A Final Deployment
I regret I never served my country, but war, ever insidious, plays out on many fronts.
Walking into the ICU, I noticed frenetic activity in one room. It always felt lonely to be assigned a patient there, because the room sat at the end of the hall, near the supply and dirty utility rooms. I lost count of the number of patients who died there, but it was enough to give the room a reputation for bad outcomes. When I read the assignment board, I groaned. My name filled the box by the dreaded room 634. I thought about the number of steps required to the med room, the break room with the coffee pot, the bathroom, and the infamous room at the end of the hall. My feet already hurt.
"I call him The Soldier". Laurel, the night nurse, began her report while rushing from task to task. She excused herself to draw blood, place orders, or talk to a young man in scrubs sitting at a computer. "That's Connor, the on-site transplant coordinator." If auras were visible, hers would have been a jagged halo of neon oranges and pinks. She thrummed with energy. I needed some space, armor for protection from her emotions. Her discomfort made its own sound and drowned out her words until she said: "He was pronounced dead last night at 8 p.m."
It was 7 a.m.
"So, what are we doing?" Peering over the nurses' station into the room, I counted the IV pumps and other equipment tethered to a body made ghostly by a sheet, a sheet more pale than white, thanks to industrial-strength bleach and super-sized wash machines.
The Soldier served in Iraq and returned home with debilitating PTSD. Before his deployment, he completed an Advance Directive and expressed his wish to donate his organs if anything happened to him. When young, no one really believes they're going to die. Why not?
A lethal combination of drugs and alcohol delivered him to our ICU, adding another casualty to a year with a record number of suicides in the military. After several days of life support and continuous neurological evaluation, The Soldier met the criteria for brain death. The procuring of organs began.
I stepped softly into the room. I saw, cloistered beneath a sheet, a lean, wiry body sheltered by the penumbra of fluorescence. It did not move. "What am I to do with you?" Shaken by my quandary, I didn't know to whom the "you" referred. But The Soldier was no longer an it. He required a cascade of care as intense and complex as any provided to a living, cognitive human being. The challenge stemmed from my own complex system of ethics and emotions. I possessed the skill for the required tasks; the spin of my moral compass created the uncertainty. In the new era of corporate medicine, I weighed costs, risks, benefits, and outcomes. I knew all the PC verbiage of the Rights of Patients, the Pain Scale, and patient satisfaction scores. Nothing applied to The Soldier.
Laurel provided the list of lab tests to be done every four to six hours, parameters for the vital signs and urine output, and progress of "the arrangements". I heard nothing about The Soldier, the person who once inhabited the body.
"We don't have to chart anything." Laurel reassured.
Not chart anything. Not bother commenting about a man who served our country, who was a son, a brother, an uncle. Not take care of his beard, his back, the cracks in his lips caused by the tube in his mouth. I wanted to shake her. Charting was my last concern.
"Go home. I've got this." I needed room to breathe.
I am caring for a dead man.
The Soldier didn't look dead. I summoned my energy and closed myself off from the rest of the unit. The room became a private cave, the body in the bed the focus of my attention. An unseen force stopped me from touching him. With living patients, I followed a specific routine. Pathways etched in my brain commanded me to perform them automatically. But this was different. I didn't know where to begin. I stepped towards The Soldier. A weight settled into my shoulders and I cowered, hunkering down to absorb an invisible blow.
Should I introduce myself? My conscience dictated that at the very least, I had to tell him who I was. "My name is 'Cindi' and I'm going to be your nurse today." I silently practiced this introduction before I leaned in close and whispered into one ear. When I said it out loud, I personalized it, calling him by his given name. It sounded smarmy, the worst adjective I could ever use. I managed a gentle tone; a susurrus of sound flowed from my mouth. In the privacy of the moment, I studied his face for the tiniest muscle twitch. Nothing.
I asked about pain. Maybe there had been a mistake and if I asked the right question, I would get an answer. Delusions of grandeur, of making a difference, of being the one who changes everything. "On a scale of one to ten how would you rate your pain?" What I really wanted to know was: "Does it hurt to be dead?" Shame on me.
Usually with unresponsive patients, I applied pressure to the nail beds, a sure way to elicit a response. I placed my fingers in his hand. "Can you squeeze my fingers?" I knew this wasn't necessary, but it felt more right than wrong. More human. More humane.
I found myself discussing the plan of care. "I'm going to make you as comfortable as possible while we do all the things necessary to get you better and get you home." That wasn't right. An inner debate began. Could I really say: "I'm going to do all I can to maintain your organs so they can be matched and placed with the greatest number of recipients." I stuck with the first statement, but omitted the lie about getting him home.
I noticed a gush of colorless urine draining into the bag hooked on the frame of the bed, a sign of the body's response to changes in intracranial pressure. From report, I knew this happened twice during the night and had the potential to create organ-damaging imbalances. But there was no real doctor to call and I foundered, uncomfortable with the responsibility before me.
Connor slipped into the room behind me. I sensed a deliberate restraint as if he were testing me to see if I knew what I was doing.
"Diabetes insipidus," I said. I knew what drug to give but didn't have an order to allow me to. Not within my scope of practice, I reminded myself.
"Give a little 'bump' of Vasopressin. I'll write all the orders. Let's get a set of labs as well." In his role Connor not only wrote orders, he maintained a network of contacts identifying need, location, urgency, and coordination of personnel in relation to any potential organ for transplant. He conducted a macabre orchestra.
I administered the Vasopressin. The urine output slowed. The urine changed from colorless to dark yellow. The blood pressure hovered within a safe parameter.
Crisis averted. Whoever had been given a "heads up" that an organ might be available could start packing for the journey to the hospital.
In the short time I'd spent with him, I began to see The Soldier as a treasure to be shared, a conduit for someone else's survival, not a territory to be divided. I observed a slender man. Not an ounce of fat. Muscled. He needed a shave. At least two days' growth of beard grew around the device securing the endotracheal tube in his mouth. His hair, clumped and oily, covered his head in a stringy mess. Using the draw sheet, I repositioned him single-handedly. It usually took two people to turn a flaccid patient, but he required only one. I thought about the threat of pressure sores caused by immobility.
Reality check. What was I doing? I felt I needed to look for the pupils to react, to listen to the heart and lungs and belly, to check the circulation of all the limbs. I wanted to provide creature comforts: to bathe and shave and lotion the skin. I wanted to honor The Soldier with compassion.
I thought about my niece; she had served in both Afghanistan and Iraq.
I had a conflict about organ transplants, not the people involved, but the process. I felt witness to a crime when I heard people pray for an organ. It reminded me of O. Henry's The Gift of the Magi, only in this circumstance, for one person to receive the gift of a new heart or lung, another had to die.
I collected the first set of labs for the day and replaced electrolytes depleted by the flood of urine.
"He needs some blood," Connor said.
More conflict. I knew the cost of blood, its often-limited supply. I struggled. Can you do this? Should you do this? Finally: I will do this.
It bothered me not to chart something, anything about The Soldier. I wanted to describe the resilience of his skin, the tan line suggesting he liked the outdoors, the intricate lattice of a tattoo, the birthmark on his right hand. I wanted to note the things that had made him unique, even though I never heard him say a word. Had he a favorite book? A hobby? A pet? All things under ordinary circumstances, even in ICU, I might have come to know with time.
Although charting wasn't required, I adhered to strict protocol with blood administration. Two nurses checked The Soldier's identity. I scanned his armband and the essential barcodes to make certain they matched. I entered vital signs at the start of the transfusion and fifteen minutes into it. I recorded them again at the end, only to start the process all over with a second unit.
As I adjusted the rate of the blood, I noticed two stuffed animals on the window sill. Both possessed faces with generic features, four limbs, stubby tails, and brown glass eyes staring at nothing. One wore a collar made of green ribbon. A card attached to the collar said: "I love you Unc." I dusted off the sill and positioned the animals to watch over the man in the bed. I didn't want The Soldier to feel alone and hoped no one witnessed me doing something so silly. I frowned at the black lens of the video-cam.
Connor began a monologue. "Do you know the surgeon on call? I think we need a liver biopsy. I may know someone who'll do it." The words rushed from his mouth addressing no one, with no pause, no punctuation. He paced with cell phone to ear.
I drew more blood, gathered supplies, and caught a rare word from phone exchanges between Connor and his endless connections. In less than an hour, a surgeon arrived and performed a liver biopsy at the bedside. I struggled with the absence of "informed consent" and the knowledge that things were being done to The Soldier, not for him. I hovered and monitored his vital signs with the same vigilance I used with every patient. I checked the puncture site and palpated it for a bulge that might indicate internal bleeding. The Soldier's body never changed.
By the end of my twelve hours, emptiness overwhelmed me. I felt as depleted as the body in the bed. I stared at the gray screen of the computer and entered a last set of vital signs. The screen, a blur of meaningless numbers with no words, no images, did not reflect either the flesh or the soul I knew lingered somewhere in the room. I sighed, too tired for anger or tears.
Laurel arrived. I survived my shift and suspected The Soldier would be gone by morning.
"How was your day? Hope I didn't leave too much undone last night." Laurel asked. Meticulous and conscientious, a typical critical care nurse.
I didn't want to think about my day and aggravate a wound not even starting to close. "I think they may take him tonight."
"Are you back in the morning?" Giving a report to the same nurse on consecutive days eased the transition between shifts.
"Yeah. See you tomorrow." If the hall had been longer, I might have gotten lost. I walked without seeing, saved by years of working in the same unit. After dumping my stuff in my locker, I grabbed my purse and headed home.
The next day, The Soldier's name remained on our assignment board. An EKG sliced across the monitor space with his room number. Muscles in my neck and back rebelled. I felt the heaviness of the previous day settle back onto my shoulders.
Laurel chattered and brushed non-existent strands of hair away from her face. Her hands busied themselves in the repetitious movements of a nervous youngster. "We did a CT of the chest, a cardiac cath, two more sets of labs. He's gonna go to surgery at 11 a.m."
The day began. I never realized how policies and protocols provided me with a sense of control over my work environment. Without the usual operative permit, without pre-op teaching or communication with the patient and the family, I felt my care slipped below acceptable standards. No education prepared me for this juxtaposition of roles and rules. As a student I believed everything would be black and white, scientifically based, logical. Navigating this assignment was like trudging through a quagmire.
A new transplant representative, Marlene, replaced Connor, who had been up all night. She entered The Soldier's room carrying a plastic box filled with test tubes. "There are about thirty of these. I need them all filled. They're already labeled."
I shook my head with an inner shrug of capitulation, but couldn't hide my look of dismay. The blood administered yesterday would go into a bunch of test tubes.
Marlene proved herself no novice. She offered me solace in the form of justification. "We need a set of several tubes to match every organ we are going to use. That means each kidney, each lung, the heart, and possibly the liver." Many lives depended on what I did on the speed and efficacy of my actions.
Patients always ask "How am I doing?" I answer and they follow with "Are you telling me the truth?"
I can't lie. I can't bluff, which is why I never play poker. My face is the "tell".
Marlene read my face. "Not much longer. We're just waiting for everyone to get here."
A confluence of divine proportion. I wanted to see stars align, the world's problems solved, and The Soldier to find his "better place". Once he left his room, my redemption could begin. I could try to forgive myself for what I perceived as doing harm.
Saliva dribbled from The Soldier's mouth. I washed his face, dabbed it dry, changed his gown, and laughed at the futility. Who the hell was going to know if his gown was clean? I transferred readings of blood pressure, pulse, and respirations from the monitor to the electronic medical record. More waiting. A call from the operating room heralded the surgical team's arrival. I tucked the paper chart, thin compared to those of our usual long-term critical care patients, between the mattress and the footboard of the bed. I wanted to say something to him. Thank you for serving your country. Thank you for thinking of those who still live. I'm sorry we couldn't help you when you got home. I'm sorry it ended like this for you. Why couldn't we have done better? Only the hissing suction, the whisper of the ventilator, the subtle machinations of the IV pumps, and an occasional airway pressure alarm spoke for him.
The team arrived in a cacophony of discussion.
"I have tickets to House of Blues this weekend. It's a Bugs Henderson tribute," said the OR tech. He unplugged the bed and positioned the transport monitor.
The bonneted scrub nurse filled out her paperwork. "Have you heard about the new restaurant down in The Arts District?"
While connecting The Soldier to an ambu bag for transport, the respiratory therapist quizzed: "Can anyone guess how much the oil change on a Lamborghini cost? I read it on the Internet. You won't believe it." His tone promised an intangible reward for the correct answer.
With my back pressed against the wall, I listened to the drone of the mundane.
I updated the anesthesiologist on the most recent labs, vital signs, infusion rates of the drugs used to maintain the blood pressure. Satisfied he had enough information, casual conversation resumed. The bed began to roll through the door. Adrenalin released during the demands of minute-to-minute activity began to wane. I felt ready to crumple on the floor.
From the window sill, four glass eyes managed accusatory stares from two stuffed heads of buff-colored fur. "He was a veteran, you know," I said, trying to sound loud and authoritative. I didn't know if I had pulled it off until the bed stopped as it angled out the door. No one said a word. A reverence filled the room. Casual faces turned solemn. Each person retreated into private contemplation. They transported The Soldier in synchronous steps similar to those of pallbearers, a meager affirmation of his sacrifice.
There should be a flag.
I wiped my tears away. I had no right to cry. No matter how grueling my workday, I was able to return to the sanctity of my home, to the love and support of my partner, to the unconditional affection bestowed on me by my cats.
Several days later, a tacky, computer-generated sign posted on the employees' kitchen door issued thanks to the staff members who facilitated the organ donations. It mentioned no names; I was glad. I was no hero. I deserved no thanks. Three people enjoyed new lives because of The Soldier, the only real hero.
The Soldier haunts me. Forgive me for not serving.