Friday, January 22, 2010

Bob Brown in ICU 17

I went to dialyze patient Brown in ICU 17 this afternoon. Dr. R had told me to maximize the fluid off of the patient, but cut the treatment to three hours, because his fluid overload was so severe, and his phosphorous was so very low. I’d called the ICU, and told the patient’s nurse, Nick, when to expect me. From Nick, I learned that the patient was male, had come in with pneumonia and had alcohol-related cirrhosis and subsequent liver failure.

It’s a common clinical picture, actually. Have seen it 100 times.

I checked in with Nickfirst. He’s a grizzly bear of a man, and from what little I’ve seen of him, a damned good nurse. He gives me the lowdown of the patient’s clinical situation as well as the social story (i.e. family dynamics) in 20 seconds or less, and I always appreciate that.

I wasn’t sure that Bob was male when I saw him at first, as his face was discolored with bruises. This isn’t because anyone had hit him; this is because his liver was no longer making clotting factors. The bruising went down his left arm, and onto his left leg, too. I wonder if he’d fallen at one point. He looked every bit end stage liver failure, with a profoundly round (firm) and distended abdomen, yellow cast to his skin, and very thin, thin arms and legs from the long malnutrition of alcoholism. He was intubated, but not yet on “pressors”, or vasoactive iv drugs. His A-line showed his pressure hovering at a wan 90 systolic, with a sinus pulse in the one-teens. Intravascularly dry, severely edematous in the tissues. And bleeding anywhere a blood cell could leak. I could smell it in the air.

I was there because he hadn’t urinated in a week (shock kidney from the liver failure, and possibly hypotension). I introduced myself to Bob, told him who I was..(eyes opened, but icteric and unfocused)...and as I touched his arm, by way of introduction and reassurance, I gently pressed a finger against his skin. My finger made an indent a half an inch deep. Imagine a half inch right now….that’s deep. It told me most of what I needed to know about the shape his body was in. There was no way in hell I was going to meet Dr. R’s hoped-for goal.

Then I turned my attention to his wife, Carol. I introduced myself, told her what I’d be doing, and what to expect. I told her it was important for us to remove some of the excess fluid in his body, because it was filling up his lungs, and making it impossible for him to breathe on his own. Get the fluid out, and hopefully get the tube out. “Yes, this is our third time with this dialysis. I understand.” I smiled. She’s an old pro, then...or more likely, trying very hard to be a pro because her world is spinning out of control. I shook her hand, and told her I’d set up. She wasn’t chatty as I did so, which was okay with me. She quietly did Sudoku, and gave noncommittal monosyllables as I commented on the weather, and the depth of the snow in the mountains. I let her be, and began my spin.

I started off with a blood prime, meaning that I pull almost a unit of blood (most adult bodies have 5 to 6) out of the body before returning any saline to compensate for the volume loss. I do this whenever I think I am at risk of having to give more fluid to a patient than take it off, which is ultimately harmful to the patient. Most patients roll with this all right. His pressure dropped 20 points. His body didn't like it. It took him 10 minutes to recover.

Nick came in to check, as the alarms went off at the desk. “Need anything?” “Nope, sorry, I blood primed him. He’s a closed circuit now, and I’m hoping it’ll go back up.” He nods, repositions the patient with me, gives a few meds due to the patient, reviews some orders with me.

We’re busy, and we’re also noticing that the pressure is crap, and we’re busy so that Carol is less aware of the fact that Bob’s pressure is crap. Oh, says, Nick, “incidentally”, I got a PICC line placed today, in case we need it. I nod. This means: “Let me know when you want the Levophed. I was prepared for you.” I coulda kissed him. This is wonderful. He knows we need it; he's known for three days that he's taken care of Bob. He knows. We don't diagnose. But we do know, and we prepare for it.

The pressure recovers somewhat. But I'm aggressively pulling fluid out (i.e. pulling water from the pipes), and I fight with Bob’s blood pressure for an hour, having to give back almost every milliliter I’d gained. After an hour, I’d gotten a half a liter. This is pathetic, compared to the goal set by my doc. My doc's goal was to help get him off the ventilator, and that wasn't going to happen with a half a liter an hour.

Bob’s sister arrived at the bedside, and was asking questions. Carol was too weary to notice how often the pressure was too low; Bob’s sister was not. After a full hour of the treatment, I paged Dr. R, to let him know that we were getting nowhere. He asked me to try albumin. Okay, cool. Let’s try some albumin. Nick gets it from the pharmacist for me, as I explain to Carol and the sister what albumin is, and why we think it might help.

Alcoholics have no albumin to speak of. This is because they do not tend to eat. They drink instead. I explain this gently, by saying, “Bob probably had a very poor diet before, (Carol nods) and that, compounded by the fact that his liver isn’t working, is making the amount of protein in his blood very low.” And then I explained that it would effect the amount of fluid I’d be able to take off…big molecules and little molecules. The sister appreciated the explanation “in English” (as she said), but Carol was in sleep-deprived numbness. She nodded when her sister-in-law nodded, and let someone else ask all the questions.

The sister asks about how the machine works, and I tell her. Dialysis is easy...it's salts and water. People can understand saltwater. And it works with the heart, which is also easy, because that's just electricity and plumbing. I mean, obviously, an electrophysiologist disagrees, and s/he is right....cardiac automaticity and periodicity is ridiculously complicated. If you're interested in those groovy details. I love pathophys...and I to love the complex chemistry behind dialysis. Bob's sister doesn't care. But she gets it when I tell her I'm squeezin out saltwater. And that I have a filter (to which I point) and this is where the blood is cleaned before I pump it back into her brother. And she appreciates understanding.

Before I finished getting the albumin into Bob, his pressure dropped to 69/32. Nick was at the bedside with me (because it looked dicey well before that), and I said, “Nick? Do you have an intensivist handy?” “Yup, whatchoo want?” “Um. I just suspect it might be a good plan to tell him we’re havin trouble getting fluid off.” “Yup, me too.” Exit Nick, for a few minutes.

I explained to the two women that the physician might want to consider a medication to keep up Bob’s pressure, since it just wasn’t cooperating. Because they wanted to know what to DO, if the fluid won't come off. I said the medication was ‘a big gun’, but that it might help him. It was serious, but it was just a tool, like everything else. The sister-in-law loitered some, but left, because Carol told her that "Bob is supposed to rest today."

Nick brought in a line already primed with Levophed. (Did I mention that this guy is an awesome nurse?) As he hung it, he explained what he was doing to Carol, too. She nodded. Repetition isn’t done to annoy when your family is in this state; it’s because they don’t really hear what you’re saying. Nick did warn her that the good thing about it is we’d be able to get fluid off. The downside is that there was a risk that it would be difficult to then wean Bob off the high-octane medication. She nodded again. And went back to Sudoko. Or numbers on a page.

The good news (sort of) is that I was, from there on out, able to pull fluid! (I guess this was a win, right?)....

Carol and I sat mostly quietly for another hour. She had her Sudoku, I had an eggplant-colored ball of yarn I was crocheting into an afghan. Sometimes she would call someone, and talk about Bob, and this "blood pressure medication...he's on the dialysis now...he's still on that breathing machine...he doesn't look good today....I wonder if he's in pain, because he looks so uncomfortable right now...." Interspersed with more quiet number puzzles and crochet loops.

The intensivist came in to see Carol. I was a little fly, stuck to the wall, in a small chair in the corner. A dialysis nurse isn’t supposed to go far when s/he is dialyzing, and I tend to sit quietly in a corner and read. Today, I made eggplant-colored loops, 150 to a row. I am stuck in the corner as this happens:

Doc was gracious, and kind. He was also truthful, which is my favorite kind of doc. He told her that the prognosis was very poor. He said, “He has several organs that aren’t working right now, we say they have ‘failed’. His kidneys have not made urine in a week, his blood pressure is too low, he’s unable to breathe on his own, and his liver has severe damage from cirrhosis. We can put him on the ventilator to support his lungs. We now have him on medication to support his heart. We are doing the dialysis for the kidneys. But the liver…. Transplant is not an option with a history of alcohol abuse, and transplant is the only thing we know how to do for the liver. We cannot do anything about his liver. He is in very serious condition, and we are not seeing improvement. We are seeing a gradual decline. I feel his prognosis is very poor at this time.”

Carol was standing, and nodding. She was hearing, and part of her was understanding. “I understand.” She was calm (sort of) but, “Nobody had told me yet that this was ‘end-stage’” She nodded. Shuffled her feet.

In short, no doc had actually said yet that Bob was going to die. She suspected. She said she’s talked about it with her family, what they would do, what Bob really wants. But nobody’d SAID it to her yet. She was waiting, fearing, to hear it. And now she’d heard it.

And this is why I have profound respect for intensivists. Because every one I have known has had to deliver this news to someone who deeply loves their patient, this person lying in the bed. And because intensivists are THERE at the ICU bedside, they see this suffering, and they understand that when it is time…it is so important for them to be honest and say that it is time. And the intensivists I've worked with have been honest and I think that takes courage.

The doc said, “I’m very sorry to have to deliver such bad news.” She nodded. She said Bob never wanted this much STUFF (gesturing to the entire room). This is not how he wants to live; they have a living will that is very clear. “He doesn’t want all this,” said Carol, “I’ve talked to the whole family and we all agree that if he isn’t going to get better, he doesn’t want this.” She wobbled. He pretended not to notice. I made eggplant loops and tried not to breathe loudly in the corner.

The doc said gently, “What we can do, then, is maybe wait a day or two to see if we see any improvement. To be honest, I do not expect any, but no doctor can tell you for sure what will happen. If he does not want us to do this, we can stop this. Why don’t we give it a day or two and then make that decision?” “Okay…..How long?” “Maybe we could re-evaluate, say, Sunday? Will you be here Sunday?” “I will be here Sunday…..I will be with him. I will be here. Yes. I can. I can bring the family Sunday, too. Yes." She nods more.

The doc nods, too. “I am sorry to deliver such bad news.” She thanks him. Nods. He nods. He makes a quiet exit. She turns to the window, which is dark because it is evening. I can see her reflection in it quite clearly. She holds her hands over her face, with her index fingers in the corners of her eyes. She is very still. I think I hear the word, “Sunday,” a whisper.

I stand up and walk softly, in my rubber-soled shoes, up to Carol. I touch her left shoulder, so as not to startle her. And then I wrap my arms around her shoulders and put my ear to her shoulder and squeeze.

She shivers, and then a sound comes out, a little like an infant’s burp. And then there’s the sob…...this...SOB, this reverse gulp of air....less a sound than a shockwave from a mushroom cloud. Before it becomes red or grey, when it's just this visual disruption thing. Not heard, so much as felt , down in the belly, right in the gut...and it feels like it has hit every bystander within 10 miles and made them wobble and gasp for air.

My eyes sting with saltwater and I hang on tight so that her molecules do not fly apart.

Monday, October 5, 2009

My buddy "Zack"...

...who I wrote about on August 31 is sitting 20 feet from me, dialyzing 'emergently' again. His blood pressures are in the 220s over 130s. Heart rate in the 120s. Potassium is 6.7. Creatinine of 10.1, and BUN of 28.

He left hospital Q on Saturday, against medical advice. Now, he came to this ER and I drew the short straw.

"Zack," I said, with large 15 gauge needle in my hand, "I'm not trying to piss you off or anything here, but seriously, why do you do this to yourself?"

"Do what?"

"Blow off your dialysis appointments, the dialysis that is keeping you alive, and drag your butt into ERs around town when it gets too bad?"

"I'm supposed to go tomorrow."

"Yes, but why didn't you go to the one you were supposed to go to in the beginning? The point is what brought you HERE...TODAY... And every other time we see you?"

"I don't know what you're talking about."

At this point, I jab the first needle into his skin. This is soothing. "I think you do, because I don't think you're an idiot though you are acting like one."

"No I don't!"

"Whatever. Sit back, relax, and I'm not taking you off this machine for four hours even if aliens land, so don't even think about it."

I jab the second needle into his fistula and hook him up. I let his admitting nurse know he's here, what's goin on, brief history, and to be mindful of where her Against Medical Advice paperwork is. She may need it.

Thank you, Colorado taxpayers, for paying for my services today. I'm a nurse and I save lives.

....

(Maybe I'll have some nice, responsible patients who want to get well later this week. One can hope. It does happen sometimes.)

Tuesday, September 22, 2009

Americans and their sliced cheese.

I stopped off at the grocery store after work Saturday, still, of course, in my scrubs that mark me as a Healthcare Person.

I was in the dairy section as a large man using a walker huffed and puffed and sweated past me. He burst out in frustation (to me): "WHERE is the sliced cheese?!?" (Since I'm a nurse, of course, I know everything and am trustworthier than other customers.)

I pointed to a location across the store, and said, "Oh, that's way back near the meat stuff on the other side of produce." He shook his head, agitated.

I said, not unkindly, "Or, save yourself a few cents and slice your own cheese. The blocks are right over there." (Pointing to a refrigerator around the corner from us.)

"I have arthritis! I can't cut cheese myself! I can barely walk!"

I bit my tongue out of habit, because I'm polite by habit. I let him stomp and huff his walker away toward the sliced cheese section. Infantile cheese-cutting jokes aside, what I should have said is:

Well, if you cut your own damn cheese and USED your muscles in your hand, you might not lose use of your hands completely.

Or:

Better yet, skip the damn cheese altogether, lose 125 pounds and watch your arthritis diminish to a tolerable level, you whiny, lazy bastard.

I should have. I really should have.

I wear scrubs, and I know what I'm talking about. I'm trustworthy, even doing my grocery shopping. Right?

Saturday, August 29, 2009

How do we do this?

Steve commented on my last post, suggesting that there are two sides of reform needed to fix health care. The users and the payers. He's right.

Insurance has an important place in the picture. We could have a system that each individual pays out of pocket for all their health care needs. This works for the very healthy and the very lucky. I myself was minding my own business one day in January of many years ago, standing at a streetlight, waiting to cross...and a Pontiac hit a patch of ice, popped up the kerb and took me with it. I don't remember the car accident (which was a hit and run). The first thing I remember after the 'minding-my-own-business' part is waking up while being rolled into an MRI.

In 1994, that entire mess had cost upwards of $25,000. Which is cheap by standards I know now. But when I was 25 years old, I was living hand to mouth and that 25K might as well have been $25 million. I was glad of having insurance. I was lucky. Dumb, stupid luck.

Thousands of people are not lucky, and bad things happen to good people all the time. Insurance holds a very useful place in the economy. It's a gambling business....who to whom can we provide a safety net while keeping the most in our coffers? There is absolutely nothing wrong with this. Yay, capitalism.

Logically, though, this leads to abuses. It's expensive to treat human beings who've been unlucky. With cancer, tuberculosis, diabetes...you name it. Obama's discussion does focus on reform on the insurance end of things.

So what DO we do about the other side of the equation?

I am not a doctor, and therefore, do not know boo about medical malpractice. I believe the many docs who say there needs to be reform here. My guys say it all the time. Others can speak to that.

What do we do about the fact that among users of health care, some people abuse the system? Read any nurse blog out there, and you'll find stories of those patients we really don't enjoy taking care of. How do you make Americans responsible, accountable, fair users of the health care system?

What if every American was required to carry health insurance, the way that you must have car insurance to drive a car....irrespective of pre-existing conditions. Obama's plan could conceivably force this in a number of ways.

Would spending less money out of pocket motivate people to improve their health? Might there be incentives in discounts on monthly rates, or in deductibles or in percentage paid for services? Incentives for:

* Having a healthy BMI or weight range or body measurements range?

* For belonging to a health club? For fitness training? For working with a physical and/or occupational therapist for some post-op surgeries?

* For safe driving records (e.g. no DUIs)?

* For proof of appropriate annual checkups that make sense? Annual physicals, or well-baby, or gyne PAPs/breast exams for women over 18, eye exams for those who need it and for people over a certain age (40? 60? I don't know). Mammograms for women, prostate exams for men...etc.

* Among diabetics, incentives for having good quarterly HB1AC values? For going to cooking classes? Among ESRD patients, incentives for going to their dialysis appointments three times a week, having good monthly KT/V and/or albumin numbers.

I don't know. I'm not sure how to encourage Americans to take care of themselves. Saying 'this is good for you' is useless. Saying 'this is less painful and difficult for you' is useless.

I'm thinking out loud, and I don't think any of these are original ideas. How else could we curtail user abuse of the health care system. Quit giving Dilaudid to people not genuinely screaming in the ERs?

I beg my docs to not order 'stat dialysis' after hours for patients who blow their dialysis appointments the same day, come into the ER feeling crappy, but their potassium levels are not yet dangerously high. I ask if they can wait 12 hours until morning. Some of my guys do this, some do not. It's a cost difference of a couple thousand dollars to the hospital/Medicare/the taxpayer. Rarely has this 'stat dialysis' been for a patient who missed an appointment in good faith. It's usually people like Zack (see below). (Zack, by the way, has been back to Hospital B this week.)

What else can we do to prevent abuses by the users of health care?

Friday, August 21, 2009

A tale of two patients.

Meet Zack. Zack is 26, and will be dead by age 30. He has severe hypertension (240s systolic tyically, because he will not take medications to control his blood pressure). His kidneys have been blown out for a few years due to that bustin pressure, and he has an appointment slot at a clinic.

He doesn't go.

Last month, he was in Hospital A's ER "because he felt like ****." We dialyzed him, and he left AMA (against medical advice). He did not go to his scheduled dialysis appointments. Four days later, he returned to Hospital A's ER "feeling like ****." I dialyzed him, we discharged.

Last week, I saw him being dialyzed at Hospital B by one of my colleagues. I didn't ask why or when or whether he ended up again, leaving AMA.

Today, he was being dialyzed by a different colleague at Hospital C. He walked unaided to the inpatient dialysis room. This delightful boy flopped on the chair and barked at my colleage, "I'm having some ******ing pain, I need some ****ing Dilaudid. Those pills never work. It's chest pain. Eight out of ten." By the time we did our end-of-day hospital charges, his name was greyed out as being 'discharged'.

Now....call me stupid, but if you're going to different hospitals and sleeping over at least twice a week, going to your thrice weekly outpatient appointments seems like less bother. So is it about the ******ing Dilaudid that makes you want to spend the night at different hotels around town? If it's really that great, why not stay in the hospital and keep getting more?

I don't know for a fact that Zack doesn't pay for hospital bills, which cannot be less than $10,000 each visit.

But I do know that it is being paid for somehow, by somebody. The hospitals may write it off, but they do not take a cut in profit for someone like Zack. Those costs shift to elevated costs on other patients.

The next time I see Zack, I may ask him if he pays his multiple hosptial bills. I will be standing out of arm's length (he's thrown a punch at one of my colleagues, who is 60something and a grandmother and sweet as pie).

But I'll bet you're wondering the same thing, and for you, gentle reader, it might be worth the string of expletives.

****************************

Meet Josephine. She is 82. She is trim and active. Her two sons and their families live close by, and she has a strong network of friends. She went to the ER yesterday "feeling strange and nauseous" and they found Josephine to be in a rapid AFib. She was cardioverted today, and popped (tentatively) into sinus rhythm. (Cardioversion = low-end electric shock to heart in controlled environment.) (This can hurt.)

We also found her creatinine and BUN to be elevated enough that acute dialysis was appropriate. The cause of the acute kidney failure isn't yet clear.

She was profoundly exhausted when I arrived to dialyze. The fentanyl and versed had knocked her tiny, drug naive body SO hard that she got Narcan'ed and Romazicon'ed (reversal drugs...unpleasant to even watch them being administered). Fortunately, she does not remember this. She just really, really wants to sleep.

So I set up my half-ton of equipment and did my chart review and lab review and normal routine. Got her blood spinnin. I had assured her that once it was going, she'd have a nice quiet nap. If she woke up, I'd be at her bedside, charting and reading if she needed anything. Easy. That's what we did.

A few minutes into her dozing off, her eyes suddenly snapped open, "Is this? (she points to me and to my machines) Is this paid for by my Medicare?"

...."I'm sorry??"

"Because I have Medicare and supplemental insurance through ABC Company." She was genuinely worried.

....

Here's a LOL (little old lady) who just had 50 or so Joules direct to her heart, a cocktail of narcotic and anxiolytic that tied up her brain's opioid and other happy receptors so completely, her respiratory drive started to crap out...and then they administered meds to rip all those happy molecules right off her brain (ouch!)...and then I come in, slurp her blood into a machine, whip it around, pul off more electrically charged molecules, dumpin protein into her body to keep the blood pressure stable...and...

And she couldn't drift off to sleep because she wants to make sure she can pay for my services.

...

....

Saturday, May 2, 2009

Ejection fraction of 4

F O U R

Patient walked into the ER, and within an hour, fell down, went boom, and landed himself in the ICU with FIVE maxed-out pressors, cooling blanket, CVVHD....everything but a head bolt.

Think about that: ejection fraction of F O U R.

When his heart beats, it spurts out 4% of the blood volume that sits in his heart while it is at rest. How many cc's you suppose that is? If his heart has 100cc at rest (possible, but probably more), it would pump out 4cc at systole.

I can spit more than that.

Jeez, if I'm sleepin good, I can DROOL more than that.

And what does it mean to max out dobutamine and dopamine on a heart with an EF of FOUR? Dobutamine, dopamine, levophed, epinephrine and vasopressin.

The frustrating thing to me is that I don't get to find out what the hell happened to this guy (other than the obvious cardiogenic shock...*why* the cardiogenic shock, I won't know.)

EF of 4. New record for my personal little observations.

Tuesday, April 21, 2009

The conscience clause.

This may be one of my last posts to Sinus. But I’d like to get involved in one more nurseblog debate on the conscience clause and the discussion as to whether Obama should work to undo this legislation.

Namely, Emergiblog Kim’s initial post here

And subsequent ‘rebuttals’ (if you will):

Duncan Cross wrote.
And Manchmedic wrote.

I agree with Manchmedic.

I think that the government has no place regulating …as part of a state Constitution (much less Federal)…what private American worker should do as part of their job description for a private employer. Legal precedent exists to protect workplace safety (OSHA, child labor, harassment). The government can direct a soldier to war, because that soldier enlisted for that job description. (I don’t like the draft, either.) There are laws about taxation on income, and discrimination.

But this conscience clause is about driving contractual details (i.e. job description and responsibiities) between private corporations (i.e. non-VA hospitals) who hire citizens as employees.

Despite the fact that all civilized people believe that workplaces should be equal opportunity, the need for actual LAWS within a state or federal constitution that direct how workplace equality is to take place is still debated.

California nurse to patient ratio laws are new. Some CA nurses have said that their ratios are better, and they've lost ancillary staff and charge roles as hospitals even out the bottom line. That the ER's overflow. Government with good intent is slower than private enterprise. Perhaps not the optimal solution.

In my opinion, Dubya confused church and state and understood neither. Our founding fathers were very clear on this whole church-state separation thing. This issue is not about God, or beliefs, or hot-button Roe v. Wade.

It’s about what your employer expects that you do for them.

Do you really want the state constitution getting involved in that?

On this ground, I think the clause is a horrible idea and should be un-done.

****

There’s a secondary reason why I disagree with the conscience clause.

I believe with every molecule comprising my body that every human being should be treated that way when they leave. That they should be treated in a way that THEY direct. That we should do the utmost to provide for THEIR needs. That they are free of pain. That they are treated with dignity and respect. That we do everything we can to alleviate the other horrible undignified ‘symptoms’ of the dying process: nausea, vomiting, incontinence, wakeful coughing, clinical anxiety. And in the best situations, people are surrounded by love. The reality is that not everybody’s gonna get that. But I believe it’s what we need to aim for.

Some nurses like sunrises. I like sunsets.

Babies are great, fun, joyful. When I am the best nurse I'm capable of being, it's often with a patient who has made a decision that they're ready for their next big adventure. I am a rabid advocate for pain and symptom management.

I don’t believe in flogging bodies through endless complex procedures that have poor chances for positive outcomes. But sometimes I do it. I'm dialysis, for chrissakes.

There are many situations where I have participated in medical care that violates my humanist beliefs in the right for a patient's dignity and self-direction. Every ICU nurse has participated in cases that have gone before ethics boards. The young person who is HIV+ and after long, protracted illness, wishes to die. A parent wants everything done. Ethics board decides to go for the gusto. Dialyze!

A patient whose family has such financial interest in keeping patient alive that they are able to get him declared mentally incompetent under suspicious circumstances. When clinical psychiatrist, after thorough evaluation of patient, finds patient (to no surprise from staff) to be not only sound, but erudite and thoughtful about his own care, lawsuit by family ensues.

The dialysis patient who is a social work nightmare who becomes pregnant…the highest risk pregnancy I have ever seen. Patient has multiple hospital readmissions since the birth. Have we done that child any favors? Will the child become president or did we bring a human being into terrible suffering and adversity?

I find it morally reprehensible to paralyze a patient with vecuronium and provide no pain medication. I have done so and charted the hell out of the calls to the cardiovascular (bastard) surgeon who had me perform this odious torture. I advocated for my patient in much gentler ways through the family (uneducated in such medications) as well.

I have NOT given blood to a Jehovah’s Witness with a hemoglobin of 5, because the patient does not want that intervention. The patient understood that a lot of physical suffering could be alleviated. To the patient, the spiritual suffering would have been worse.

At no point in time did it ever occur to me to refuse to care for any of these patients. My point here isn’t that any good nurse would not have provided the same care. My point is that a pro-lifer's moral difficulties with abortion are very like my moral difficulties with the 92 year old CABGx5.

But here’s the rub:

IT’S NOT ABOUT ME.

If I don’t want to do the job, I can find a different job. There are nursing jobs that will not put me into a situation that violates my humanist values. My chosen nursing path so far is one of the least morally obstacle free I could have chosen for myself: critical care and dialysis.

However, if I am not going to choose to get a different job where I find such tasks ‘morally repugnant’, I choose to be a professional. You do your job. You prolong the life, you give the person comfort AND advanced intervention of Western medicine. Chemo. Or dialysis. Or intubation. Or surgery. Whatever.

It is not for me to decide whether or not a woman should have an abortion, or a 92 year old should undergo a cardiac bypass graft times five. It’s not for me to decide a crack addict has any business going home with her premature baby. It’s not for me to refuse to take care of an critically ill withdrawing alcoholic/any-other-substance-abuser because I think alcoholism/substance is ‘bad’. Or whatever.

I volunteered at a health fair today and a man asked me which substance be more 'okay' for his heart condition: cocaine, marijuana, alcohol or speed? I answered his question indirectly: cocaine and speed will kill you. No, I don't want him to go smokin pot.

It is for me to provide the best clinical and compassionate care for the patient that I can. I’m not giving up my personal rights as a nurse. Nobody’s asking me to have open heart surgery. Or do anything with my body. Or take up heroin. If I find somebody else’s medical choices to be repugnant, that is entirely my problem.

Besides.

Nobody LIKES abortion. Think about it. Whether you’re pro-life or pro-choice, nobody thinks abortion sounds like a fun time, or something that’s really cool. Nobody says, “Hey! Let’s murder a fetus/baby (whichever you prefer) today!” No. Nobody wants to have one. Nobody wants their daughter to have one. We are all in agreement on this point.

The great thing is that we don’t have to agree on whether abortion should be available to women or not. Abortion is available to women by law and has been since Steely Dan was cool and I was still in diapers. In 2003, one method of abortion was made illegal, thanks to Dubya. Nobody is asking any of you nurses to ‘participate’ in that procedure, as no one is performing it in this country.

****

I don't need a clause in the constitution of my state to tell me that I can refuse to participate in a medical procedure.

If I have a problem doing my job, I can refresh my resume.