Thursday, March 01, 2007

Florence Nightingale's Winter update

This is part of an ongoing series of updates from the military hospital in the Green Zone of Baghdad. Our Florence Nightingale is halfway through her year long deployment. This is an intimate perspective of the war that we don't necessarily hear.

Hello Everyone!

It has been a long time since I last wrote and many of you have sent along messages checking in to make sure that I was okay. Thank you so much for caring. I am doing okay. I have been having trouble finding restful sleep and am usually very over tired. The months of January and February have been extremely busy as well. I have also come to a point where I am having a difficult time taking care of my patients and the demands of this deployment. You don't realize how much a deployment like this can take out of you until you are knee deep and trudging through the muck. I am almost at the half way point and looking forward to leave. I am hoping to become refreshed and refocused after leave so that I can finish this final sprint to deployment end.

I experienced many new things these last two months. First, I "coded" my first American patient. By "coded," I mean that I had to do CPR and give medications to try and save his life. It was a sad case. The patient was an American contractor and only 30 years old. He suffered from a massive heart attack and was transferred to us after he was found unresponsive on the scene. The pieces to the puzzle were a bit confusing to put together, but essentially this patient was admitted to my ICU and a fellow co worker and I were the nurses caring for him. He came up intubated/vented and we began our normal routine admission procedures. Soon enough things started to turn around. We noticed some EKG changes (electrical changes in the heart) and we got a 12 lead EKG to get a better picture of what was going on. He was having another heart attack. Our doc started the normal protocol for our heart attack/chest pain patients. I actually had many firsts on this day. I gave TKnase, a medication given to bust up clots. I have never given this medication before and there are so many precautions you want to be aware of. It is weight based and can cause massive bleeding because it is able to bust up any clots in your system as well as make your blood extremely slippery and prone to bleeding. We gave him the typical ACLS (Advanced Cardiac Life Support) medications as well during the times when his heart rate dropped and his blood pressure became nonexistent. He was a complex case. There were multiple doctors coming up to see him. Our cardiologist did an echo (ultrasound of the heart to evaluate the valves and blood flow through the heart as well as possibly identify the area causing the heart attack). We had our vascular doc come and evaluate his leg because an IO(bone) needle was placed and his leg below the needle was blue and pulseless. It was one thing after another. I was so glad that both Tammy and I were working on this patient. We had to start CPR eventually. We were doing chest compression's and I was giving medications through the available IV lines. He started bleeding from every place he had an IV and started to bruise all over his body from the clot busting medication I had given. We ended up doing 2 rounds of CPR and was not able to save him. We tried everything. It was so upsetting. We got him back after that first round but we couldn't getting him stabilized and he crashed again. It was a code type situation for like 4 hours. It only seemed like minutes while we were going through it though. You are so busy and focused on assessing the patient and giving meds and CPR and reevaluating for the next planned intervention that time flies by without you even blinking to notice.

I got to experience the American morgue for the first time that day. Usually we put the Iraqi deceased in a very large refrigerated container. It really looks just like a very large box like one of those storage pods but larger. It is also refrigerated and the patients are stacked 3 on each side. Nothing fancy just the basics. The American morgue however is just the opposite and rightly so. It is in a building and there are long "trays" that pull out where you place the person. They are 3 people across. There is no stacking here. It has an illuminated American flag framed in glass and a poem on the wall paying tribute to the sacrifices of the American soldier. I had to hold back the tears as I entered this room. I was amazed and stunned. I was touched that at least the American Heroes were placed into a room that held an air of the utmost respect. It was a humbling experience.

Unfortunately I was hoping that this would be the only American that I would have to put here. If only that were true because a few days later an American soldier was placed here. He was admitted to the ICU and had a lethal gun shot wound to the head. This posed a serious ethical dilemma on the floor for many of us. We were fortunate enough to have a visiting neurosurgeon at the CSH when this soldier came in. He made the determination that he was not going to operate on this man because he essentially would have no quality of life ever again. He would not be able to speak or comprehend words/speech or conduct any of his basic needs. He would be a vegetable as most people would call it. It was a most difficult decision for the doctor to make and then when the soldier arrived on the floor and I was assigned to him I was tortured by the principle of sitting back and easing this man, this Hero into death. I have taken care of many dying patients in my career, but not like this. This was completely new. I was here in Iraq and I was taking care of my brother in arms, but I wasn't taking care of him and fighting for his life. I was making his remaining moments more comfortable. I also had to face his unit. I had to tell them what had happened and the damage that was done. The doctor of course also explained everything to them and conferred with them to ensure that they agreed to his decision to withdraw care.

The doctor made this decision and his wife later agreed to the course of action that was taken. It posed many questions among the soldiers on the unit that day. There was discussion amongst the doctors and nurses to help understand why we weren't doing everything in our power to save this soldier. Being a medical professional can be a difficult place to be sometimes in a situation like this. For example I can understand the doctors point in that the soldier would have no quality of life and that he would be potentially in a coma for the rest of his living years. On the other hand I have seen the other side where heroic measures have been performed to save a soldiers life. I have taken care of the brain injured and wounded of this war back at Walter Reed. Yes, these soldiers lives are irreversibly changed forever and they can become burdensome to their family, but how do you decide which is the better outcome. Is it better to have your loved one die in combat or from wounds in combat or be saved to potentially die later from complications of injuries or live a life with more challenges than ever dreamed? It is a tough call to make. I still don't know how I feel about the whole situation.

My deputy chief of nursing came up to speak with my battle buddy and I about the situation and to get our thoughts. She said that she could see in our faces that the situation had hit a nerve and wanted to be assured that we were okay and coping with what had happened with this soldier. It was nice that someone in our chain of command took notice and allowed us to verbalize our feeling without repercussion.

As I mentioned before the months passed were very busy. We were lucky in not seeing many wounded soldiers but many host nation civilians, Iraqi Police and Iraqi Army. The bombings seem to have picked up and there are more and more everyday. I just don't understand how the people of this country think. I wonder if the people setting up these IEDs and VBIEDs or even the suicide bombers realize that they are killing their own people. It is just so sad that a child cannot play with their sibling in their back yard without fear of being blown up. A family or an individual cannot go to the market place without the potential threat staring them in the face. I cannot tell you the numbers of children that I have cared for and those cared for by the other ICU and the wards that are changed forever. Their subtle innocence is gone. They are wounded by not only their injuries but in their spirit. Yes, there is medical care here in this country but it is nothing like the United States. There are now children without parents and siblings from the effects of this war. There are people who will never be the same again because of their injuries. It just doesn't make any sense to me.
I have also been experiencing what has been termed compassion fatigue. The research team has been looking at the effects of seeing trauma everyday on the medical professional providing care to these individuals and if their empathy/simpathy is affected. The challenges that I face everyday includes trying to overcome communication and language barriers as well as cultural constraints. If there is a female patient, we need to try and pair her up with a female nurse. You need to ensure that she is covered and not exposed for people to see. This isn't as easy as it may sound when your staffing is limited. The other part is that some of these people act like you should be at their beckon call. It is in the culture that when a loved one is sick all their needs be tended to on a 24hr/7day a week basis. Now when you have only one patient that may be possible, but with the days we have had lately it is not an option. I had a patient banging on the side rails for my attention and demanding his pain medicine this instant. I knew this through the interpreter who I called to help me figure out what was wrong with my clearly agitated patient. Even after an explanation that pain medicine was given to him and that I cannot make his pain go away completely, he continued this behavior. You find yourself doing things that you would never do back home. I had the interpreter explain that his behavior was unacceptable and that if he continued he would not get anything form the nurse. I had her tell him that he would be given pain medicine at every opportunity that was available with in the restrictions of the doctors orders. I really just wanted to tell this man that he needed to stop acting like a child and chill out. Now I really couldn't say that since my Arabic can only get me so far. You tend to ignore the ones that treat you badly. You care for them, but when they are pinching/hitting you and disrespecting you at every moment the challenge to care for them is magnified.

I face situations like this often. It seems like the people here are never satisfied. You try to do the best for them with the best that you have and it's not enough. You start harboring some resentment. You think to yourself, "hey, I didn't shoot this guy or try to blow him; all I'm trying to do is take care of him and get him back home. Why is he behaving so badly toward me?"

You also find yourself comparing injuries. You look at the guy that has burns all over his body with limbs amputated and loose your compassion for the guy that had an open fracture of an extremity that was fixed surgically and screaming in pain. You think to yourself, "what are you complaining about it's just a broken arm and now it's fixed. Look at that guy over there with the burns and no legs." It is so difficult when you feel so under appreciated by those you care for. Granted nursing has always and probably will always be a thankless job. We are the worker bees. We tie all the loose ends together. We carry out the doctors orders and tell them when their patient isn't doing so well. We are by their side 24 hours a day, 7 day a week. We are there in their worst moments and sometimes their greatest triumphs. It is a job that I love to do, but can also be a trying job to continue to do.

It has been the months of new challenges and experiences. I'm sure there are many more to come. I am trying to find quiet moments to myself to reflect and find peace. I have learned so much in this deployment, not only about nursing but about myself. I am looking forward to my upcoming R&R and hope that it will help push me through the remaining months of my deployment.

I want to again thank you all for your continued support. I could not have made it this far without you. Please forgive me for not writing sooner and being lax with my communications these last two months. I have chosen extra moments of sleep and relaxation to help keep my mind in the game and focus on the mission I need to complete. I think of you more often than you know. I miss you all and look forward to seeing everyone soon.
Lots of love,


pogblog said...

Thank you so much for sharing so much complex detail and insight. (It is also important for you and yours that you do do this journaling in spite of exhaustion etc because the wrenching immediacy will fade when you get home and there needs to be a record.) Stay safe.

Carrie said...

Thank God for angels like you

Chancelucky said...

You know, these are pretty much the most direct reports I see from anyone stationed in Iraq. Real lives, real families....all of these individuals wanting to serve their country....and no accountability at the top.