What I Learned From Caring in the ICU
I struggle with how to describe what I do. When someone asks me about being a nurse, I try and keep it positive. The story I tell is one of redemption for myself and my patients. I relate how I’ve grown as a person or how my patients have recovered. I call my job “challenging” or “fulfilling”. I mention how it’s increased my compassion. I like the feeling of respect this can inspire. I like the goodness of this story, even if it’s not complete. There are still other words that, although true, I avoid using. It’s hard to talk about the sadness and fear I feel in the intensive care unit (ICU). I don’t like to mention the distress. And not just because I care for the sickest of the sick in the ICU. It’s because in a way I’ve come to resent my growing compassion for patients. A popular phrase used to describe nurse burnout is called “compassion fatigue”. The idea is that continual empathy and care can eventually lead one to be apathetic. This isn’t what I’m talking about. My compassion isn’t depleted; it’s troubled. I can deal with tough situations and the mad merry-go-round of patients and their ailments. I can handle the outlandish tools of medicine; the dangling tubes, wires, and monitors that can make a person appear defaced and unnatural. And while I’ve gotten to know the machines and used to seeing sickness, I’m not limber enough for the moral splits my conscience is forced to do. The lives of my patients are often tragic, and as my compassion for them grows, so does my sadness. It hurts to grow to care for someone and then learn that the world does not care for them.
As the patient improved over several days, we withdrew the aggressive interventions. The breathing tube was pulled, the sedation turned off, and we slowly met Tom. He was a fury. He rose with a thunder, screaming and thrashing as though possessed.
I remember Tom. He came to the ICU from the streets manic and with a serious medical condition that he couldn’t understand. He was out of control, homeless, and was unknowingly dying from an infection. A doctor put in a breathing tube and a nurse started the sedation. The patient was scanned, tested, and given medicine. As the patient improved over several days, we withdrew the aggressive interventions. The breathing tube was pulled, the sedation turned off, and we slowly met Tom. He was a fury. He rose with a thunder, screaming and thrashing as though possessed. The patient was vengeful and wild, hurling slurs or feces or fists whenever he was able. But he was still sick and his life required certain ICU interventions. If we sent him back to the streets or a psychiatric unit, he would surely die. We tried antipsychotics and pain medicine, but it only offered temporary relief from a tortured mind. Nurses were hit and the patient was restrained with arm ties. He would spend the nights swinging between the calming medications and attempts to rock his bed over.
Eventually we heard from Tom’s family and talked to his kids. Tom used to have a conventional life with a degree, a job, and a house. His mind then slowly took everything from him. The story of Tom’s life began to play out in my head. I imagined how he used to drive through traffic to work, how he came home one day to see his wife had left him. I thought about how he sat at home in sadness, too depressed to go to work, and lost his job. With no health insurance and no family, his safety nets were gone. He lost track of the rules of society, no longer knew how to care for himself, and ended up on the streets.
This image of Tom’s past life humanized him for me and the other nurses. We would sit by him and try to talk to him. We would put on movies and take off his restraints. He was still wild, and at times violent, but what if his former self was still in there? What if his reason was only temporarily lost and we could help him find it? When I first took care of Tom, he threatened to kill me. These were some of the worst shifts I have had as a nurse. After weeks he was walking calmly with me through the unit. We learned to trust and work with each other, even if we didn’t completely understand each other. My compassion for him grew.
I treat many people dying of preventable problems. I see a diabetic mom too poor to buy her insulin, ending up in a temporary coma. I see an uninsured man drinking himself to death to avoid the pain of a high school football injury… These moments of crisis occur at the end of a long series of societal failures for patients, where the ICU is their last resort.
When I was younger the world seemed fixed in place. I gave up on society too soon because change for me was a zerosum game. I couldn’t see the little successes. The world was broken and we were too corrupt to set it right. There was no mending a divided world, just little arcs of hope too short to make a bridge. Now I realize I was cynical. I recently read an article in Harper’s by Rebecca Solnit. She wrote, “Cynicism bleeds the sense of possibility and maybe the sense of responsibility out of people. There is a naive cynicism of those outside the mainstream who similarly doubt their own capacity to help bring about change, a view that conveniently spare them the hard work such change requires.” Confronting Tom’s behavior and empathizing with him was hard work for me and the other nurses. Yet there was an improvement to Tom’s condition, which ended in a certain victory for us. His family came and visited him and we got a psychiatrist involved in his care. We felt that, in caring for Tom, we had helped him regain a little bit of himself. That feeling was powerful. In that moment of solidarity with Tom, I had a sense that a bridge was built between us. But as compassion grew, a distressing sadness emerged. How did Tom end up here, in my ICU? I wondered where he would go and who would take care of him? Tom’s past and future looked bleak, and it hurt to have compassion for him.
This wounded compassion has opened up a desire for social justice, an indomitable belief that universal health care is a human right. The world is unjust because as I care for some people, I learn the world does not care for them. I imagine if Tom, after losing his job, still had health insurance he wouldn’t have ended up on the streets and eventually in my ICU. I imagine he would have gotten the mental health care he needed, before he forgot how to care for himself, before his health would sour. And I see Tom in many of my patients. I treat many people dying of preventable problems. I see a diabetic mom too poor to buy her insulin, ending up in a temporary coma. I see an uninsured man drinking himself to death to avoid the pain of a high school football injury. I see a fractured insurance system that fails to insure rehab after repeated suicide attempts by someone’s wife. These moments of crisis occur at the end of a long series of societal failures for patients, where the ICU is their last resort. I don’t resent compassion; I resent a society that lacks it. Empathy helped bridge the divide between Tom’s distress and my own world; brought me to a see the human cost of inequality. But bridges do that﹣they insure us against difficult paths and make the distance between us smaller.
Grant Trenary was born in Vancouver, Washington and earned his bachelor’s at Reed College. After working with wine and cheese for a few years he went on to earn is bachelor’s in nursing from Regis University in Denver, Co. He finished a nurse residency program at Legacy Health in Portland and currently works in the ICU there.