Thursday, December 23, 2010

Life Support

I am preparing to return to work after being on medical leave for nine months. I am excited and nervous, worried that I've forgotten too much, that I will be even worse at placing IVs, and that the crush of responsibility will wear me down in a matter of weeks. Being an RN means that I am the eyes and ears of the MD or midwife when they're out of the patient's room. I have to make quick judgment calls, ask for appropriate meds, and be alert and vigilant for 8 hours straight. I work in a high volume, high risk, high stress unit. Never a dull moment, which is both good in terms of learning and bad in terms of feeling like I am drowning. In my first month on the job I had a patient hemorrhage with an inverted uterus, a neonatal code, several fetal demises, and more than one emergency c-section. I am fortunate that I work with a team of exceptional nurses who support me; I am not completely alone, although there are shifts when we're understaffed and I might as well be. One such time there was no Advanced Life Support RN for the baby, and no resource RN at delivery. I had to dry off and assess the baby, do APGARs, and simultaneously get everything that the MD wanted for the patient (hang new IV bag, get sutures and lidocaine, etc.). THAT made me into a huge stress monkey. Too bad I don't have 10 arms.

Because my job often takes me to the OR, I have to be certified in Advanced Cardiac Life Support (ACLS), which is a fancy way of saying that I need to be prepared to run a code when someone goes into cardiac arrest. I have to recognize ECG rhythms, know which ones are shockable, which drugs to use when in what amounts, and how to delegate and check in with team members to make sure that my orders are being carried out as directed. It is pretty complicated, although there are algorithms to simplify things. I spent the better part of five days trying to remember heart medications and proper treatment for myocardial infarctions and stroke. I spent one day in a classroom going over the algorithms and being coached, and then on the second day, I had my big test, called a megacode.

I am a nervous person at the best of times. Polite people call me vigilant; less polite people call me jumpy. I am a perfectionist with a low startle threshold. I can forget to breathe. You can imagine what being in charge of a megacode did to me.

The tester usually began by asking where the team leader worked and what kind of job they did before coming up with a scenario. I was hoping that I would be asked, so that he could come up with some OB scenario in the OR or labor room involving bleeding out. That I can handle. But I wasn't asked, and my "patient" was a 38-year-old IV drug user, coming into the ER with heart palpitations and dehydration. I had my team put my patient on the heart monitor, checked the rhythm, and ordered an IV start and labs to check blood count, electrolytes, kidney function, liver function, and drug toxicology. The tester informed me that my RN was unable to start an IV, so I had to order an intraosseus (within the bone marrow) line. Then the tester asked me where I worked, and the paramedics and ER nurses chuckled because I had forgotten that toxicology screens have to be checked from urine. Oops. I didn't order a Foley catheter. Then I forgot to shock the patient immediately when he went into ventricular fibrillation. I guess I looked frazzled, because the instructor said, "It's okay. You're doing fine. Remember your algorithms."

I got back on track and passed. It was nerve-wracking, but having been in real codes that were less well handled, I feel as though I can contribute more meaningfully. I hope. Practice and faith in oneself really does matter. And in a real-life situation in the OR or labor room, I would NOT be running the code. Hooray for having three MDs in the OR and a code team to call!

Then I got to thinking about the algorithms. If you follow the boxes and answer questions, things are simplified. You know what to do when, if you constantly reassess the patient and make decisions based on that information. Very few people actually survive codes, but there is a best practice to be followed. That is reassuring.

It made me wish that there were some algorithm to follow when trying to sift through the complicated, clotted emotions that come along with adoption. There are theories (such as the primal wound, and modified Eriksonian crises), and there are examples (such as the interviews that B.J. Lifton published in her books) of other people's searches and reunions. But no adoptions are alike, no adoptees are exactly alike, no first mothers are the same. There is no algorithm for coping: we do the best we can, muddle through, and hope for the best. Sometimes I feel like I am performing CPR on myself, pounding on a chest in which the heart has stopped beating for lack of an emotional home. Sometimes I wish I could give myself epinephrine to give myself a better chance to reset my heart's nonperfusing rhythm.

Over the past few years, I've been given a lot of advice. "Say this, say that, never say that, don't contact, contact now, demand that, ask politely, give more time, show up on her doorstep," and so on. Problem is, there is no script to follow that works for everyone. We all have to write our own as we go. I remember someone telling me not to tell my fmom in a letter that I wanted anything less than her love, and that she had mine. Well, turns out that my fmom isn't the loving kind of person who wanted to hear such words. As she put it, "I feel nothing for you as a child of mine, but you are nice, and if I met you in the line at the grocery store we could have a nice talk. Let's work on a friendship like that." So I am a stranger--that's a given--of no more importance than someone met incidentally while running errands. I will take it, although it wasn't the reception I had hoped for. One step at a time, one step at a time.

Then I sink back into this terrible sense of feeling alone. I have an amazing family, loving friends, and I belong in many ways. I don't belong in my nfamily, at least not yet, and probably never in the way I'd like. How is it that I slipped down a rabbit hole and ended up here, where I can't enjoy what I do have?

Although I become annoyed by people who are so scientific that they cannot begin to understand or process human emotions, I do wish I could pull a card out of my pocket with an algorithm that outlined life support for me in more concrete terms than taking antidepressants, thinking happy thoughts, doing things that bring me joy, and surrounding myself with loved ones. It's these things, oddly, that often reinforce how alone I feel.

In ACLS, there are some rhythms that are shockable, and some that aren't. Can't shock dead, they say. They may shock a flat line on TV, but it doesn't restart the heart. There has to be the right combination of electrical activity, oxygen, circulation, and chemicals for that heart to pump.

Right now, I am not in a shockable rhythm.

ABC. Airway, Breathing, Circulation. Airway, Breathing, Circulation. It can keep you alive, but to what end? What is life vs. quality of life? Oh yeah, there's no algorithm for that one, either.


juxtaposition said...

"Sometimes I feel like I am performing CPR on myself, pounding on a chest in which the heart has stopped beating for lack of an emotional home."

Beautifully written, my friend. You are quite right, that feeling of being alone..even though we have friends, family, people who love us,but we can't accept that love because of the missing piece inside of us that won't allow it.

I've been trying to analyze myself (nothing new), and what I've come up with is that I am able to give my love, I'm just not able to feel love. I don't know it, I don't understand it,and I don't trust it.
We are truly in that dark hole, Adoptees in Wonderland, forget Alice.
Keep writing. You are inspiring.

Campbell said...

"I remember someone telling me not to tell my fmom in a letter that I wanted anything less than her love, and that she had mine. Well, turns out that my fmom isn't the loving kind of person who wanted to hear such words."

Thank you so much for sharing this. I think it's so important for searching people not to have predetermined expectations and to have a "feeling each other out" period in the beginning.

Unknown said...

Great post! Very well written, as usual! Good luck as you head back to work. :)

Anonymous said...

"Sometimes I feel like I am performing CPR on myself, pounding on a chest in which the heart has stopped beating for lack of an emotional home."

How amazingly true that statement is, unfortunately. What a way with words though...

Oh and I loved the nurse parts of this post :)

ms. marginalia said...

It's interesting to reread this, a couple of months down the road. I like the way I described the confusion and trying to come to terms with crazy stuff. I am in a different place now, definitely less suicidal. That's positive. And my relationships with C and A are definitely improving.

I won't say that I am out of the woods. Some days I can't imagine living another 40 years, even with all the great things. Depression is a terrible disease.

etropic said...

Oh that pesky ACLS! My mom's an RN and works in a free standing day surgery center. I can remember the nights I have spent with my mom studying with her. That is a VERY hard class to study, keep straight, and actually pass. The instructor for my mom's class use to practically give them the answers so they could all pass. She would nudge them in the right direction so the studying really was kind of pointless. Glad you passed as I don't think I could ever keep any of that stuff straight! I'll stick with CNA work such as EKG's and testing blood sugars!