Reflections on my first year of nursing

If you had told me in July of 2019 all that I would face in my first year of nursing, I would never had accepted a position in the ICU. I would have definitely chosen school nursing, labor and delivery, or even a doctor's office. (Not that those don't have their own set of challenges, they definitely do! They just seem more akin to my personality, something I could more easily take on.)

(back in the days when I still wore make-up and did my hair for work - enjoy the selfie progression throughout my first year of nursing 😊) 

Instead, I chose to accept a position in the intensive care unit, because it seemed like a fantastic place to gain experience. It was only a 14 bed ICU - nothing like the St. Francis Medical Center in Peoria, Illinois, where most of my nursing school clinicals had been at.  SFMC had four 20+ bed ICUs. So, a 14 bed ICU in a small community hospital seemed very approachable. 

(my face after my first CODE BLUE - still a baby nurse on orientation) 

(Coffee and my blue light filtering glasses - trying to adjust to night shift 😴) 

However, the events of COVID-19 changed everything. Before the COVID crisis, we only had a few unstable or severely ill patients in the ICU at one time, and usually the nurse taking care of that patient would have a stable patient as their second patient. However, during the events surrounding the large influx of patients, there were times when I was caring for 3 patients that were all on max ventilator settings, paralyzed, proned, on vasopressors - in other words, unstable. 

There have been times when I have been absolutely terrified - in the room of a COVID patient for hours trying to help stabilize them, worried that my other patients are also crashing and I am not seeing it. Or that the IV bag holding their life-sustaining vasopressor medication is beeping in the pump and I'm not hearing it, putting their life at risk. When there is only one of me and three critically ill patients, I cannot be everywhere I need to be at once. And all the other nurses also have three critically ill patients and do not have time to help me watch my patients while I am stuck in a room for hours. Not to mention the nights we didn't have a STAT nurse or charge nurse. The stress has definitely taken a tool on me. 

We had a break from all this for a few weeks and it seemed like we were seeing the light at the end of the tunnel, but the second wave just started hitting the last few weeks. I have been fighting feelings of dread and fear as I head into work each night. 

And - to see the positive in all of this - I have learned SO much! My level of experience, confidence, and proficiency has totally skyrocketed in the last five months. Things that totally stressed me in just January and February of this year,  have become second nature. I have learned how to ask for help - to delegate. I have learned to see how to help other nurses without them having to ask me, because I totally know how it feels to be drowning in a heavy patient load. 

(my shoes worn during my first year of nursing - my "covid shoes". I finally threw them out about a month ago and invested in a new pair.) 

As I look back over my first year, there are a few patients that especially stand out.

Prior to COVID, two patient experiences stand out to me: 

- Thanksgiving week, I took care of one of my favorite patients I had ever met. She was an elderly women who had experienced a fainting episode at home while beginning her thanksgiving meal prep. She came into the emergency room and was admitted up to the ICU because she needed to have a procedure the following day - and would hopefully be able to go home in a day or two. I stood by her bedside that first night as she worried about not being home to welcome her children and grandchildren who were arriving for the holiday. Her husband was a pastor and such a kind man. We became fast friends and I lingered at her bedside enjoying the rare pleasure of such friendly (and awake!) company. It broke my heart the following night, the night before thanksgiving, when I returned to find that she had experienced a terrible complication to the relatively minor procedure and was going to have an extended hospital stay. I lingered at her bedside that second night - giving her as much pain medication as I safely could and listening to her express her heartbreak as she would miss getting to spend the holiday with all of her children and grandchildren. And that all the food would spoil - she was so disappointed that all her food and planning for thanksgiving dinner would go to waste. I will never forget how special she was. When her pain got worse and I couldn't safely give her any more medicine for a few more hours, I tried distracting her by telling her about my own thanksgiving woes - we were suppose to host thanksgiving that day and Isaac had texted me at 4am that our electricity was out and we had no way to cook the turkey! She laughed with me as I told her that all of my thanksgiving food may spoil as well :) Everytime I came into her room the rest of that night, she wanted to know the status of our electricity coming back on - she was just so sweet, we developed such a tender bond and I don't think I will ever forget her. 

As a side note - one of the other nurses answered her call light for me at one point in the night because I was with my other patient and she looked at her and said, "Where's my little girl?" 😂usually when my patients call me a "little girl" it is NOT a good thing, but from her, it was just the so endearing. :) 



- The second patient that is so firmly fixed in my memory was a man who had experienced a massive fatal heart attack. He was actively dying. He was on maximum ventilator settings. My job was to keep him alive through the night until his sons arrived, at which point they would remove the life-sustaining interventions and allow him to pass. His wife sat at his bedside all night, stroking his hair. I remember her saying "He always loved me to give him backrubs" and "I'm going to miss how much he loved me."  We had him on every medication we had available to sustain his blood pressure - and it was still dangerously low. We knew that if we gave him any pain medication it could bottom out his blood pressure and possibly hasten his death. As he drifted in and out of wakefulness at times his pain was so intense, and I would offer to his wife, "do you want me to give him something, even if it would lower his blood pressure further?" but she would shake her head "no." She wanted her boys to see their father one last time. She told me, "I would never have put him through this terrible night if my boys lived here." It was heartbreaking to watch her suffer beside him all night, waiting for her children who lived scattered over the United States to arrive. It made me mourn for people like her who have no children living by them. He made it through the end of my shift and when I left in the morning, his sons would be arriving within a few hours. I said good-bye to this husband and wife - knowing that within a few hours they would be saying good-bye to each other. I went home and crawled into bed beside my husband and held him tight, reminded again of the fragility and brevity of life. 

Once COVID began, sadly most of my patients run together in my mind as they all presented as such a similar clinical picture. However, one stands out. 

She was a nurse who had contracted COVID from a patient she had treated. She was young - about my same size. Very petite, with a limited previous health history. She had beautiful skin and hair. She was transferred to the ICU on my shift due to increasing respiratory support and I admitted her to our unit. She was terrified of needing to be intubated and go on the ventilator - something that she was at very high risk for. At one point in the early morning hours, I was finishing up drawing her morning lab work when she asked me, "Will you just hold my hand and stay with me a little while?" she asked me if I could read her the 23 Psalm. She had two children and a husband at home - I remember her saying, "I can't die. I need to live to go home to my family." After that time of seeking Jesus together, through her labored breathing, she spoke a blessing over my life. "Elise, you are a wonderful nurse. I pray that your life touches many lives throughout your career." Her words meant so much to me, as my patient, but more than that, as a nurse herself. 

  After that night, I was off for quite a few days. When I came back, she was intubated, paralyzed, and proned. My heart broke for her. I thought of her and prayed for her so much over the next few weeks - especially on my days off. But praise the Lord - she ended up being extubated and getting better. 

"Even though I walk through the valley of the shadow of death, I will fear no evil, for You are with me." (Psalm 23:4) 

This verse - walking through the shadow of death - perhaps best describes the ICU. 

Throughout this first year, I have learned so much about modern healthcare. Specifically, the ethical implications of our modernized equipment. Many of our patients are in the ICU because without the medical equipment and treatments we offer here - they would die. 

As a general rule, that is a wonderful thing that we have the equipment to save lives and restore a second chance! Especially for those we are young and who have the opportunity for a good quality of life if they can only survive this horrible disease or incident. 

However, I have seen the other side of these treatments. Over and over, I have seen patients in advanced age who have fought a long fight with cancer, end stage renal disease, chronic obstructive pulmonary disorder, or other chronic condition and their body is shutting down. But they or their families are not ready to face death, and so they come in and we sustain them for days to weeks on the ventilator, giving them nutrition through a feeding tube and artificially sustaining their blood pressure or heart rate through continuous IV medications. 

Usually, we end up "withdrawing care" after weeks of very little progress, and their life ends in a crowded ICU room, connected to machines, surrounded by a doctor, nurse, respiratory therapists, and whatever family can fit in the room. I have struggled with seeing this over and over - I wish people could see that death is so normal and does not have to resisted! I wish people could see the beauty of hospice - accepting that death is coming. With hospice, they can go home, and be surrounded by their family for their last days. They don't have a breathing tube down their throat - so they can talk and say "i love you" and "good-bye." They aren't connected to IVs and heart monitors and many other lines and machines - so their loved ones can hold them and lay beside them and stroke with hair in their last days.  They aren't so heavily sedated -  so they can speak with their loved ones and tell them of the glimpses of heaven they are experiencing. 

(I love this image put out by the Institute for the Study of Birth, Breath, and Death - contrasting dying in the ICU to dying at home.) 

Isaac has heard an ear full of this many times as I vent and debrief to him after situation after situation like this. Recently, I took care of a patient who stated in the emergency room to his family that he wanted hospice - he was elderly and he had a chronic condition he had fought for years that had left him severely malnourished and weak. He stated that did not want the major surgery that was required, he didn't want to be intubated, he didn't want his blood pressure to be artificially maintained. He stated all of that clearly to the ER doctor. But, his family came into the room and convinced him to "give it a fight."  

Three weeks later, his mental status has so deteriorated due to the delirium from the immense medications and being intubated for so long that he can no longer make eye contact or interact with anyone. He is thrashing around in pain even though I have him on two different continuous IV pain medications. He is even more malnourished than he was before - he looked more  like someone from a Holocaust concentration camp than anyone I have ever seen before. His skin is flaking off. He has a deep wound on this bottom. He is still needing the ventilator to keep his oxygen levels in a safe range. And his family is still "not ready" to let him go. After caring for him three nights in a row and watching him suffer constantly, I was steaming in anger. I wanted to knock some sense into his family. 

But, my husband, in his wisdom, shared the perspective with me that perhaps sometimes in the ICU, my job is to provide the patient or the families with an extension of grace. Maybe this extra time before his death provided that family with a reconciliation to God or each other that was needed. Maybe there are things going on that I do not know or cannot see. 

Working in the ICU this first year has certainly changed the way I see death. It has changed my vision for my own death and for the death of those I love. I want to die at home surrounded by my family - I want to sit at the bedside of those I love as they are dying. 

I do not want to fight death when my time comes. I want to welcome it and accept that it is natural in its time and not to be fought or feared. I want to find the gift in death.  Those last moment can be sacred and special. I do not want to miss that because I am fighting the very idea of death until the end. 

So, here's to year two of nursing in the ICU! Of continuing to walk through the valley of the shadow of death with my patients, and to learn to fear no evil - for HE is with me & HE is with them.