by the numbers

A part of having a highly variable workload from day to day is that it becomes necessary for me to show my work. I have to keep statistics, in the form of a list of time definers. Checkmarks, quite literally, for exactly what I did as part of saving a life.

I always have a bit of a chuckle as I’m doing my stats. How are these numbers even calculated? How have they figured out that it takes 17 minutes to do a respiratory assessment, 8 minutes to change a cylinder, 18 minutes to insert an arterial line? There are many where I write down actual time spent, and it seems a cold kind of truth to me that at the end of the day, 45 minutes spent counselling a family about the impending death of their loved one gets aggregated with other staff members for my department over the month, and written in a tidy little box. #3740, service recipient support, a nice round number for a bureaucrat to sign off on. The funniest part is that I’ve done stats at other places where this kind of service wasn’t even something they had a time definer for. As far as the bureaucrats could see, emotional support didn’t exist.

It seems funny to me that I can distill a really fraught encounter down to numbers. A code on the floors, intubated, sent to ICU, set-up on the vent and handed off. It rounds up to around 4 hours of work, spread across a multitude of time definers. What isn’t in the stats is the looks I exchanged with the ICU nurse, the frustration at the physician who was content to sit on his hands, using my ass to hold open an elevator door, rearranging a barely-set-up-freshly-clean ICU room, and the heartbreak of prolonging the inevitable indefinitely. It doesn’t include the bone-weariness that comes with five flights of stairs times five or six trips up and down. It doesn’t include an entire team of people content to place their anxiety at not knowing what to do squarely on your shoulders, because now you’re here, and they don’t have to worry. But no pressure.

No pressure. I mean, I don’t stat mistakes as mistakes, they just get lumped in with an actual time definer. (#4420, arrest attendance.) It’s funny to me that things which are truly chaotic, which can truly not be distilled down to a series of single actions are lumped in together. The time definer for arrest attendance may as well be #4420: unmitigated chaos.

How does one stat “agonize over a decision”? How do you stat “sat in boss’s office venting”? It’s a rhetorical question — I could find a way to stat either one — but the point is, I can’t put a numeric representation on how hard I’ve worked when sometimes the hardest things I’ve done aren’t things with statistics attached to them.

The weight of their grief

We approach the humorless with humor; I think it’s the only way to cope. Sometimes there’s nothing to be done. Sometimes it’s sudden. Sometimes it’s a sudden insult but death doesn’t come suddenly. Then, their watch begins.

The rules about how many visitors to an ICU room go out the window. As many people as that room can fit, and outside visiting hours too. Sometimes we break other rules too, to allow children and the burning of smudges. The treatment decisions are guided by family, not the doctors anymore. The doctors have washed their hands.

The neurosurgeon has seen the CT scan (ah, technology) and too much time has passed since the bleeding begun. Your brain, in a box. Increase the pressure too much and it becomes toothpaste squeezed through the hole at the bottom of your skull. The phrase we use for this injury is “not compatible with life.” It’s less politically correct amongst ourselves. There’s just joking: “go towards the light;” when we have to shut off life support sometimes we dryly refer to it as being “the grim reaper.” In his room, though, it’s different. Their vigil makes it a sacred space.

Those who enter do so only out of necessity, with more respect than even the cemetery commands. We are quiet and as discreet as we can be, but somehow it still feels like a violation to go inside and do my job. Moreover, it’s difficult to watch their internal struggle: they have heard our words, they know there is no hope, but they reach for it anyway. They are grieving not only the death that hasn’t happened yet but the lost opportunities for his recovery. They’re grieving their lost hope at the same time as his loss, and all their losses before it as well.

They share these losses with me when I enter, while he actively dies; they’ve lived through this more than once. I try and keep my words to a minimum, aside from condolences and apologies for my intrusion. I am more proper than I usually am, even on a good day. I ask if they want the door closed. I enforce silence in myself. It isn’t my words that they want.

When I leave that room I feel like I walk slower, my breathing and my body heavier. I am moving in slow motion through water, the resistance of the air demanding more of my strength. I am brought back to where I was, when I last experienced such grief. I say a silent prayer for the fact that I had no vigil, in retrospect the finality of these things is a gift. I try to shake off the heaviness of it all, perhaps remarking at it to my manager or a coworker.

It is impossible to be wholly unaffected when they only currency in use is hope, and I have empty pockets. I can’t make this easier. All I can do is try to remember enough that it’s harder to forget, as I will eventually, as I always seem to. I’ll be reminded again of their grief soon enough, except at the same time it won’t be theirs, it will be someone new, and the grief will be fresh, and I will have my task, to be the cup-bearer of the good death.

on being called “a hero”

There’s a hazard to having a friend that’s a sociologist: she forces me to think about why things are the way they are. In this particular case, she’s turned me on to some interesting reading material that seems never to fail me for something to think about.

I am not unaccustomed to risky jobs, and the people who work in them. I work with paramedics, firefighters, prison guards,  the most commonly thought-of “life is on the line, he’s such a hero” sort of stuff. The book they’re talking about is right on the money: for the most part, they don’t think of themselves as anything other than ordinary people in control of an extraordinary situation. Any mishaps that laypeople consider to be risks inherent in the job (a cop getting shot, a firefighter dying in a fire) are not seen as particularly risky to the people engaging in them. I’ve spoken to cops about going into buildings armed against people who have gone totally butternuts and are armed to the teeth — the risks they talk about aren’t that they might get shot at — it’s the fact that butternuts in the shed over there isn’t predictable. They’re trained to predict what the rest of us think are unpredictable.

This, of course, thanks to the grooming of my friend the sociologist, makes me think of the times when I’ve been told I did something “heroic.”

Usually what happened is there was a very sick person in a very bad way, and I was part of a team of people who predicted the unpredictable and then responded. The response is to perform a number of different interventions in order to change the course of their illness or injury. I don’t think what I’m doing is heroic. I don’t think about how people are going to die if I screw up. I don’t feel the pressure, really. What I am is in control.

I can see the signs. I can measure and quantify how bad the situation is using specific parameters which allows me to manipulate those parameters with drugs or pressure or gas. I can control the oxygen or the respiratory rate. Sure, there’s a bit of a scramble trying to get to the point where you’re in control, when you’re on the move from prediction to execution, but you know what to do, so instead of being stressed about how it’s do or die time, you just stop thinking and do.

I find us RTs especially tend to think in “the worst thing that could happen is” sort of parameters. When others are afraid to extubate the patient we’re shrugging our shoulders going, “the worst thing that could happen is she/he gets reintubated.” To us, it’s no big deal. We’re trained to predict what the worst possible scenario could plausibly be, and then be prepared for it. We controlled the airway by putting in a tube, we did it once, we can do it again. If I can’t do it personally, there’s someone close by who can.

I remember a couple of these do-or-die situations happening to me and there was a lot of muscle memory in that st0p-thinking-just-do. A sick neonate thrashes a bit on the overhead warmer and self-extubates, and there’s no pediatrician within a shout’s reach? I’ve been trained for this. They taught me how to intubate precisely so that I could respond to this situation. Paralyzing myself with fear and waiting for the pediatrician to haul his ass into the room is an option, but the worst thing that could happen is I try and I miss. I’m also trained in what to do in that case: the patient would be no worse off for me missing. Besides the fact that I’m qualified and trained and skilled in intubation — the patient needs it right bloody now. If I waited for the pediatrician I’d feel like I had chosen the wrong line of work and would probably quit soon and go become an accountant. What I did was grab the (conveniently located) necessary equipment and make with the intubating. I know what has to be done, and I’m qualified to do it, so I do.

There are those times when despite your best efforts you lose control of the situation. Just like the firefighters do, I find we look for something to blame. Somebody screwed up, somebody didn’t notice the alarm, the monitor was malfunctioning, I gave up too soon and should have kept trying, we didn’t get there in time, they waited too long, and so on, and so on. I failed to predict the outcome. I failed to respond accordingly to the situation in the way in which I was trained. I look for how I could have gained control, therefore, I don’t really fear the loss of life that happens due to variables that are beyond my control.I learned very long ago as an RT that there’s some parts of the clinical situation that you just can’t change.

I’m scared of screwing up or missing something, I’m scared of missing the prediction or failing to respond. I’m also confident that the longer I spend in control and the more I refine my muscle memory, the more I lift the mental weights that allow me to consider more of the situation, the more that muscle memory allows me to automate simple tasks so I can spend more mental energy being observant to other signs, the less likely it will be that my simple screwup results in somebody’s death.

It’s happened in the past: I’ve failed to notice a sign that the patient was in cardiac arrest and then the patient died. That said, so did everyone else in the room fail to notice, and given how sick the patient was prior to going into cardiac arrest, the chances of us being successful even if we’d caught it were pretty slim anyway. No one person killed that patient. The culmination of many factors did, and some of them were beyond our control. Did I learn a hard lesson? Yes, I did. That one’s a notch on my proverbial shield that I’m not ever going to forget — and the next patient will benefit from it.

Therefore, by the same token, no one person involved in saving another’s life is “the hero.” The collective sum of our teamwork and brains and muscle memory and situational awareness and skills are the heroes. We just predicted the unpredictable. We executed our plan for how we were going to gain control. We gained control of the situation quickly and effectively, and then we held on to it. It holds no mystery to us.

We are comfortable.

the one who doesn’t cry

An unanticipated death; some professional embarrassment in there for good measure. Difficult, due to the fact that the one who died was a child, and a sweet one; that, and the fact that it was likely our fault in some way. (The reader is left to imagine the multitude of ways in which one person in a team of probably hundreds could be possibly at fault. Trust me. We’re all wondering the same thing.)

A debriefing; listening to the vignettes of the family and the child from the circle of chairs in the playroom. Some tall people on some tiny chairs, wilted from night shifts, or the ones fresh from days off, with perfectly applied makeup. They had a long time with this baby, they laid down in his bed and hugged him, patted his tummy to comfort him in that way they had seen his dad do, taking him to the playroom instead of starting his feeds … interviews with mom … years of past history … perhaps wondering why they hadn’t intervened earlier.

If there’s anything I’ve learned through a multitude of shitty situations, a multitude of debriefings, it’s this: no matter what is your fault, it’s over. Learn from it, for it’s the only possible positive outcome of an entirely crappy situation. Beating yourself up about how it could have been better if you had the power to go back in time and fix your fuckups is ultimately a failed exercise in self-loathing, and the self-loathing is an obstacle to learning: what’s happened has happened, so learn for next time, and prevent it from happening again.

A lot of that happened in that debriefing. From the strong and silent among us semi-blaming themselves, knowing what they’d do different, to the ones who have what seem like the easiest jobs in that they are only so tangentially involved, nearly everyone seemed upset nearly to the point of tears.

Except me.

It came to be my turn near the end, and I spoke of equipment malfunctions, problems with sensors, recalibrating X and Y, and of being pissed at myself (not blaming) because I had been so absorbed in the equipment that for that critical minute, I forgot to look at the patient. I wasn’t upset at the death of the kid, I was more pissed at myself that I had immediately jumped to the conclusion that the equipment was messing up on me.

To be fair to myself, the rest of the equipment hadn’t exactly been working as intended, and I’d had problems from the get-go. Things were quiet and stuff that should have been watched wasn’t, but it’s hard to not feel a bit like an uncaring goon when the people who weren’t even there for the arrest seem significantly more shaken up than I am.

It’s remarkable to me because, I think, this is not simply because of respiratory or because of the sheer amount of times I’ve been there when somebody’s died. I don’t think it’s that I’ve become desensitized or somehow heartless regarding the whole incident. Indeed, I was upset about it — I just did all my crying immediately afterwards and not in the debriefing. So it goes.

I think, however, that last paragraph is a bit reflective of how RTs are. We have the face we show to the rest of the team, and then there’s the things we say, the stuff we complain about, the opinions we share, the discussions of what bother us, the planning what to do next, that we all do behind the closed door of the respiratory department. The reason I never cry at organized debriefings, the ones headed by a social worker or someone with training for crying people, is because in order to keep doing what I do, I have to do it every day, by myself, behind a closed door. More often than not, I do it with other RTs. Sometimes, like the particular instance that struck me this time, I end up doing it at 2am with other health professionals, like the nurse who gave me a hug before I cleaned my vent and went home to bed.

I think it’s healthier that way; that I know how to debrief so that I can sleep, that I do it automatically and without needing hand-holding or prompting. I think it’s what means I can do my job without having a nervous breakdown.

Long ago I used to worry that not crying about these things meant I was getting callous and gritty, jaded and bitter, all those things that they usually say about surgeons and cops. I don’t worry about those things anymore: I think I have a better understanding of grief and attachment as a result of having done it more times than I can count. I can survive without losing compassion. Maybe some would call it tough, but I hate that word for this. It’s not some kind of machismo bullshit need to appear all stiff-upper-lippy. It’s just self-preservation. I can sleep without waking up screaming, I can go to work the next morning, and I can still have fun at work. I still love my job. No matter how shitty it gets, I plan to. For a long, long time.