apartment, nor feeding the cats nor what I scarfed for dinner. I just remember falling into this deep black bottomless pit of sleep.
And then five hours later being woken up by the knowledge that Chewy was gone.
---------------The ICU was a disheveled chaos when I walked in on Sunday morning. Only one of the overnight techs was around; everyone else was elsewhere. It was that calm that settles in after a disaster.
I glanced at Chewy's run and saw it empty, the bedding soaked, the fluid lines that had been attached to him scattered across the floor as if removed in a hurry. Annie had already assigned the cases and I looked at the board, searching for Chewy's name. It wasn't there.
I put my belongings away in the break room and walked back out just as Manuel and two of the other overnight techs walked back into the ICU from the exam rooms. They all looked like they were still in shock.
"Chewy died, didn't he?" I asked Manuel.
"I'm so sorry," he said. He was so upset.
It had been horrible, a story that I don't care to repeat in detail. Around 11:00 pm Chewy had suddenly taken a turn for the worse, into what turned into an hours-long ordeal of trying to reach his owners to let them know what was going on in the hopes that they would give permission to stop because he was not going to get better, while the dog suffered hopelessly. (Guys, if you have a pet hospitalized in the ICU, you MUST keep your phone close to you!!)
He had finally been put to rest at...you guessed it: 4:00 am, right when I woke up. The owners had just finished visiting with his remains in the room when I arrived at 7:00 am.
Manuel needed to talk and I let him. He needed to tell someone in detail about what had happened, to rehash what he had done and what he had seen. He needed to hear that he had done everything right, which he had. We always blame ourselves, we always wonder if we missed something or if we could have/should have done anything differently, if the outcome would have been different. Manuel and I ultimately stood in the middle of the ICU talking about supernatural experiences and sixth senses and all those things that you know when your job involves constantly walking the line between life and death. Eventually he was called over by another tech for help, and I wandered off to receive rounds on my other patients.
In a funny twist of fate, my most critical patient on this Sunday would be a black cat named Magpie. A black cat, like my patient on Friday. Magpie had a horrific infection that required my wearing gloves in order to touch her, and was one of those cats with Opinions. Like Victoria, that I had told you guys about before.
Magpie was very, very, very sick. And her blood pressure was low when I did her first round of vital signs, which then involved a rush of stabilizing treatments to bring her back up to normal. But that tough little girl rallied like a trooper during her 13 hours with me. It was an especially chaotic Sunday, with stress levels running higher than normal, but that little cat was the one thing that without fail brought a smile to my face throughout the day. First, when she ate for me: she had not eaten for a week at home and it was one of the primary reasons that had led to her ER visit. The doctor had already discussed having me place a feeding tube later that day. But Magpie ate. She ate all the food that I offered her by hand and then almost ate my fingers too! Her doctor's jaw dropped when I told him. So we held off on placing the tube and I was given the go-ahead to offer her small amounts of food every few hours.
The way she felt was cyclical: she would have moments where she was lethargic and would curl up at the back of her cage, sleeping. Eventually she would wake up and would start howling until I showed up. Sometimes I couldn't get to her immediately so I would call back at her from wherever I was in the ICU, "Magpie!" And her howls would change to meows, "Meow!"
And so on and so forth.
If I stopped talking to her, she would howl again. Until I finally reached her cage, at which time the howls would change to mews once more. Her demands were compounded when she figured out that every time she did this and I was able to make it to her, I would offer food. It became our agreement: if Magpie asked, she received. And every single time that she received, she ate.
This is not common.
Because her blood pressure had been so low that morning and because she was so sick, I had to check her blood pressure every other hour. Normally if they climb up firmly to within normal parameters, we space out the blood pressure checks more, but she was so close to borderline that I kept checking to make sure she wouldn't tank again. Cats aren't normally huge fans of having their blood pressures checked because it involves gently pressing the Doppler probe smeared in cold, wet ultrasound gel against a shaved spot on their legs, close to their large paw pad. Cats don't like cold, wet slimy things against their skin.
|Blood pressure check on a kitty, using her front paw. The tech is holding the Doppler probe against the cat's paw (black cable across right palm.) Photo from here.|
I later figured out that what bothered her the most about the whole blood pressure ordeal was having the tiny cuff wrapped around her leg. She wasn't moving a whole lot in her cage, so I just left it on given how often we were using it, which she did not mind at all. Once we had that sorted out, she would just lie down for me to get her blood pressure readings, patiently waiting for me to find her pulse with the Doppler probe and talking to me with soft meows.
My favorite moment of the entire day was when I was sitting on the floor across from her cage while I helped one of the other techs with her patient, and Magpie started howling at me:
"There you are, slave! Why are you sitting on the floor with that stinky dog? I'm hungry! Feed me nao!"
I laughed and laughed. I was welcomed with purrs when I was finally able to bring her food.
She was still far from being in the clear by the end of the day, but she was better. Even her bloodwork, which had been horrible the day prior when she had been admitted, was significantly better. It was almost magical, what happened with her that day.
I loved that little black cat because she healed me. She settled what had been unsettled by the near loss of my black feline patient on Friday. She was a gift, a confirmation that I am doing what I am supposed to be doing.
I finally slept on Sunday night.
And that is the true beauty of ICU work: we fix a lot of cats and dogs, we bring them back from death's door, and sometimes we send them through peacefully. We buy owners time, we put their pets back together, and we heal them...the pets, and sometimes the owners too.
But so many times, it is the patients that heal us.