Category: ER nursing

Corkscrew

When you become an ER nurse, you get yourself a front row seat to some of the toughest moments a human can experience.  Over time, you absorb a lot of other people’s trauma. For many of us, there is a fine line between accepting the randomness of things while still believing in the inherent good of the world vs. plunging headlong into fear and anxiety about lurking danger and beginning to see death around every corner. If you spend enough time seeing really messed up things, you may begin to think of the universe as some kind of demented Rube Goldberg contraption where each swinging lever meets up at the exact right time with a rolling ball, causing calamity. In my work, I see how all it takes is a single second of distraction, a missed phone call, a misperception, a momentary lapse of judgement that cascades into something terrible. Nothing will ever be the same again. Everything from that point forward will be demarked into “Before” and “After.”

I naively entered the gaping maw of Emergency and Combat medicine with a desire to help. I threw myself into the role of healer, of “fixer”. Eventually I found myself dependent on the rush, then over time, when the unfixable things started coming fast and furious, I internalized all of that cumulative damage.  Instead of looking for ways to unpack and unload, I just absorbed it with a sense of “this is just who I am now”. I think I saw it as the price  to pay for the privilege of getting to save lives, and on some days, being the one there in the sacred moment of death. It is a heavy burden and a calling. For me, my inability to unload all of the absorbed traumas devolved into a sense of self-loathing and punishment for not being able to handle it all better. I came to see myself as the unreliable narrator of my own life. I accepted the idea that once damaged, I would stay that way. The solution was to just find a way to numb it all since I felt myself being constantly, internally divided into Before and After.  I developed a lot of hyper-vigilance, trying to control every little detail as if I could ward off the horrors I saw, make it not be MY family, my little world, my patient. I thought that somehow I could keep it from happening by just trying to control, to manage everything, to avoid the swinging levers and when I couldn’t, when I “failed”, then I would drink to numb myself. Addiction blinds us to many things, especially our true selves. I was operating under the false idea that my self was irrevocably broken because I just wasn’t strong enough. And every time my hands started shaking I just saw it as proof.

In year two of sobriety, I took a deep breath, and decided it was time to look into the abyss of my PTSD. I started going to therapy, looking for tools to help me move past some of the things that haunt me, learning how to practice saying “I am just feeling triggered right now. I am safe. This isn’t happening right now.” At first, I kept getting stuck in wishing that I hadn’t chosen the life I had. I wanted to go back and re-write the past. I thought about the roads not taken, my own choices to wander down the tough paths I have.  I wonder what might have been had I not traveled down the road of trauma and addiction.  If I had accepted myself, my identity as a lover of solitude and quiet. If I had chosen the life of a writer or professor, instead of running headlong into adrenaline and excess because I wanted to appear strong, and feared a small, quiet life.  The irony is that now, coming out the other side, that is what I long for the most.

Alcohol was originally a coping mechanism to turn down the noise, to slow my racing brain, temper my tendency to fly too high and then crash.  And it worked for a long, long time. Until it didn’t. I knew at about 25 or 26 years of age when I was in the Army that my drinking wasn’t normal.  I was the classic apex predator of MORE. I had no off switch once I started. I would lead the charge at the bar, was always there when the lights came on. I rolled back into our barracks at 0200 only to be in PT formation at 0500 with my fellow soldiers, the cloud of alcohol fumes no doubt streaming behind us as we ran in darkness singing loud cadences. Most of us were probably not clinically sober when we started our duty days. I had a few painful consequences to my drinking, but they weren’t bad enough to make me really stop. It also wasn’t out of the ordinary in that warrior culture to be a heavy drinker…I believe the military, with it’s focus on being tough and strong and the realities of war can engender addiction in those of us who may be predisposed.  We are told to be cast iron, the last line of defense. We aren’t supposed to be afraid. Feelings make you vulnerable and get you killed, so you just stuff them down. So many sacrifice their mental health in order to never appear weak. I certainly did.  My second profession has many of the same expectations or subliminal messages: Keep it together, get the job done, don’t break down, don’t fail your patient by letting your emotions override your skill. Don’t let anyone know how scared you are.

Many of us who have lost years to addiction and dysfunctional patterns of survival wish we could go back and do things over. We can get stuck feeling the need to constantly make amends for errors of judgment, for our very “lostness”. In my first few months of sobriety, I had an overwhelming urgency to make things count, to grow, to head a thousand miles an hour down the road in the opposite direction.

At the beginning of this journey, I applied a lot of force to my recovery in typical impatient, “I’ve gotta work this out, heal this, fix this NOW” black and white thinking.  In therapy, I started digging out all of the things I had been stuffing down and tried to rush through them. I was just going to be the best patient ever, and I would have this all figured out in no time.  I would do all the homework I was given and then press even more, and if I failed, then I would just charge back into it. It was the same extremes I had been swinging between for as long as I can remember.

And then, six months ago, with 950 odd days of sobriety, I drank for three consecutive nights. I didn’t drink to excess. I applauded myself for making my drinks in a glass, with ice and appropriate mixers like a “normal” person.  I didn’t guzzle straight out of the bottle. I didn’t pour another and honestly, I sat for a moment enjoying the pleasant buzz, the temporary muting of my inner noise. I didn’t call or text anyone, which is what I should have done when I found the bottle hidden. I didn’t dump it out, just quietly planned to drink it once the kids were in bed.  I just wanted to stop feeling broken and full of holes. I wanted to numb and to change my state. And it did. For a bit. With almost the first sip, my old worn neural pathways kicked in. I felt that familiar old sense of well-being, the relaxation of my tense muscles, the smoothing out of my rumply thoughts and then I slept.  Dreamless, blissful oblivious sleep that had been eluding me for months as I was excavating old thought patterns and working through old traumas. I didn’t plunge headlong back into drinking in the morning or blacking out. I just woke up on day 4 and decided “no more.”

Reliving that feeling of looking at myself in the mirror with a sort of film over my eyes–everything muted, turned down low and muffled made me realize something. I don’t want that feeling anymore, nor do I need it. I like the razor sharp clarity, the quickness of mind that comes with being 100% present and unaltered. Over those 950 days sober had become my new default. I knew that deep in my bones.

The first few weeks after my slip were a jumble of thoughts, regrets, trying to understand how I got to that place. The waves of worthlessness that had prompted me to pick up the glass only grew taller in the weeks after, and the darkness that lies under my surface became enveloping. I know deep down that alcohol doesn’t mix well with my mental health. But I drank. I felt like a failure, like someone was going to pull up to my house with flashing lights and revoke my “sober blogger” card.

I told my closest friends and sober sisters, then sat down and did a long inventory. I made a pretty long list of warning signs that had been brewing.  I had some back to back really bad shifts at work that were very reminiscent of my last few months of drinking when I was at my breaking point. I felt constantly triggered. My insides were shaking, my heart and thoughts were racing and I was distracted, disorganized and doubling down on being hard on myself.  I was also struggling with deeply painful changes in some important relationships. At the same time, juggling three kids and their school and sports schedules on my own had reduced my self care to basically zero.  When I wrote it down in black and white, it was clear to see how I had been escalating for weeks before I ever picked up the drink.

I’ve grown a lot since I started writing this post. I had actually written the first part before my slip. I’ve done a lot of hard work and soul searching since then, and a lot of changes have resulted from what I saw as a failure.  But with time, I see it as a perfect alignment of that swinging lever that bumped into the ball and caused a cascade reaction.  Except it wasn’t a calamity.  It was a catalyst.

In the half year since, I’ve continued going to therapy, and I’ve expanded my tool box considerably. I’ve learned new coping mechanisms. I still have some really bad days but I’m allowing myself to take my time, to float in things. I’ve started taking medication for what has been a lifelong struggle with undiagnosed type 2 bipolar/ADHD. It’s been hard to admit I needed more help, but it became clear that if I am going to keep doing the work I need to do to that it was time to try meds. I had tried literally everything else. Including nearly drinking myself to death.  My therapist told me a few weeks ago that my “kinetic energy” has toned down a lot. I think that was a nice way of saying I’m no longer so hypomanic. But it feels good to be at peace with not needing the extremes. I don’t feel less like myself. I actually feel like I finally have a chance to understand who that is, with the constant head noise turned down a little. It’s definitely a work in progress. Some days are rough. I still want to rush, to get to wherever I think I should be immediately.  And then other days I’m a river of zen. (So maybe my extremes aren’t quite gone).  But there are more days where I can hold loosely and work through the anxiety, the days of the mean reds, knowing that it will pass.  That I’m ok.

I think perhaps the hardest part to accept has been the loss of my vision of myself as a perfect rocket launching into sobriety. A new ghost ship sailed away as I waved from the shore: that story line wasn’t one that I could claim, perhaps wasn’t meant for me. I will never know. But looking back, I’m glad it happened. It cemented for me that I want to be sober more than I want to be safe. I want it more than anything.

“I’ll never know, and neither will you, of the life you don’t choose.  We’ll only know that whatever that sister life was, it was important and beautiful and not ours.  It was the ghost ship that didn’t carry us. There’s nothing to do but salute it from the shore.” -Cheryl Strayed

 

Scars and mirrors

Her twisted face is mere inches from mine and my ears are ringing from how loud she is screaming inside this small room. Her shrieks are echoing out into the rest of the Emergency Department which has gone eerily silent.  Black eye makeup streaks down her cheeks to mingle with tears and sweat. She is screaming obscenities and commanding me to let her go. The smell of alcohol, dirt and sweat stings my eyes. In the next breath she is screaming, begging ,”please just kill me. Just kill me”. I am speaking quietly, calmly down near her ears where I hope she can hear me. ” I hear you. You need to try to calm down. We don’t want to hurt you. We are trying to help you.”  But she is beyond hearing.  She is spitting, kicking and trying to bite my hand that is holding her hand down onto the bed as our staff struggle to put on the locked wrist and ankle restraints without being kicked.  I look down at her slender wrist, see the thin blue veins which are lumpy and scarred from shooting up and then my eyes travel further up to a network of silvery and red horizontal lines, scars from cutting. There are hundreds of them. A small, homemade broken heart tattoo hides on her inner arm. Her eyes are pleading, enraged, defiant and sad all at the same time.

Later, when the medications I have given her have taken effect and she is lying quietly in the darkened room with a warm blanket she whispers to me, “You just don’t know.  I have to get out of here. I got kids.”  She is barely out of childhood herself, though she looks much older. I imagine if that was one of my children, with a scarred body and shattered mind, strapped to a gurney in four point restraints, strung out and off their meds and so drug addled and drunk they want to die. And I know that I’ve seen the look in her eyes in my own mirror after I’ve been drinking.

**********
The gurney rolls up the back ER ramp, surrounded by EMS workers in blue uniforms. On the stretcher is a man a greyish white color that any nurse recognizes immediately as a bad omen.  He looks frail, his skin translucent and clammy. His eyes meet mine with an animal desperation as he vomits cascades of bright red blood into a cheap plastic bucket. I can read what he is asking me without words: “Am I going to die?” I speak to him calmly, recognize the smell of vodka mixed with blood which is a smell that stays in your nostrils long after you’ve gone home and showered in scalding water. He vomits again, a seemingly endless gush; a startling crimson sea. I start his IV, type and cross for blood transfusion, start hanging IV boluses as I watch his pressure dropping precipitously. I send a tech on the run down to the blood bank.  As the monitors start alarming with a startling cacophony, he grips my wrist with his grey cold fingers and he says “is this it?” And I say, “I don’t know. We are going to do everything we can.” He is whisked off to the OR to fix his ruptured varices.. veins in his throat that are torturously dilated after years of chronic alcohol use. I survey the wreckage in the room he has vacated.. the trash on the floor, the suction equipment, the empty bags of transfused blood, the air still heavy with fear and vodka and the unmistakable metallic smell of blood. He is a year older than me.

***********
The car screeches up onto the ramp in front of the ER, the doors fling open and a body is tossed out onto the sidewalk which is more like a river since it is pouring rain. I run down with my radio, immediately notice the blue color of the boy lying on the ground, call for help and start CPR. My team arrives, we load and go with me sitting on top of the gurney still doing compressions as we roll through the waiting room, full of wide -eyed back pain sufferers, toddlers needing stitches and miserable flu patients, back through the pneumatic doors to one of resuscitation bays. Everyone does their jobs, we administer narcan and suddenly the dead boy is back. His eyes open, he takes a gasping breath and immediately starts yelling and cussing at me, calling me the cunt who ruined his high. I remind him that he was dead five minutes ago and that we just saved his life. The doc and I calmly explain the need to monitor him for a while in the ER since the heroin he took could cause respiratory depression and death when the meds we gave him wear off.  He tells us to go fuck ourselves, rips the heart monitor off, flings it at me, cusses a few more people out and storms out of the ER, out onto the street as thunder rumbles.

Forty five minutes later we get a call on the EMS radio that they have a priority one overdose en route to us with a 5 minute ETA. They roll through with an intubated patient,  CPR in progress. I see curly wet hair, then peer at his face and recognize the boy who had just left an hour ago. EMS said unknown down time. We work the code for a long time, check with ultrasound for cardiac activity, and finally he’s pronounced dead, exactly 2 hours and 24 minutes after I first took his pulse out on a sidewalk in bucketing rain.

***********
I hear a familiar voice from behind the curtain of room 3. I know who it is, even before I go in the room to go assess my latest patient.  He smiles at me as I enter and I check him out. Double amputee, Vietnam vet in the bed, wild grey hair he has covered with an old bandana. He has a raspy cigarette voice and a deep laugh that makes the fluid wave in his distended belly ripple. He is dayglow yellow and smiles with perfect white teeth in his wasted face. His spindly arms are cradling his massively distended belly and he jokes “We’ve gotta stop meeting like this, Wen.”  He goes on to brag to me that last week, when I was off work he came in and they tapped him for 4 liters of fluid. His personal record. His stories are great, his attitude is amazing. Yet his body is failing, his liver is shot and most likely I won’t be seeing him much longer. But there is something about him. He talks about the joy he found in sobriety. A joy that sustains him, even when he is obviously dying. I look at him and I think how can he be joking and laughing when he’s in so much pain. How can he be telling others about his peace and serenity now that’s he’s finally sober?

In my gut, deep down, under my neat blue scrubs and name badge that says “RN” on it, under my professionalism there was a voice that I tried to ignore. A voice that was warning me. A quiet voice drowned out by the raging need I felt after shifts like those when I would pull into my driveway in the wee hours. I’d come up the steps with throbbing feet and reach for that glass, hear the glug glug glug of wine that I was gulping before I even had my coat off.  When I was still a young, unjaded nurse, I used to come home and pray and go to bed…. then years later I would tiptoe into my sleeping babies’ rooms and kiss their sweet innocent cheeks and breathe a prayer of thanks over them, then lie awake until the call of the alcohol drew me downstairs for a glass or two. But in that last year, I couldn’t face their innocence knowing that I was bringing a monster inside me into their rooms. I didn’t want to breathe my poison on them.  I felt tainted by what I had seen.. and utterly convinced of what I knew was coming for me. I would sit in my dark kitchen and drink until the faces faded. But they still haunted me the next day when I would wake with a splitting head, queasy stomach and a soul that felt shredded and hollowed out.

***********
My last shift before my last drink.

EMS rolls in with another intubated patient. Eyes fixed and dilated, she’s posturing on the gurney, a sure sign of neurological damage. I’m the primary nurse. Rest of the team shows up to help. EMS tells me that she was found unresponsive by her family. Suspected alcohol overdose. Respiratory arrives and we put her on the ventilator and we start multiple IVs. She starts seizing and I yell for meds. Someone brings them and I am hanging them as her family enters the room. 16 year old son acts as spokesman and her two younger daughters, age 10 and 5 hang back with fear in their huge eyes. One of the nurses goes over and speaks to them quietly, assuring them. I speak to her son who tells me that she had been in recovery for alcohol for a year, started dating a new guy who he said was bad news. She decided last night to have “just one more” which turned into him finding her slumped on the floor of the kitchen when he woke up in the morning at 10 am. He wasn’t sure when she stopped drinking or how long she had been lying there.
I start focusing on titrating drips as her blood pressure is dropping and she’s continuing to have intermittent seizures. I listening to the rhythmic hiss and whoosh of the ventilator breathing for her. Her jaw is slack, her eyes rolling. Her two little girls are crying quietly at her bedside and kiss her arm and hand.  The son takes them out to the waiting room to meet their aunt who has come to take them. I stop focusing on numbers and the medicine for a minute and really look at her. Notice that her necklace is digging into her neck around the ties that are holding her breathing tube in place. I can’t loosen it so cut it off and place it in a bag with the clothes we cut off. I wonder what the story is behind it… an angel with a single wing.

Boyfriend arrives, staggering and slurring, yelling at her to wake up and pulling on her tubes and lines. I call security and we all try to calm him down. His eyes are blood red, his hair is wild and nothing we are saying is registering. He keeps grabbing her and crying he’s sorry. He turns his eyes to me and towers over me saying ” the paramedics told me she was fine. Why did you do to her? Why aren’t you helping her.” His voice gets louder and he comes closer, grabbing both my arms. I grab his hands and twist away as security steps in and end up dragging him out of the ER.  Her son appears a few minutes later and tells me he called the cops to have the boyfriend arrested because he tried to assault him in the waiting room. I ask him if he’s ok and he says in a shaky, shuddery voice, “yeah. We’ve been through this a lot. I thought she was finally better. I can’t believe this is happening. She just kept saying she just wanted one more and then she’d be done for good.”

A few hours later, I’ve taken her to CT and xray and we’ve discovered that she had aspirated (vomited while unconscious and breathed it into her lungs), had a massive hemorrhagic stroke and most likely an anoxic brain injury. She will probably never wake up. I’m reading the CT results on the computer I’ve rolled up next to her bed and I look at her. Freckles across her nose, red hair, slender. A few years older than me. She looks like me.  I have a premonition and the hair is standing up on the back of my neck. I shake it off.  I give report to the nurse taking my assignment. I turn in my radio, grab my bag, walk out of the ER and drive home feeling that need. The need.

At home, it’s 0300 when I get in the door. I’m shaking. I can’t stop thinking. I drink. And I drink some more. As if I can just wipe that memory out of my mind, deny the premonition I felt.  The irony that I was making it come true was lost on me as I just slammed shot after shot.

I stumbled to bed, woke with my alarm, had a rough morning getting the kids to the bus. Fight with my son who was melting down about the seams in his sock, sending him off to school in tears instead of with a hug and less annoying socks.. still seeing her face when I shut my eyes. More drinking. A whole bottle of whiskey. Then darkness. Blearily waking to realize I forgot to get my preschooler off the bus. Squinting with one eye to see to drive when the road looked like four roads. Entering the school office, realizing I was slurring terribly. Bursting into tears and telling some unintelligible story about having the flu and oversleeping my alarm. Alarmed faces of the office ladies. Maybe the real truth was too hard to believe. I was almost falling down drunk at noon and about to drive my five year old home. I have no idea why they let me take her. Another squinty eyed drive up the road. Home. Making a peanut butter and jelly sandwich, pretending to be the competent mom who gives her kid lunch after a busy day learning her ABCS. Except I dumped a jar of olives instead of jelly onto her bread. Started over. Opened a second bottle of whiskey. A few more shots since the shame was trying to creep in past my “don’t care, nothing can touch me” alcohol fueled bravado.  I remember giving my girl a sandwich and some fruit and then stumbling upstairs to my room and that was it for the next 12 hours.

I remember horrible blips and snapshots of that night. I somehow called my husband in my blackout and told him to come home. I remember him trying to pull me out of the shower and my voice that sounded like someone else’s’ just crying over and over that I wanted to die. Telling him I’m an alcoholic. I want to die. All those fearsome truths that I’d been skirting around for years. The truth was out. The curtain was whipped back like in Oz and this was the new reality. Around midnight, I sat up in bed, finally able to steady my spinning mind to ask about my kids who I was assured were safe. Looked down at my legs and saw that my kneecap was completely dislocated. I felt nothing. Not a thing. Absolute numbness. Stood up and it popped back in, hobbled to the bathroom, squinting in the light to see the entire right side of my face covered in bruises, my lip split and swollen, my tooth missing, my entire body covered in bruises and aching from falling. I have no idea how I busted my face. Limped back to bed, pulled my covers over my shaking shoulders, feeling ice in the pit of my stomach. And I sat there in the dark and realized that I had two choices: I could ignore it. Chalk it up to a bad shift, a rough week, just a one time mistake. Yes, I’d had blackouts and hurt myself before but never that bad. I could cut back or try moderating again. Or, I could absolutely face the fact that I was going to die if I continued this way. I could choose to surrender to the idea that I simply can never, ever drink again. I could have killed my daughter or myself or someone else. The school could (and should) have called the cops. I could have fractured my skull falling with that much force, could have aspirated and been just like my patient, leaving my three kids crying and never understanding why I left them.

I chose the second. And every day I wake up and choose the second.

And I see these patients with different eyes now. I don’t fear them anymore, being terrified to see myself in them, wanting to deny the similarities.  Now I see the commonalities. I feel compassion.  I am able to quietly share, ask questions now that I never would have before. Because I KNOW them. I am them. And they can make that second choice too.

So, I’m like my dayglow yellow man now. I have hope and joy. I am utterly grateful that I was given the chance to walk away, though limping and looking like a hillbilly with one front tooth for a few days. I still have a lot of challenges, a lot of scars. But I have gratitude too. Oceans of gratitude instead of oceans of shame and despair.

Now when I look in the mirror, I can see the lines on my face, the remnants of pain. But I also see a twinkle in my eye.

And there but for the grace of God go I.

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