The Ceilings I See

Passing Time in Harborview's Trauma ICU

NOTE: My recollection of events, when they happened and where, is sketchy at best. Kendra clarified and corrected some items, but I've largely left things as my brain remembers them, which is to say again, is not accurate. So this is the remembering. Most of it is true; some of it is accurate.

I am a nurse. I graduated from Loma Linda University's School of Nursing in 2004. At that time, hospitals were desperate for nurses, warm bodies to cover shifts in any area of nursing. I was a warm, eager body that happily started on Unit 8100, Surgical ICU. We didn't have an ICU designated solely to trauma, but as the name indicates we saw various types of surgical patients. In addition, we took care of sick transplant patients, neuro patients, and those experiencing the worst of what the day had to offer - trauma. It wasn't lost on me that I was a brand new nurse going directly into a busy and demanding intensive care unit. I would argue that the only more difficult ICU would be pediatrics. I was young and innocent and so, so eager.

In the melee of all that is ICU, the bane of our existence is the awake, extubated (no breathing tube) patient. When a patient is weaned off sedation and extubated, this is a fast-pass to a step-down unit. Our work here is done. There are occasions when the awake, extubated patient needs some time in ICU, but this is rare...and unwelcome. If you can talk, you should be somewhere else, and me or any other ICU nurse will do everything we can to help you on your way. We save your life and then you go somewhere else to recover and to get on with your living.

____________________

My time in Harborview's Emergency Department has come to an end. While here, much of my time has been spent sleeping or yelling out whenever they move me from side to side, the fentanyl doses largely smoothing out everything in between. My wife is here and her sister; our friends Ray and Athens made the trip up to Seattle as well. I see their faces when they lean over my bed. I hear their voices. Much of what they are saying is encouraging and kind. I feel odd here. I feel uncomfortable being this center of attention. I don't want to be here. I don't want to be the one who warrants this attention. And yet, there seems to be not much else to do. I am here and I find myself in need of things I've never needed before. My path forward is dependent on the actions and care of those around me. Period.

It's Memorial Day weekend, so while there is a threat of surgery for my spine and pelvis, there is not much happening. I am stable. Any human more emergent than me will be handled first. I have no choice but to wait my turn.

I have some awareness of what is happening, but I'm not fully clued into any timeline or my accruing list of injuries. Irregardless of my ignorance, this is what my body has sustained:

• Right 1st-3rd rib fractures

• C7-T1 ligamentous injury

• T1 superior endplate fracture

• T2 right transverse process fracture

• T3/T4 superior endplate fractures

• T7 compression fracture

• T8 spinous process fracture

• APC Type 1 pelvic ring injury

• Chronic left medial malleolus fracture

• Right Rockwood type V AC joint injury

• Grade 2 right renal laceration

• Right adrenal hemorrhage

• Perihepatic hematoma without definite hepatic laceration

• Pelvic hemorrhage collection extending into left inguinal canal

• Left lateral hip Morel-Lavallée lesion

• Left knee laceration traumatic arthrotomy ruled out

• Back laceration

• Scalp laceration

Because I am supine - flat - I am experiencing minimal pain. I am in full spinal precautions which dooms me to log rolls from side to side, but the real pain is that I will be staring at the ceiling until I don't know when. I see nothing else but ceiling tiles and lights.

And yet, I feel no agitation or fear or anxiety. My brain seems to have shifted, to have settled in the direction where I've always wanted it to be, and now, without even trying I am here, at peace with all that is happening around me and all that isn't happening. I am in control of nothing.

It is the middle of the night and I am wheeled to Harborview's Trauma ICU on floor 9. Not much changes, the ceiling tiles are only slightly different than the ones downstairs in the ED. The big difference is that I am next to a window. I can't see out the window. The lights here are bright as Allison, the nurse, does her assessment. My arms work, but my body is sore, achy. I'm of no help to anything that is happening. I am just here, stationary. There is a flurry of activity to get me settled and then it is all dark. And I sleep straight as board.

The details of what happens next or when are blurry. The hard boundaries of what a day is shift, morphing into one continuous living, neither darkness nor sleep enough to define what I am experiencing. I am alive, breathing. That is all. The time from the clock hanging on the wall at the foot of my bed means nothing. It only advances and I am here to witness it, as if I am abstaining from time itself.

Kayla comes on in the morning. Her voice is raspy, low, and I find myself drawn to both the way she communicates and the sound of her words. She is humorous and witty and confident. I'm entirely in her care, and whether because of my mental peace or her demeanor, I'm okay with my life in her hands.

Ordinarily, I would avoid bringing up my profession. I don't need any special treatment. I don't need anyone feeling any extra pressure. I just want what is being offered. Today, I can't resist. I feel out of place, like I shouldn't belong here. And based on my history as an ICU nurse, I have an awareness that every nurse on this floor loathes that I am there and surely wants me gone. I am too awake. I am too conscious. I am too able to hit the nurse call button and make requests. And so I acknowledge my out-of-place-ness in ICU. I call myself out for being the unwanted patient, even though I have no choice in the matter. I'd like to think this endears me to Kayla, but I have no way of knowing if this has the intended effect.

My roommate tries to code this morning. He is not successful because Kayla is a competent nurse. They remedy the situation efficiently and he is back to baseline in no time. As with any codes, or even a threat of a code, the room quickly fills with all the bodies. Extra nurses materialize to help and usually various layers of MDs come in to give orders and supervise. During this threat of a code, purely cardiac in nature (more rhythm than stoppage of rhythm), they did have some trouble locating magnesium. They did find it, and it was a administered, albeit after a slight scramble. We are humans after all.

When the room clears and Kayla's real ICU (read intubated and sedated) patient is out of the woods, and with only Kayla tidying up and making sure her patient is comfortable and organized, I quietly pipe up, "Hey, Kayla?"

"Yes, Kevin" Her voice has an edge, as if she knows.

"Would you like me to help you find the magnesium?"

She laughs. "I know, right? It would have been great if you could have helped find the magnesium." I'm doing my best to ensure she really loathes having an awake patient in the TICU. Because as any good ICU nurse would want, she would much prefer if I had a tube down my throat, some sedation in my IV, and be wholly unable to reach the call button or comment on their code efforts. She makes my day bright, even now, in the midst of all my ceiling staring and all the work she is required to accomplish.

Someone comes in and sutures my left knee. I don't see their face. There was a delay in doing so because I needed to have a scan of my left knee to see if air had entered the joint - It had not. The skin overlying my kneecap is now reconnected. The needle with the lidocaine felt like the stings of a a team of Bald-faced hornets, long and sharp and angry, but the knee was closed and the pain subsides shortly, either from the numbing or the decreasing frequency of needle pokes. They use warm water to irrigate the wound and I remember this feeling pleasant, the only part that does.

Someone comes in and sutures the two lacerations on my scalp. The needle with the lidocaine is less intense on my head than my knee, but still sharp. Kayla comes in later and slowly irrigates my scalp, washing away tissue, dried blood and debris from the trail. There is so much dried blood. Except for my face, chest, and the back of my legs, it seems that I am covered in various sizes and intensities of abrasions and wounds. My oozing skin sticks to the sheets beneath me.

Kendra returns today with her mother. Imprinted in my memory is a picture of her mother's face as they turn me and I am screaming, "Fuuuuuck!" as my body rolls from supine to my right side before they settle me back onto the pillows they have stuffed behind me. The pain from this open pelvis surprises me every time. And now that I know the pain that is to come, the anticipation bandwagons and I brace for the pain, making it all worse, making it all more intense. Despite this pain, the right side is my preferred side. My leg and hip tolerate this position without searing discomfort. When I am turned to the left, it feels as if I can only tolerate this position for 30 minutes before the pain overwhelms. I'll take the right side.

Somewhere in Sunday afternoon's melee my c-collar is removed. Someone has determined that I no longer need to be in C-spine precautions and the order placed has made it to the bedside. I am relieved. Having the C-collar removed allows my neck to breathe. It is a small bit of freedom, but not one to be taken for granted. Also, looking side-to-side becomes that much easier, allowing me to actually look into the faces of those visiting and working around me.

This freedom, and its associated joy, does not last. Later that evening, when Allison is back, the C-collar goes back on. Someone somewhere jumped the gun. This became our joke during subsequent log rolls, someone having to hold my head when I had just spent a few glorious hours free of this C-collar and free of the four person roll. Someone made a mistake and now we were able to revel in the irony of it all.

Monday comes and still no surgery. The kind human on the pelvis team assures me that surgery will happen soon. I am off and on NPO status, or nil per os, which means I get ice chips and ice chips alone. I am so thirsty. When they give me meds - usually methocarbamol, gabapentin, and acetaminophen, with the occasional oxy thrown in for funsies - I gulp greedily at the water offered, now requiring more water than I've ever needed to swallow five pills. All this gulping with little satisfaction.

Kendra is back today with my sister. Apparently, there is an online fundraiser on my behalf. Kendra asks, "Do you want to see it?" I think I do. She holds her phone between my face and the ceiling. I read two comments and their anonymous donations and I can no longer go on. I do the equivalent of turning away in my C-collar, averting my eyes. "I can't. It's too much." Tears overflow my lower lids, running down, directly into my ears and the foam of my C-collar, before continuing to the back of my neck. How is this possible? This is a question that goes two ways. How is it possible that I am in need of this help? and then How is it possible that so many humans are showing up to do just that, to help me? My brain cannot comperehend this level of generosity, this overwhelming kindness. It also struggles to understad that I am in desperate need of whatever is being offered. And yet, all I can do is be right here, right now. I have to let these kindnesses wait for me, for another day.

The spine team wants an MRI of my spine. That means that this sheet skirt I've been wearing since my arrival to the ED, needs to go. The sheet isn't the problem, but the giant metal hemostats that they've used to secure the sheet need to be removed before I can go to MRI. There is some deliberating over this. Team Pelvis isn't sure my body will handle the sheet skirt's removal, believing that my blood pressure may fluctuate and drop once it is removed. They end up deciding to remove my tight, mini skirt. Blood pressure is taken. I am watched and assessed. Nothing happens. Off to MRI I go. No more sheet skirt.

I have never had an issue with the enclosed space of an MRI before. Never. Today, I am unsure of how this will go, knowing my body struggles to remain in one position for any amount of time. I am only willing.

I am given a call button in case I need something, the ladies step out, and the MRI begins. There are sounds, noisy and loud, but little else. I do my best to lie still, focusing on my breathing, in and out, in and out. Time passes, but the quantity of minutes does not register. My pelvis begins to ache. My spine burns. Sweat forms on my upper lip at the base of my moustache. I grit my teeth and grip the call button, willing myself to finish what we have started. My arms and torso begin to shake, short bursts of tremors at first, only a shiver of pain here and there. I think I can hold on, my pain and shaking escalate quickly. These convulsions are both a response to my pain and adding to it. I'm not going to make it and decide to push the call button, to tap out. At this exact moment, the lady running the scan mercifully stops the MRI and pulls me out. I immediately make adjustments to my position to relieve this pain. She says that what they got will be sufficient. Relief washes over me. I thought this was only a break. She called it. I am grateful.

The rumor is that surgery will be tomorrow - Tuesday - and the pelvis and spine teams may be able to do both surgeries while I am under. The pelvis team is present and communicative. The spine team feels aloof and distant, noncommittal about joining in on the fun tomorrow. Now that surgery is scheduled for 10 AM the next day, I am allowed to eat until midnight, the luxury of something more than ice chips. I experience delight.

It's Tuesday now and Kayla is back. She comes in laughing and she wants to share. "Do you want to know what I'm laughing about?"

"Uh, yeah," I say, staring at the ceiling for the third day in a row. I'm here for any entertainment anyone might provide.

"Okay, so I was looking through your chart, and I noticed that your admitting diagnosis, like your main diagnosis for being here, says, 'Fall from greater than three feet.'"

Her laughter continues. I am incredulous. Give me some credit. I know that diagnoses in general can be quite vague, succumbing to broad categories, but three feet? This seems a bit underwhelming, not quite capturing my pinballing from ridge to the snowfield below. The rumor is that I fell 200 to 300 feet, or so estimated Mike when he and his helicopter friends came to pick me up. (Yesterday, as I scrutinized my GPS routes from my phone and watch, it seems my fall may have been in the neighborhood of 180 feet. Either way, slightly more impressive than falling from a three foot kitchen step ladder).

The word surgery looms large. I think on the surgeries to come but I don't know what to think. My brain, usually fluent at fixation and rumination mixed with a healthy amount of anxiety, seems to have released itself from these default measures. The peace remains. I am here at the mercy of what these people decide and the subsequent care they give. I abstain from any effort at control because I know that I am not in control of one thing today. For everything that I need, I am dependent on the humans around me. I will get what I get.

As luck would have it, I need to poop. As a nurse, I have provided bed pans and cleaned up hundreds of patients. While this is not my favorite care to provide, it is essential, and I wouldn't blink at having to give this type of care again. And yet, all of this, with me in full spinal precautions, feels quite different. I need this care, but I don't want it. I don't like that I'm in this dependent position. But my likes and wishes don't matter here. My distending bowels definitely fall under the 'needs' category.

I call Kayla and let her know that I need help. She arrives with friends. It takes Kayla and three other people to turn me. Two lovely humans turn me, another holds my head in line with my spine, and Kayla places the bed pan. If this activity could be more humiliating I'm not sure how - a group of humans, my butt out, and my feces and their associated smell about to be on the outside.

Going 'flat' is painful, with my pelvis raised to accommodate the newly placed bedpan. I haven't pooped since Saturday, since I was on the side of Mount Washington. Now, three days later, I can only imagine the destruction I'm about to bestow upon this humble bedpan. I'm not happy about any of this. In addition, I have yet to poop with my open pelvis. I can't imagine that my imminent pushing will fall on the pleasurable side of things. If I could hide, I would.

There is no hiding. Kayla and her three friends leave. There is nothing left for me to do but push. And so I do. I push and strain as I'm laid out like a board and poop goes from my insides to the outside. It smells, and terribly so. I still wish I could hide, fully reconsidering surviving this fall.

I call Kayla and her friends back and they roll me again, while I cuss and moan in response to the pain. Kayla makes sure I am free of any dingleberries and they turn me to my other side, sheets changed underneath while I roll. The pain remains exquisite, but now my embarrassment of my poop and its subsequent smell in this room, shades the pain of my open pelvis. They all file out. I wouldn't be surprised if they chatted about my stench and my imminent death, I mean, who could survive this?

And yet, we all survive. It takes me many moments to realize that I'm the only one stressed about this defecation. They are consummate professionals and never even battted an eye, even while I nervously chatted through my whole cleaning. My brain is no longer experiencing total peace.

I'm wheeled down to surgery. "Bye, Kayla." I will miss her. She has caused me much delight even while I lay supine staring at whatever ceiling was above me. I'm onto the next thing, that one thing I've been waiting for, surgery.

I'm wheeled into a curtained room and I wait. The pelvis team visits shortly. The nurse comes by and introduces herself. The spine team comes and even in their presence still feels noncommittal. My pelvis is definitely getting repaired today. My spine? Maybe. I realize this is all about timing, but they're saying hi just in case they can squeeze me into their surgery schedule whenever the pelvis team finishes their tinkering.

A CRNA, Sandy, and a student will be doing my anesthesia. Sandy's eyes are kind, quiet. She seems unflappable, calm. I realize I get what I get, but I'm happy with what I've been given. I'm happy to be in her care even though I just met her 17 seconds ago.

Kendra says, "Good bye." She kisses me and I'm off. The OR lights are bright, even while they point in odd directions. I feel light, floaty. Surely they've slipped something into my IV. I'm dreading the move from my bed to OR table, but Sandy assures me they are going to put me to sleep in the bed and move me once I am asleep. I am jubilant and I fall asleep with this joy. I don't have one pang of distress or worry. The bright lights dim and darken, then, go black. There is nothing left to see or experience. All is well. I will be okay whether this is my last thought or perhaps there will be more. Either way.

*Photo credit to Kendra. I took no photos, although I wish I had captured some of those ceilings.