Tales From the Trenches: When The Patient is the Healer

I woke up with a start, my eyes flying open.

"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.

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I had said I wasn't going to write any more of these but this past weekend was exhausting physically, emotionally and psychologically on all counts and this time I think writing about it will be cathartic. If only to tell the tale of sixth senses and the realities of nursing jobs, whether human or veterinary.

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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!

I had already worked out for two hours that morning: one hour of hard-core volume leg work, and another hour on the treadmill, but the sun was shining when I left work and I decided I was going to run outside because I just needed to pound my feelings out against the pavement around downtown Frederick.

It was well worth it. The Universe gifted me with one of the most spectacular afternoons outdoors that I have experienced in a while.

I clocked in another 3 miles before deciding I should probably stop before I wore myself completely out. It was hard to leave the sunlight and the Friday afternoon crowds ready for a night on the town to go hole up at home in preparation for a working weekend. I felt alive again driving home.

But I still did not sleep well that night.

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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.

I walked into the little break "room" (" " because it's more like a nook off of the ICU) to put away my stuff, glancing at the board where Annie was finishing assigning patients: there is a large dry-erase board where she writes all of the techs' names and underneath them, the patients that we would each be in charge of. We have been short-staffed for a really long time now, with Annie and I being the only constants (and sometimes the only techs) on the weekend daytime shifts to five doctors. We finally, finally have five techs on the team. ICU veterinary work is the absolute most demanding of all of the veterinary branches: it takes all of your skill, all of your strength, all of your will, all of your knowledge and all of your intuition. It can be the most heartbreaking but it can be the most rewarding, even more so than strict emergency work, because you get to develop relationships with the patients and their owners. But it can easily suck the life out of you if you're not careful, and it takes a very special kind of person to be able to do it long-term. Stress levels can be elevated throughout the team, especially when the case volume and patient acuity are both high, and redirected aggression amongst the staff as a result of stress is a real side effect. Burnout happens all the time in both vets and techs, and it is not uncommon for new techs to run away screaming when they realize just how intense the environment can really be.

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.

My other two patients had simple treatments so I got them out of the way first so I could dedicate time to Chewy's battery of required therapies.

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. 

On an awake patient, however, you have to attach it to their lip. Dog lips can still be quite hairy and are often pigmented black. Other alternatives are ears (if the dog is very fine-haired), or the webbing between their toes, or their prepuce or vulvas (the probe does not pinch; you would be surprised by how well they usually tolerate this.)

Pulse oximetry options for awake patients. Photo from here. 

Movement of any sort will affect the reading, and these devices aren't very quick: it can take them at least a minute to get a correct reading. When you have an awake patient trying to chew on the probe or wiggling their lip to make it fall off, or moving their head to keep you from attaching the probe to begin with, it can turn into a half hour ordeal. I usually end up training my patients to let me do this by using pressure-release techniques like you would with a horse.

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.

Chewy would be no different. He was already head shy to begin with, but I convinced him to lie down somewhat on his side, which was different from the position he would be in for oral medications. Once he was able to understand that I was not trying to touch his face in order to give him medicines, he let me attach the pulse ox probe to the corner of his lips and he was quite cooperative for it. I obtained a normal reading (98%, which we were really excited about because it was the first normal reading in days) and re-positioned him so that he was lying on his sternum again: lying in sternal recumbency makes it easier for them to breathe.

An adorable puppy demonstrating sternal recumbency. <3

He was my most critical patient that day, and anytime I walked into his run was with the understanding that I would not be available on the ICU floor for at least half an hour, but despite having a reputation for being inordinately stubborn, Chewy really gave me no trouble. Halfway through the day I found myself actually looking forward to sitting in his run with his enormous hairy self lying down next to me, while doing his treatments and gently stroking the white stripe between his eyes until his third eyelids peeked out and he fell asleep.

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.

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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!"
"Magpie!"
"Meow!"
"Magpie!"
"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. 

Magpie was very patient for her initial reading...until she was not, because her pressure was low and I was having a hard time finding it. I had her out on the treatment table, lying on her side with minimal restraint, and she quite literally turned her head so that she was making eye contact and very deliberately yelled, "MEEEAAAAAAAAOOOOO!" "Why are you taking so damn long?"

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.

The Perfect Wave

I've kept journals since I was in middle school, waaaaay back before the existence of things like high-speed internet, WiFi and blogging. We first got dial-up internet when I was 14. Despite the uber-slow connection, my brother and I enjoyed hanging out in role-playing fantasy chat rooms, with Forgotten Realms being our favorite. We pretended to be animals that could talk (#nerdforevaaaaah!!!) My favorite character was a giant she-wolf I named Tundra who was a bit of a prankster. One of the leaders of the group was this asshole magician that everyone loved to hate. Tundra was the only one he genuinely liked, that could make him laugh...even though she was constantly jumping on him and trying to sit in his lap when he was trying to throw one of his prismatic spheres at whomever had most recently pissed him off. One of Tundra's things was disrupting arguments. Funnily enough, Ananda, the Dalmatian mix that showed up at our doorstep when I was 17 and adamantly insisted that I was her owner, eerily shared my wolf's penchant for breaking up arguments between both dogs and people, sitting in people's laps despite being 60 lbs once fully grown, and "talking" back at you when you tried telling her what to do. We have never had a dog like her, before or since. I always thought I had somehow brought Ananda into existence by creating Tundra.

But you know, magic realism isn't real and all that. Spend a decade living in the Caribbean and then we can sit down and talk. :D

Arroyo this past weekend. Photo sent by my mom.

Arroyo this past weekend. A storm was moving in from the mountains.

Anyway. The journals.

I have all of them to this day. They are part of the book collection I brought with me from Puerto Rico when I moved stateside. They started out as only written, but when I joined the Sea Scouts with Carlos, I started illustrating my entries as well. There was so much that we couldn't photograph that I wanted to capture the images of, that I started drawing the things that I wanted to remember more vividly. Because a picture is worth 1000 words, and this was way before cell phones were equipped with cameras.

These illustrations and entries would eventually include our adventures at the Arroyo beach house as well.

The story on the left (among other drawings): I was always the only girl in the lineup when surfing. (Are you recognizing a theme yet??) I caught this amazing wave...and didn't lift the nose of my board in time, which meant I dived straight down from the crest of the wave and head-first into the water at high speed. I got water so far up my nose it felt like it had reached the back of my brain. I was then rolled around and around against the sandy bottom and dropped unceremoniously at the feet of two boys who were just getting into the water to surf themselves. I popped out of the water with an instant headache from nearly drowning...while laughing and laughing and laughing.
What else can you do?
The story on the right (among other drawings): Miguel was a guy that I met at Arroyo. He was two years older, super smart, and SO FREAKING ADORABLE. I liked him lots and lots. We dated briefly and he drove from one end of the island to the other (this was a four hour drive...!) just to see me...until Carlos scared him away. *eye roll* But that's another story.

We used to spend every vacation, including Holy Week, in Arroyo. As written in a recent IG post, in Puerto Rico we don't have spring break: we have Holy Week. 85% of the population is Catholic: it is part of our Spanish cultural heritage. So Holy Week is actually kind of a big deal on the island: all government offices, schools, colleges and universities, both public and private, regardless of religious affiliation, close for Maundy Thursday and Good Friday. Many places close for the entire week even. So technically, Holy Week IS our spring break, and it's one of those cultural differences between PR and the US mainland that I found terribly confusing when first moving stateside.

This is Arroyo, Puerto Rico, as of this weekend. The pics were taken and sent to me by my mom. And here is a blurb about island life, especially for those of you that have shown interest in my former life: In PR we don’t have spring break. The island is mostly Catholic (inheritance from Spain) so Lent, aka Holy Week is kind of a big deal. All schools, both private and public, close for Maudy Thursday and Good Friday, but some close for the entire week. Technically that’s our spring break. How do we celebrate? THE BEACH!!! Everyone goes to the beach! Regardless of religious affiliation. Coming from a family of teachers and college professors = my whole family was off for Lent. And so for the last 20 years, my family has spent Holy Week at the Arroyo beach house. This year was no different. I was, of course, working in Maryland while my mom and the aunts had fun. 😊 These pics were a balm, though. I lived for waking up early to run downtown to the shore to see the sun shimmering off of the water, to smell that salty tang, the soft sand underneath my bare feet. A part of my soul will always live on that beach....You have to drive through the central mountain range to get to Arroyo and there was always something magical about driving through mountains to get to the sea...one of my favorite songs when I was in college told the tale, "And the crystalline knowledge of you Drove me through the mountains Through the crystal like a clear water fountain Drove me like a madness To the sea..." It's an obscure Stevie Nicks song, part of the soundtrack for Practical Magic. But it was my song for Arroyo. I think the ocean is calling again. 😉

A post shared by Saiph (@ntorrech) on Apr 1, 2018 at 3:12am PDT

March and April are a gorgeous time of the year to spend time at the beach in PR. It's "spring," which on the island means that the sun is warm but the breeze is cool. It also marks the end of surf season, so there's a 50/50 chance you'll either get waves to ride or flat water to wade into or kayak on. This was my favorite time to go to Arroyo, and that is when we had some of our more remarkable adventures, which I wrote about in my journals.

The caption at the bottom: "Todo en el mar comienza, y todo en el mar termina."
Everything begins in the sea, and everything ends in the sea.

I was nostalgically flipping through them the other night after my mom sent me the pics above, and I stumbled upon this entry, about a wave that I didn't ride:

"Time stopped, and all there was was the wave as I stood mesmerized. It was my height from the water's surface to the crest, not that big but still stunningly powerful. It rose from the water like a wall, the farthest edge foaming and curling under and so on, as the edge of the wave rolled over itself and around the barrel, a tunnel that closed as the wave came rushing, crashing, roaring forwards like a living thing, the sun glinting off its glassy surface, and tongues of spray flying backwards off its crest with its speed. The perfect wave. And it lifted me up with its passing as I held on to my board and left me behind as it exploded in bubbling seething foam, and melted away from the sand only to return once again."

                                                                                                       - Me 11/99

My photo. Taken at Arroyo with my telephoto lens.

It reminded me of how I was always trying to catch that perfect wave. On my board, in photos, and with words.

Me on the crest of a wave, about to drop. Amazing shot by Carlos.

But sometimes the best way to appreciate the perfect wave is to just sit back and watch its wild and untameable beauty unfold.

My photo. Arroyo.