An April Kind of Day

Her day had been a definite eight out of ten on the bad scale of long and taxing ones. To begin with, it started way too early; even earlier than her usual four am workday alarm. It had started with a phone call from the nursing home around three thirty from a familiar and panicked voice on the other end complaining that “the nurses aren’t giving me my medicines and they won’t give me any coffee.” As the seasoned nursing professor sat up in bed and listened to her mother, there was no being worked up in emotions, as she had run interference many times before. The difficult part was calming and appeasing her cherished, yet very stubborn parent. The staff would listen and follow any suggestions she would give them, not only because they knew her so well, but because she had been a clinical coach in college to many of them. Her mother would get a cup of coffee.Having put that small fire out, coffee didn’t sound like such a bad idea. Besides, her cat was insisting on being fed and the two dogs needed to go outside. She remembered she would need to dry her uniform to make sure it was fluffed out of any wrinkles. “Ah, another day,” she thought, as her morning routines began. By this time her mind had fast-forwarded to the plans she had for her students at the clinical facility where they were training.

There were eight students in her group and as the bell curve goes, so does the level of challenge for the instructor. Some were ahead of the expectations, so pushing harder with more difficult opportunities was vital to growth. Most of the students only needed minimal guidance in the care of their patients, and that would mean business as usual, but then there were the ones that required more time and attention to grasp concepts and for safety of the patients, Professor Ellie made this her priority.

In a healthcare facility, the morning transcends from a very still and quiet, dimly lit lull into a crescendo of call lights, demands, and swirls of frenzied non-emergent activities. Everyone is going someplace and has something “important” to do. There is competition to complete tasks between departments, and an unspoken frustration to obtain results to selfishly accomplish goals both promptly and safety. Having students in this morning environment only adds to the intensity. Nurse Ellie often had to exercise diplomatic assertiveness to advocate for her students place in the grand scheme of routines. Today was no different.

Assignments were made, reports given, lab values obtained, medications checked and rechecked, and critical thinking applied to each situation before meeting the patients with each student. Each patient had their own struggle, each their own way of dealing with those struggles. Nurse Ellie emphasized to her students the importance of getting out of their “world” and stepping into the world where the patient lived. “In doing this,” she said, “you will become extremely grateful and see how beautiful your own world truly is.”

As the morning faded into the afternoon, a sense of accomplishment ensued. Nurse Ellie made it her routine to walk the halls and check on each patient and the interaction between them and the students. She also checked to see if the room was clean and safe, the patient had their needs met, and to look for “learning opportunities.” In the nursing profession, there are no shortages of learning opportunities; skin color abnormalities, wounds, dressing changes, urine color and clarity, edema, breathing difficulties, and so on. When hands- on application chances to meet with what has been taught in theory, true education begins.

During this rounding, true education would be found. As physical therapists worked to get a morbidly obese, mid-aged man with multiple chronic health issues out of bed, he suddenly ceased to breathe, turned very red, and sank back into bed. A “code” was called immediately. Nurse Ellie and her student, Rob, were background in the room as staff nurses took charge. The crash cart was called for, but no board to place under the patient for effective chest compressions was with it. Nurse Ellie lifted the footboard out of the bed and handed it to the much younger nurses to use as a backboard. A valiant effort was then made as the student was witness to the charge nurse, who was on the bed pushing down into this man’s heart, hoping for it to bring life once again. It did not. After a code, there is a gross sense of unexplained stillness. The room is a mess with the strewn aftershock of death. And then enters sadness…for the patient, the family, and the sense of failure to save a life. There will be self evaluation and team evaluation. In Ellie’s case, there would be post conference time with her eight followers where debriefing occurs. She had danced this dance many times before, but she didn’t relish talking about death. The students did though, in their youthful exuberance and eagerness to assimilate this part of nursing into their portfolio. It was necessary for them, so she discussed professionalism and empathy with them. And she taught about post mortem care.

In the parking lot and safely in her own space, Ellie found solace behind the wheel of her beloved ten-year-old jeep. No noise, no intrusion, only silence and sunshine streaming in the windows on the driver’s side. The warmth of it was comforting and she smiled as she thought of her husband who had surprised her with the jeep she had always wanted a few years back. Even in the sunshine, she became aware of a migraine creeping over her left eye. “I’ll take a nap when I get home,” she thought. That usually stopped them from becoming worse.

Once home, she decided to call her mother before closing her eyes. She sounded better, still fussing that her little “white” pill wasn’t being given to her when she asked for it. Her mother’s voice became softer when Ellie told her she’d call the nurses and ask them to give her the med which calmed her nerves. “Besides, it would soon be dinner time at the facility and her friends would be at her table waiting for her,” Ellie reminded her mother and said, “I love you” to her before talking to the nurse about the pill. Now, finally she could sleep for a bit.

Ellie awoke thirty minutes later feeling groggy, yet rested. The pain to her head was now only dull, leaving room for the events of the day to echo in her head. Yes, it had been a very long, hard day. And then the phone rang. Shaking her head and smiling as she looked as she looked at the caller ID, she thought “what can the problem be with Mama now?” She teasingly spoke, “Hello again!” But it wasn’t Ellie’s mother this time. Taken aback temporarily, she heard the soft Indian- accented voice of the Director of Nursing at the facility where her mother lived. She said, “I have some bad news for you, I’m afraid.” Ellie thought her mother might have had another fall. It had first been her hip, then her ulna, then the tibia and fibula. The thoughts raced as did her heart, “What now? And why doesn’t she stay in her wheelchair?” It hadn’t been a fall, though. Ellie heard the words, “dining hall, coughing, slumped over, EMS.” “Maybe another hemorrhagic stroke,” thought Ellie.

On the way to the hospital, Ellie mentally detailed the information that the hospital would need; medical history, medications, power of attorney, and code status. She was the POA (power of attorney) and her mother, a full code. They had decided together that prolonging life might not be the best answer in all situations, but it would be at Ellie’s discretion. She rushed even faster to be at her mother’s side. She prayed that God would lead her into the right decisions if necessary.

Ellie noticed a few people in the waiting room as she approached the emergency room window, but she couldn’t tell you if they were male or female, young or old. She was in a fog it seemed. The young male nurse seemed to make her wait forever before sliding the glass open to acknowledge her presence. And she quickly told him, “My mother was just admitted to ER and I am her POA. I need to be with her.” Ellie was met with, “Sweetie, you’ll have to wait. They are working on her now.” To which she responded, “I am her POA and I am a nurse. I need to be with her NOW! And I am NOT your sweetie.” She wasted no time as she dialed information on her cell phone and asked for the hospital’s emergency room’s nursing director.

No sooner as Ellie spoke to the director, the doors opened and the director along with the emergency room physician presented themselves to Ellie. Ellie’s heart was pounding as she saw their faces and heard the words, “Intubated, running tests, will need CT.” So, translated, it meant stroke, bad stroke, very bad stroke. She braced herself and followed them to her mother’s room. Ellie was met by another young male nurse who appeared calm and confident, and spoke gently to her regarding “where they were” concerning her mother’s care. He treated her respectfully and included her in findings and decisions made thus far. Of course, her mother was already intubated, a decision made without Ellie. She wondered momentarily if making her a full code had been wise, then stopped her thoughts from any useless backtracking. She had, in fact, told many family members of patients to never doubt their decisions when she was charge nurse on a neuro floor and its ICU. “I have to be strong,” she told herself.

Ellie made her way to her mother. As she did, her trained eye surveyed the environment. She taught her students to always do this. She saw tubes for lab draws, IV paraphernalia, a foley catheter to collect urine, a blood pressure cuff on her arm, monitors, telemetry, a tube in her mouth, and a tube in her nose to drain the contents of her stomach. Ellie’s mind gathered the information and analyzed the data, but strangely, her heart was comforted when she saw the contents of the nasogastric suction. It was coffee with cream. It was a sight she had seen since she was a little girl. Her mother and all her mother’s family had been serious coffee drinkers. It was family around the table always with coffee and laughter.

As Ellie held onto her mother’s warm and unresponsive hand, with her eyes closed, and her breathing being controlled by the machine, Ellie could rest knowing that her mom was enjoying that cup of coffee with her friends in her last real moments of life.

The decision which led to her intubation allowed family time to visit and speak precious words to her. So, it was not a bad decision. The stroke had been a massive one, shifting the brain from one hemisphere to another. This meant that Ellie had to make yet another decision. And that was to have the tube removed. That was the hardest one for her, but one which she knew would grant her mother the freedom to leave this world and be off to a better one. It would occur the next morning. Ellie, her brother, and her husband had the night to share with their mother.

Taking someone off a ventilator is no easy or pretty event. There is that monitor, still on. As the seconds pass into minutes, the blood pressure goes down and down and the heart rate slowly diminishes until there is none. A flat line remains and a still body. Within that time, the mind and heart of each family member present struggles somewhere between hope that she will miraculously live and despair when they understand that she cannot and just won’t live and breathe again.

After it was all over, with her mother’s remaining personal items in tow, Ellie walked outside to the car with her husband at her side. She noticed that on such a sad, sad day as this, the earth had the audacity to be filled with pink buds and green grass and blue skies…while in Ellie’s heart of pain, it had to be winter. An ending, but after a long cleansing breath, what she inhaled was a spring, a new beginning. She was at peace for her mother because now she would be taken back to the land in Louisiana that had been her beginning and which she had so loved to be buried next to the family that waited for her. “Maybe she would soon be having a sweet cup of coffee with them in Heaven on this April kind of day,” she reconciled.