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Category Archives: Dealing with Death

Life is fragile, handle with care

I wrote this on the subway home from last week’s clinical but didn’t post it.

How quickly I forget. I know I am not alone in this matter, but I can only speak for myself. I am in a hurry so I cross the street without looking left, right, and then left again. I speed through a yellow light; God forbid I have to sit at a red for 2 minutes. I don’t wear a seat belt in the back seat of cabs.  I have no idea if our smoke detector even works.

Riding my bike every morning, I have become so careless in being a defensive cyclist. I am impatient and even borderline aggressive when cars don’t give me the right of way.

I am so lucky to have periodic reminders to be more careful with the precious life that I temporarily own. I am reminded to heed these more gentle warnings, minding the fragility of life. And you should, too, because there is a more than likely chance that if you are taking the time to read my blog, you love me and I love you.

This morning, I got off a stop early on the subway and walked through Central Park. I woke up smiling, literally, because this is my favorite day of the week. On Thursdays I get to be with my mentor, a stellar DNP (Doctor of Nursing Practice, semi-new terminology for a nurse practitioner holding a doctorate). My step had a bounce to it, and I beamed at all the passersby even if they didn’t smile back. I even thought about telling a cyclist waiting with me at a stoplight that he should buy a helmet. But, I didn’t because that would be an unsolicited intrusion in a complete stranger’s life, right? Wrong. I wish I had said something.

My day was good, great even. I arrived and my instructor informed me that I would do my normal tasks, and in addition, perform part of a physical and take a partial patient history. I got an amazing, hands-on, taste of my future life as a nurse practitioner. And I got more nimble and confident with my fingers, administering a whopping 6 vaccines. That makes probably more than 20 shots total! Heaps of practice.

The day was wonderful until the last patient. My instructor prepped me for her, but the reality didn’t truly hit home until I put a face to the tragic story. She is a nursing student, I won’t say where or what program, but mention that fact only because it eerily parallels my own life. She is young and recently married, but her spouse and her have a long history together as they grew up together. Three days ago, her husband was riding his bike, in a bike lane in Manhattan. Cars were parked to the right of the bike lane, as is common. A driver opened his door without peeking behind to look for oncoming traffic, bike or otherwise, and “doored” the cyclist, which happened to be our patient’s husband. He flew forward, cartwheeling off the bicycle and landing in the middle of the road, where he was run over by an oncoming vehicle. He died.

When our patient walked in, emotions flooded me. She was ashen, her face a mask. Clinically speaking, her features lacked any affect whatsoever. It was clear that she was grieving tremendously. She came in for Xanax and I felt completely helpless, sitting on the rolling stool because I, no actually, “we,” couldn’t do anything for her. It wasn’t just me, the provider couldn’t say anything to assuage her pain either. That was a terribly painful realization. The least I could do, and somehow managed though I know not how, was contain my own tears until she left. When the door finally closed, I was berating myself internally for the tears that had already overflown. But when I looked at my clinical instructor, I saw that she was crying openly as well. We took tissues and simply sat for a few moments in silence. It was cathartic to realize that I can feel pain. I am supposed to feel pain occasionally, but I have to work on letting it wash over me, without internalizing it.
I did my best. But when I left, I still dialed my most loved companion and asked him slightly desperately to please not ride his bike that day. Or ever again until we could talk more about it. We both ride our bicycles all the time. We are young and in love. It so easily could have been one of us. This is one of those tragic accidents that makes you feel so helpless and grief-stricken. So many of us have false perceptions of how protected we are, but everything can change in a second without changing a single thing about how you live. I feel distraught for that young woman I met. She so easily could have been me instead of my patient.
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Caution Advised: You may become attached

This is the warning that should be posted on the door of every pediatric patient on the Oncology floor. Beneath the warnings of “Fall Risk” and “Contact Precautions,” a fluorescent sign should also caution that there is an adorable, yet very sick child, that lies within the bounds of the four walls you are about to enter. Their disease might not be contagious, but attachment is catching.

Mercilessly, our clinical instructors place us with the same patients each week, if they are still admitted to the unit. Quite obviously, this is in the best interest of the pediatric patient but it also led to serious attachment issues for me. When they first told us that we might be paired with the same patients for weeks at a time, I was impressed and excited. It would mean more opportunity to learn about the child, to form a bond, to gain their trust, and of course, to delve deep into their manifesto of medications. As an uncertain freshly-scrubbed nursing student, my underdeveloped emotions clearly were just waiting in the wings to do a gutsy cannonball jump into the swimming pool abyss of my heart.

And what a cannonball it was.

During post-conference on my second to last week in Pediatrics, I almost started bawling in front of my peers while just trying to present on my three patients. I could barely string three words together, much less speak about their conditions and the care that I provided. This is the story I meant to share with my fellow nursing students, instead of the feeble, “I had a really rough day today…I am feeling very sad.”

I haven’t been able to get a couple of patients out of my mind. The first is a young teenage girl who I took care of on 4 separate clinical days. She is Spanish-speaking, and came to the US for the very first time for her treatment because she wasn’t receiving treatment in her country. She flew here alone, with baggage that didn’t need to be checked: leukemia. While there are some relatives staying with her in the hospital, her mom, dad and siblings are all back home, a few thousand miles away. Her relatives are blood-related, but they are not mama y papa. The saddest part to me is that she is clearly wasting away day by day. She is only on her 2nd cycle of chemo, with many more rounds left to go, at least a year’s worth of treatment. She says she can’t eat because food makes her feel sick. She rarely gets up and out of bed anymore. It’s true that chemo causes horrible side effects, and I can’t imagine how unappetizing food must look with the amount of nausea and pain that she’s in. But it feels wretched for me to pull the scale in each day and see that she has dropped another quarter kilo. She lost 3 pounds in a week, and this is on a slight girl who was already underweight upon admission. Each day she sighs when she sees me clumsily rolling in the standing scale. I wish I didn’t have to weigh her, almost as much as I wish I could give her MY stomach full of the nutrients she needs. But of course, that really would be a band-aid solution wouldn’t it? So much of pediatrics is psychological, and it is heart-wrenchingly sad to see the emotions play across her face when she tells me (at first too quietly for me to hear, and the more loudly) that she just wants to go home.

By the end of my rotation, I was thrilled to see her nibbling on crackers waxed thickly with butter. She might only eat one in an hour, but it is something. Her weight had almost stabilized, a milestone even though she is clearly emaciated. I also was privileged to sit in on a session with one of the child psychologists. An interpreter was present, and it was a wonderful example of some of the amazing services that the hospital offers, working together in perfect harmony. She was a little teary, but she told me afterwards that she felt better and it was good to talk. It’s amazing for me to recognize how important these social services are to the kids. Child Life is available for scary procedures (armed with teaching tools, videos and distractions galore); clowns and dancers come in for private shows; and there’s even a Martial Arts team that comes in for “Kids Kicking Cancer.” My little girl is the perfect example of how important these services are. She is physiologically anorexic from the chemo and her depression about being so far from her family. I still hear her voice, “I just want to go home.”

I heard this mantra again on my last week of the rotation, by a very different patient. This little boy, Tommy*, has Down Syndrome and ALL (leukemia). He has the cutest little face and sunny demeanor, or he did, that is, until his chemo treatment began infiltrating his subcutaneous tissue. Seemingly instantly, a cadre of nurses surrounded him, acting speedily to access the site, attempt to suck back out what chemo they could, and then re-access the tender site with another wide gauge needle. As they palpated to find the port, Tommy* got more and more agitated. As many of these little patients do, Tommy has incredible parents. Dad was holding Tommy so he couldn’t squirm away, but it was the most gentle and loving “hug” restraint that I have ever seen. Mom was positioned behind Dad and son, stroking her little boy’s forehead, soothing him and whispering encouraging words. As the nurses continued prodding and Tommy got more uncomfortable and upset, he finally said, “Mom, I want to go home now! I want to go home.” He said it in a way that was so sweet and naive and it just tore at my heart. A nurse looked up at that point and said kindly, “Ok Tommy, how about we start counting now?” Without missing a beat, Tommy shouted, “1,2,3,4,5,6,7,8,9,10!” The nurse smiled and said, “11…” And Tommy said, “12…”

On and on it went until “49…” and then Tommy was silent. The nurse asked, “Tommy, what’s next?” He replied, “I dunno what’s next!” Laughter ensued. Then the nurse said “Fifty!” Tommy said 51, and off they went again. Tommy barely flinched or cried out when the needle pierced his skin. It was truly impressive. I was amazed at how smoothly it all went, even though I was on the verge of tears for most of it. (By the time I met Tommy, I had already dealt with an onslaught of emotions from seeing other patients in various positions of pain and discomfort.)

I think my sadness about “really sick kids” was triggered mainly by another little boy, only 3 1/2 years old, who most likely will not get better. Timothy* had ALL (leukemia) long before I met him. His chemo treatment put him into remission, but also sadly, gave him secondary AML, a different leukemia – much harder to treat. He was treated with chemo yet again, and this time, a bone marrow transplant (the only curative option for AML). He was in remission for quite some time, and then he relapsed. And this is where I met little Timothy. By now, little Timothy also has a host of other complications, and it is nearly impossible to decipher whether it is the chemo or the disease causing these other problems. I met him in week 2 of my 5-week rotation, and by the end of my 5 weeks, it was pretty clear that he will be going home soon, not with a cure, but for palliative care.

Sick kids are so sad. For me. Dealing with death isn’t easy, but I thought I had a grasp on it from my work with the residents in Assisted Living. Now, I realize, that they were the ones making it easier for me. They were so graceful in life and in death. Not everyone has made peace with dying, but my residents taught me that since they didn’t fear it,  I didn’t have to fear it for them. I was lucky to learn about death in this way. Maybe some of these same concepts that I learned from my residents can be applied to pediatric patients too, but I haven’t figured it out yet. My pediatric rotation is over, but I am still working through the emotions and sadness I am feeling. I question whether I want to deal with kids that are this sick on a regular basis. Luckily, my school has a number of resources for me, including a clinical nurse psychologist with a specialty in helping children with life-threatening illnesses. I can only imagine what an amazing resource that she will be in my journey as a nursing student.

 
 

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Inglorious Bast-turds

Turd is a 4-letter word that I much prefer over test. I promise, I am not talking about wiping bums today, but I do not feel ashamed in at least mentioning it. I would far prefer to clean up after someone who passed their bowels than take a pharmacology/physiology/issues of nursing test…ANY DAY.

I am a bit worn out on exam-taking today. This week. This month.

If there was a pie chart of my life, studying for exams would be disproportionately representative. I know that I need to learn this material in order to be a safe and effective nurse, but this method of tricky multiple choice testing day-in-and-day-out really takes a toll. That’s why going to the hospital this week was such welcome relief. Patience may be a virtue, but I am sadly lacking it when it comes to waiting for competence in nursing practice. Yesterday, however, reminded me why it is worth working for.

Our preceptor placed us with telemetry/cardiac monitor patients this week. In the RICU, this may seem like a step down in terms of hands-on learning since our patients weren’t dealing with tracheostomies and ventilators, but in terms of gleaning knowledge from our patients about their present illness, it was profoundly educational and emotional. This was my first patient that could actually speak to me!  More than speaking to me, she entertained me to no end.* Breathing was difficult, her energy was low, but her wit abounded. She was a total trip. She told a doctor that she was going to kick, ahem, his little “behind” if he didn’t get her off the drug that was causing her anxiety. While she was consulting with a palliative care doctor about possible treatments, her son was telling me all about her career working for the police department and before that, traveling with the army for close to 20 years. In a break from talking with the physician, her son asked, “Hey mom, what’s your favorite gun?” Without missing a beat (quite a feat on a 50%-O2 saturation partial face mask) she responded, “M-16 and M-19,” then she turned back to the doctor and continued conversing about her treatment. I was momentarily shocked that this little tiny lady had not only handled a gun, but that the names of her personal “favorites” had tumbled from her lips as easy as 1,2,3. Previously, we had spoken about salsa dancing and I had pegged her as a dancer in her former life, but that clearly wasn’t all… She is quite a character. Unfortunately, her condition doesn’t promise a quick recovery: sigmoid colon cancer, pancreatic cancer that quickly metastasized to the liver, bones and lungs. For this reason, my day with her was quite bittersweet. I was able to talk to her about her life and illness, take my time in giving a bed bath which she and I both thoroughly enjoyed, and also meet one of her incredible children who moved here from different state barely a week ago to be with her in the hospital. I was able to understand her condition (an achievement in itself) but this also opened my eyes to the possibility (or reality) that she will most likely not be leaving the hospital with her son. This is a hard pill to swallow.

When I left the hospital yesterday, though, I wasn’t sad. Maybe my residents helped me understand death and dying a little better. There was a part of me that was sad for her and her family. But I was able to compartmentalize that sentiment and also recognize another emotion: elation. At 6am that morning, I left the house as a Negative Nelly, feeling down-in-the-dumps over another upcoming test, compounded by a serious sleep deficit. But at 3:30pm, as I left the hospital even more weary, I had a completely different outlook. Again, my patient reminded me why I am here. It made me so excited to learn more, even if it means test-anxiety, some more sleepless nights, and even the monotony of studying on a Friday night. It’s only a few more weeks until August, and then it’s three weeks OFF!

In honor of my impending cooking-fest, I will post a recipe that I found the time to make the other day and ADORED.

Eggs Nesting In Tomatoes On Toast

Adapted slightly from A Cozy Kitchen

Serves 4 (maybe…)

  • 4-5 eggs (separated, reserving 2 of the whites for another use)
  • 1/8-1/4 cup extra virgin olive oil
  • 2 cloves of garlic (minced)
  • ½-1 tsp red pepper flakes
  • 1/2 tsp of dried oregano
  • 1 24-oz can of whole tomatoes (San Marzano highly recommended)
  • 1/2 tsp of salt
  • 2 Tbsp of chopped fresh basil (I’m growing mine on my fire escape!)
  • 4 slices bread–whatever you have on hand, toasted

In a cold medium skillet, combine the oil, garlic, red pepper flakes, and oregano.  Turn on the heat and warm over medium heat until the garlic begins to become fragrant (without browning), about 2 minutes.

Raise the heat to high, then use your hands to “crush” each tomato into the pan. (I used a fork/finger to pierce them because the squirt-factor was out of control. Beware of your cute t-shirt, it is in danger!) Season with salt and pepper.  Fry the tomatoes, continuing to break them up with a fork. Cook until they concentrate and no longer look watery (5-7 minutes).

Lower the heat to medium and stir in the egg whites.  Cook until the whites become opaque and firm, thickening the tomato sauce, about 1 minute.

Turn off the heat. Using the back of a spoon, make 4 indentations in the sauce, allowing a few inches around each.  Nestle an egg yolk into each indent.  Pull the sauce in from the edges of the pan so that it cradles each of the yolks.  Cover the skillet and leave it on the stove, heat off, until the yolks are just warmed through and beginning to set, about 3 minutes for runny yolks.

Gently spoon some sauce and a yolk onto each piece of toast and serve immediately. Use a large spoon, perhaps lightly oiled, to pick up a nestled yolk without breaking it. Enjoy for breakfast, lunch, snack, or dinner. Or another special occasion time (plucking your eyebrows??)

*information changed & withheld to protect patient identity

 

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There’s a Stranger Who Loves Me!

There’s a Stranger Who Loves Me!

Ahhh, it has been awhile since I have had a good story to share. And now, I do. And also, I have the yeasty sweet aromas of baking bread coming from my oven (this is attempt number 3 of a beer bread recipe that I am trying to perfect before sharing it). Life sure is good.

I visited my assisted living home for the first time in more than a month yesterday. Two weeks before I leave on a journey to New York, I simply couldn’t leave without saying goodbye again, at least figuratively. But I put it off for a while, and there’s reason why (although misguided) that I was nervous.

It’s such a small, interconnected world. When one of my residents passed away recently, I heard through four different sources about it. Three friends and coworkers let me know via phone and in person, and a fourth coworker let me know yesterday. I was at the gym, powering away on the elliptical. Oblivious to all events around me, I was totally focused on the magazine in front of me – intently trying to decipher the tiny words from the vantage of my bouncing eyeballs. A disembodied voice said, “Hi Rachel!” I looked up, a little brain muddled. It was a med tech that I recognized from work. We chit-chatted. She let me know about Addie’s* passing, and then told me a funny story. Something like this: The med tech, we’ll call her Cassie, knew that I had given all of my residents hand-painted picture frames when I left as a small token of my love and appreciation for our time spent together. Clearly, I didn’t expect many of my residents to remember where these picture frames hailed from. But this story beat my expectations, hands down. Cassie observed the picture frame of one resident while she was passing medications. This resident has a funny memory – sometimes it’s fairly shoddy (like when she calls to go to the bathroom 10 times in an hour or asks you the same question 3 times, once a minute) but other times it’s great and she’s sharp at a tack. This was not one of those times. Cassie asked her, “This is pretty. Who gave you this nice picture frame?” Nelly* responded, “Oh, well, actually it’s actually interesting. I didn’t even know her. This nice young lady just gave it to me. I have no idea who she is.” Cassie smiled and with a little glint in her eyes followed up with, “Wow, that’s so nice. You know, everyone who meets you, loves you so much. Even strangers!” Nelly agreed with her. And then Cassie laughed and said, “No silly, Rachel gave it to you, don’t you remember?” Nelly thought about it and replied, “No, I don’t remember her. She must be new.”

I love that story. I wish Cassie hadn’t even told her that someone had given it to her that she should remember. I love that Nelly just agreed that a stranger must love her, and therefore she had given her a present. As simple as that. Why not? I wish I could give presents to strangers! I wish I could receive birthday gifts without worrying about whether I had remembered the gifter’s own birthday the previous year. Total enjoyment of a gift. But that’s a tangent. The ultimate message to me? Old people can teach young people so much. My Lifespan Psychology textbook claimed that the perception of old people as being wise was really just a stereotype and possibly a myth. I think that’s just baloney (although for the most part, that textbook rocked). But that part was false. Old people ARE wise. I learned a lot from them.

So, walking into the assisted living home, I was less fearful of not being remembered and just plain excited to be there and let memories and good feelings wash over me. My old supervisor, the assisted living coordinator, promised me that they would try to get a good turnout for social so I could lead it, just like old times. Who woulda’ thunk that I would miss mega-sized crossword puzzles and word games so darn much? After playing the same game at least 21 times, I certainly didn’t think so, but I was oh-so-wrong. I walked in and immediately the eyes of a few residents lit up.It was so obvious, I didn’t even have to pretend to see it! I wasn’t forgotten, and to be honest, it felt great. I don’t absolutely need this sort of recognition, but I sure do love it. I gave a million hugs and felt really overwhelmed with emotion. A huge lump in my throat that didn’t leave until…oh wait, I think it may still be there lingering…

I led the group in solving a crossword puzzle. Then we played another word game with the word SEREDIPITOUSLY (forming smaller words from the bigger word). I had boundless energy and it felt amazing to be there. I was able to convince one of my old residents to attend social that typically never attends. She said she would come because I made it a special occasion. She hugged me and told me she loved me. And then she pretty much spaced out and half-napped for the majority of social, but hey, at least she was out of her room! And every time  I looked her way, she blew me a kiss. Aww….

When social was over I went to visit my more independent resident, Marlene, who I used to have hydros with every Monday evening. She was lying on her bed when I knocked and entered. I announced and addressed myself, but it turned out to be totally unnecessary. She remembered me 100%. I sat next to her and held her hand and we talked about everything from which residents had passed away, to my moving preparations. We were gossiping just like we would do in the hyrdo room. It felt like I was visiting my grandma. I didn’t realize the depth and importance of these relationships really were until I came back. How lucky I was to meet these incredible people!

When I think about the passing of my special resident, Addie, I don’t feel devastated. Compared to when I lost my first resident, this feels like a completely different experience. While Addie may have deteriorated quickly, making it still somewhat shocking to everyone, it was her time to go. She had been fighting a blood clot for a long time, and apparently her memory and temperament had taken a sharp turn for the worse in the short month that I had been gone. I miss her. I wish I could have seen her again. I freeze for a moment when I think that I never get to look at her face again, or hear her voice. But letting go also feels natural. She lived a wonderful life. She told me herself how blessed she was in every way. I know that I aspire to live a life as full and satisfying as she did.

*Names changed for privacy

 

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Inaugural post

My inspiration to begin blogging actually began with the old folks. More specifically, it began with the death of one of my residents.

In a world this chaotic I try to remember the good things. I recently began working in Assisted Living. Initially intended purely as nursing experience, meant to fill my time and my wallet (ever-so-slightly), it has become the most dynamic, keep-me-on-my-toes  job experience that I can recall. As I accumulate a small stash of memorable moments, experiences and anecdotes, I feel compelled to not only record them, but to share them as well.  Some days are hard, like in the story I am about to share, but when I remember why I am there and who I am helping, it all feels so right.

Like eating lunch after a long hike...never tastes better

A few days ago, Lynn died. She had been my resident for as long as I had worked at Sunrise, three months in all. It is surprising to me that it could hurt so much after only knowing her for such a short span of time. But one thing I have learned from my time at Sunrise is that care giving is an intimate business.

I grew close to Lynn within days. Probably her most memorable trait is her ability to look at almost anything pessimistically. In a very endearing way. Her health, her dog’s health, the food at Sunrise, the mail that she receives, the tall pile of books that she has yet to read (though she reads nonstop), the plant that came in the mail that was clearly doomed to die: everything. Maybe it is because she was old that it seemed and sounded so cute. More than anything, she loved her dog, Maggie. An incredibly overweight black terrier, Maggie is sweet and always by Lynn’s side which makes an adorable impression when she sits beside Lynn while she is wearing one of her 7 pairs of terrier pajamas. Fairly independent, Lynn didn’t need my help for much. She had survived a rough bout of cancer and fought a battle to survive (even though she wasn’t sure that she wanted to) and recovered so fully that she could get around at 83 with only a 4-pronged cane.

I gave her a hydro every Sunday. I remember feeling so nervous to give my first hydro and I now know that I was lucky to have Lynn to guide me. She created an easy and pleasant experience. It soon became an hour where I could ignore the chatter in my walkie, and draw the steamy bath water instead. We both loved the bubbles. Just before she passed, one of her relatives had gifted her an economy size bottle of Sweet Pea bubble bath, knowing how often she used it. During the hydro I only washed Lynn’s back; she could do the rest. But my presence was essential to the process of the hydro because she talked the entire time. I wish I could include a transcript of one of our conversations but it mostly involved my nodding, shaking my head, and empathizing with things I didn’t always completely hear. I usually understood about 1 word in 3 since the rushing torrent of  bath water muffled her voice dramatically. At first I would ask her to repeat herself until I actually heard but then I realized that I was just interrupting her flow and what she really enjoyed was having someone to talk to. So I listened, soon realizing how much I enjoyed doing just that because even though it felt like doing nothing, it was truly doing something.

When she died I was initially distraught. It seemed to me that she was cheated out of valuable years of life. 83 may sound old but it is not in all people and Lynn still was young in many respects. Yet, I learned that when she first came to Sunrise, she told everyone that she was ready to die. She had just survived cancer and was coming to live in a place that she didn’t think of as home. The bulk of her unhappiness stemmed from the fact that she could no longer care for herself. By the time I came around, she had recovered sufficiently to do most things on her own, an incredible feat. Her strength was impressive and demonstrated that Lynn would not be happy watching her body grow weaker day by day. After her fall, a few days before her death, it became clear that she could not longer function so independently. Maybe this is when Lynn decided that it was the end. She died peacefully, without pain and without giving up her cherished independence.

*All names of all residents are changed*

 
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Posted by on January 27, 2010 in Dealing with Death, Healing Spoonful

 

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