When I received the call for submissions for Blood and Thunder: Musings on the Art of Medicine, a literary journal from the University of Oklahoma College of Medicine, I thought immediately about an incident that happened my first year as a registered nurse. We think we know everything, but then something happens that can change all that. Nursing, like writing, is a process. Well, come to think of it, all of life is. I hope you enjoy this story.
PULLING THE PLUG
I’d been a registered nurse about six months when Betty came into my life. Young, eager, and undaunted, I thrived on the challenges of my job in ICU—endless lab reports, procedures, interpreting heart rhythms, taking advantage of the constant learning opportunities in my daily encounters with life and death situations.
Betty had pneumonia, but had gone into respiratory failure, necessitating a tracheotomy. Her breathing was possible only by the continuous whooshes of the monstrous MA-1 ventilator, which we affectionately dubbed the “Mary Ann”, filling her lungs with oxygen-rich air.
Adrenalin coursed through my veins as I scurried around her cubicle performing countless tasks for my unresponsive, comatose patient. The evening sailed by as I hung life-saving intravenous antibiotics and monitored Betty’s progress or lack of, it turned out. The only sign of activity was the steady swoosh-pause-whoosh of Mary Ann’s bellows delivering regular inspirations to Betty’s lungs. As I carried out the doctor’s orders, the words of my nursing instructor came to me. No matter how deep the coma, the hearing is the last sense to leave the body. “Hi, Betty,” I chirped. “It’s me again. It’s time to take a blood sample, to make sure you’re getting enough oxygen. We have to get you well.”
Betty’s pale body filled the bed and didn’t even flinch when I poked the needle into the artery in her wrist to obtain the blood gas specimen. I swiped a cool cloth over her forehead when her temperature soared above 100 degrees and looked at her face, a soft, grandmotherly kind of face, lying there without expression. I remembered the ER nurse had given her age as 58. Just two years younger than Grandma, I thought. I felt a little knot forming in my throat as I changed the dressing around the silver tracheotomy tube in her throat and smoothed K-Y jelly over her parched lips.
At the end of my shift, I bent over close to Betty’s face and told her, “You’re doing fine. Get some rest, and I’ll see you tomorrow.” I left the hospital pleased with the work of the evening, confident that Betty would greet me tomorrow with bright eyes. After all I’d carried out each order to the letter.
She didn’t greet me the next day though. Every day for the next four days, Betty’s condition remained the same. The chest x-rays showed the pneumonia had cleared and her white count returned to normal, but she rested in a deep coma, unresponsive to all stimuli, not even a pupil response when I shined a penlight into her eyes. Swoosh-pause-whoosh. Mary Ann breathed for her through the tracheotomy tube. She’s just a patient, I told myself, but I felt a tugging inside, a different kind of challenge. Convey caring, but remain detached. That’s also what my nursing instructors had said. As I changed Betty’s position to her right side I thought, I wouldn’t want some detached robot taking care of Grandma. Of course, Betty wasn’t Grandma, but she might be someone’s grandma or aunt even though I’d noticed she never had any visitors. I asked the head nurse on the day shift about it. She told me, “There’s no family, just a sister, and she lives away.”
No family, I thought and gave her extra attention any time I could. “It’s a nice day today, Betty. Open your eyes if you can hear me.” Nothing. Swoosh-pause-whoosh Mary Ann continued on. “I’m hanging some new IV fluids. Squeeze my hand if you can hear me.” I placed my hand in her doughy one, looking for some sign of life. Nothing. “I’ll be off a couple of days. Now you get well while I’m gone, okay?”
I came back expecting Betty to be improved. Instead, her condition had deteriorated. Her kidneys had stopped functioning, causing her abdomen to bloat. She had a puffy look, even in her face and fingers. Peritoneal dialysis had been started, an exchanging of fluid through a tube in the abdomen to rid the body of toxins. There was a slim chance it would get the kidneys to start working again. The grimness of the situation surrounded me as I spent the evening hanging bottles, lowering bottles, measuring, analyzing the latest lab reports. Then I found myself saying a prayer for Betty.
The next day in report the day nurse told me, “Betty is in complete renal shutdown. The doctors have talked with her sister. With no other family and no insurance, her sister has signed the papers to stop life support.”
“What? Pull the plug? No!” I felt my face flushing as I thought of the hours I’d hovered over Betty, caring for her, doing every technical thing in the book to make her well. My heart pounded in my chest.
“The doctor will be by later to write the orders. I’m sorry this falls on you, but there’s nothing we can do.”
Nothing to do? Why couldn’t we just wait, let her heart stop beating, keep praying for a miracle? I felt sick to my stomach as I went to Betty’s side. “How are you, today, Betty?” I said in the brightest voice I could. I cleared the mucous from the tracheotomy tube as Mary Ann swooshed breaths into her now pneumonia-free lungs. Pull the plug? This wasn’t supposed to happen. You were supposed to get well. I felt all my hours of hard work being washed away. I looked at Betty’s waxy, pale face and saw the transparent look of death, but I couldn’t ignore the beep-beep-beep that came from the monitor reminding me a person lived in that body, a person I was never going to know because we were getting ready to kill her. I was glad Betty couldn’t see the tears in my eyes.
“We will use a last-resort technique to stop the life-support,” the doctor told me. “We will try to ‘wean’ her from the Mary Ann, two minutes off, reconnect, wait thirty minutes, three minutes off, and so on. I think her heart will just stop beating without oxygen after a time. I’ll be in the hospital when the time comes.” He scrawled his name across the order sheet and went with me to begin the “weaning.”
My hands shook as I disconnected the ventilator. The clock read 4:00. I watched the second hand with one eye and Betty’s chest with the other. Oh, God, I’ve always known you wanted me to be a nurse, and you’ve blessed me in this wonderful job. Why is this happening? Why do I have to be the one to do this? I thought you wanted me to be a nurse to give life and comfort to the sick. I didn’t know I would have to be an instrument of death. I watched the second-hand on the clock swoop around. At the end of the two minutes, Betty’s heart was beating steadily at eighty beats per minute, and I quickly reconnected Mary Ann to the tracheotomy tube.
“Remember, increase the time every thirty minutes. Call if you need me,” the doctor said and left.
My thoughts were a jumble. I’d seen patients die before—accident victims crushed and mangled to death, cancer victims wasted to nothing, old people with their lives spent. I’d seen death, but I didn’t want to watch Betty die. Not Betty, please, God. No longer was my job glamorous and exciting. It was pure torture. I debated calling the house supervisor and telling her I couldn’t do it, I couldn’t be the one to make Betty die, but that would be shirking my responsibilities. No, I’d cared for Betty this long; I’d see her through to the end.
At 4:30, I repeated the weaning procedure for three minutes. Nothing happened. At 5:00, four minutes. Betty’s heart slowed to sixty beats per minute, but returned to normal when I reconnected the ventilator. All the times in between I stayed at Betty’s side. I rubbed lotion on her arms and legs, gently pulled a comb through her salt-and-pepper-colored hair, stroked her cheek. If she had to die, I wanted her to feel loved and pampered until the last beat of her heart. I talked softly to her, “Betty, I know you were a fine lady. You know I don’t want to do this.”
At 5:30, I muttered a prayer, and disconnected Mary Ann. After hearing the swooshing sound from the ventilator for more than a week, the silence when I disconnected it deafened me. I watched the clock. Two minutes, three, four. . . I thought I saw a little spasm in Betty’s chest, but I knew my imagination was playing tricks on me. Four and a half minutes the clock said. The heart monitor sounded an alarm as Betty’s heart rate dipped below fifty. I watched the heart monitor. Then, another sound—like a cough. I whirled around and saw Betty’s chest heaving as if trying to take a breath. I screamed for the other nurse in the ICU to come quick. Five minutes had passed and I reconnected Mary Ann.
“You won’t believe this. I think she tried to take a breath! Call the doctor, I want to try this again.”
Within moments the doctor was at the bedside, and we repeated the procedure. Three minutes passed, then four, and then, Yes! the cough and the chest heaving. First a gargling, strangling sound coming from the tracheotomy and then the chest expanding trying to get air. The breaths came in ragged spurts, and the heart monitor went off again. Please, God, not now! Don’t let her heart stop!
The breaths continued, contorted, irregular and not my imagination! The doctor worked quickly resetting the ventilator to deliver assisted breathing instead of continuous respirations. We reconnected the tubing and watched as Betty’s heart rate returned to normal.
“Unbelievable!” the doctor said. “We gave it a shot, and look what happened? I think someone else gets the credit for this.” Yes, and I knew who. My knees shook, as weak as if I’d run a marathon. The rest of my shift I hovered over Betty, willing her to be strong and keep breathing. She did, and my fingers still trembled as I jammed my time card in the machine and clocked out near midnight.
The next day, the nurses from the day shift greeted me with smiles. “Betty woke up about three this morning. Of course she can’t talk with the hole in her trachea, but she’s alert and breathing completely on her own.” I raced into Betty’s room. The head of her bed was raised slightly, and her eyes were closed.
“Betty, it’s me. I told you you’d get better.”
Her eyes opened, piercing blue eyes, the exact shade of Grandma’s eyes, trying to focus on my face. She smiled and squeezed my hand and tried to make words with her mouth. I told her, “Don’t try to talk now. We’ll have time for that later.”
Later in the evening, Betty made motions with her hands like she was trying to write. I found a pad and paper. She wrote in squiggly letters, “I knew you by your voice.”
Every day Betty improved; her kidney function returned, and the tracheotomy tube was removed, although she had to hold her finger over the hole in her throat to talk. In no time at all she graduated from the ICU into a regular room.
The next day I peered into Betty’s now-empty cubicle and felt a flutter of contentment. I had learned a lot from Betty. It didn’t have anything to do with lab reports or oxygen percentages. I had learned that people are what count, AND God is still in the business of doing miracles. All the “stuff” we do might ease their suffering or aid in their recoveries, but no one but God can take a lifeless lump that we have given up on and breathe life into it. I know because I saw it.
At five o’clock, the phone in ICU rang. I answered it.
“Hello. Do you know who this is?” The scratchy hoarse voice on the other end was unmistakable.
“Betty!” I screeched. I’d know that voice anywhere.
She continued. “I just called to say thanks.”
No, I thought, Thank you, Betty.
Published in Blood and Thunder: Musings on the Art of Medicine, 2004.