Emergency Response: Escape to the Country
Mackenzie Jones wanted nothing more than to lay her head on the desk, close her eyes, and sink into blissful oblivion. She stared at her patient in the bed in the semi-darkened room. The rhythmic sound of his labored breathing was lulling her to sleep. The clock on the wall read two forty-five. Less than five hours to go. Hours earlier, when a colleague called in sick, Mackenzie had willingly agreed to do a double shift and work the night duty. Although she needed the extra cash, she was now regretting her decision.
The intensive care unit at the hospital in Sydney where Mackenzie worked was one large, open space, overfilled with all manner of equipment. The original design of the thundercloud-gray windowless room was for eight patients at a time. Now, twelve beds squeezed side by side in the room, all of them occupied. Tonight, five intubated patients filled the unit – tubes down their throats, ventilators breathing on their behalf. The room was softly lit and calm and would have been hypnotically relaxing except for the constant whooshing of the respirators, chiming of alarms, and the nauseating sound of suctioning every hour or so.
“How are you doing?” Sarah asked in a hushed voice.
Swiveling on her stool, Mackenzie stretched her arms above her head and stifled another yawn. “I am so tired.”
Mackenzie’s colleague Sarah was looking after the patient in the next bed – Maddy, a sixteen-year-old girl who had decided life wasn’t worth living anymore. She’d overdosed on a mixture of her mother’s blood pressure medication, her father’s sleeping tablets and a handful of her own anti-depressants. For good measure, she’d also swallowed half a box of paracetamol. The day before, paramedics had brought her into the emergency department, comatose, and within hours, she was in the unit. She would remain “tubed” for the next few days while her parents kept an almost constant bedside vigil praying for her physical and emotional recovery. Mackenzie was glad Maddy wasn’t her patient.
Tugging at the band that held her brown hair into a high ponytail, Mackenzie allowed it to fall loose around her shoulders. She dragged her fingers through the knots before scraping it back up again. For some reason she was plagued with misgivings. Or was it just over-tiredness causing her to worry about her own patient.
She recalled the brief handover from the afternoon shift: Noah Michaels. Thirty-one. End-stage bowel cancer. No other past medical history. Six months earlier Noah had felt unwell after returning from his honeymoon but had put off going to see the doctor until it was too late. An open and shut surgery found his body riddled with cancer. He was now in a semi-coma with all his major organs shutting down. The disease had spread throughout his entire body and everyone expected this to be his last admission.
Mackenzie pulled out Noah’s file and opened it. At the top was a single sheet of paper. An alert sheet. On it were the letters “NFR.” Not For Resuscitation. The medical world’s way of saying if a patient went into either respiratory or cardiac arrest they were not for resuscitation. It was Noah’s way of wanting to die in peace.
Mackenzie checked the drug chart next. Written up were two medications. Morphine and Diazepam. One for pain. One for sedation. Both “PRN.” As required. Mackenzie just had to keep him comfortable. She flipped through the history some more and read the doctor’s notes. They all said the same thing. Noah’s prognosis was nil.
“At least you have an easy patient to look after.”
Mackenzie raised her eyebrows at Sarah. An easy patient? Mackenzie wasn’t so sure. “I hope you’re right. I’m not even sure why he’s still in ICU to be honest. I only have to do hourly obs and keep him comfortable. For his sake I’m glad he’s settled, but it’s making the night drag. Just as well I brought a book to read.” Mackenzie waved the fat romance novel in the air. A bookmark punctuated her place toward the end. “At least it’s quiet. Kick me if I nod off to sleep okay?”
Sarah chuckled softly. “You know better than to say that.”
Sarah turned back to Maddy and Mackenzie glanced at Noah. Except for the thin sheen of sweat across his brow and his pasty pallor, Noah was a good-looking man. Tall and dark haired, his skin was unblemished and smooth. He played footy in winter and cricket in summer and ran his own landscaping business. He had the whole package – a gorgeous wife, two parents who loved him and a devoted sister. Had he been single, he was the kind of man Mackenzie would have fallen for in a heartbeat.
She glanced to the large photo of him and his wife taken on their wedding day. Sophie had Blu-Tacked it to the wall where everyone could see it. In the photo they stared at one another with looks of pure devotion. Sophie had left at midnight to go home to shower and change and wasn’t expected back until seven. She had slept the night before beside Noah’s bed on the uncomfortable recliner they brought in for her, but tonight Mackenzie had convinced her to go home and get some sleep in her own bed. She promised to call Sophie immediately if Noah’s condition deteriorated or changed in any way.
An alarm pinged and Sarah got up from the desk at the foot of the bed and hit the silence button. Mackenzie glanced at the monitor above Maddy’s bed. Her blood pressure reading was low.
“Everything okay?” Mackenzie asked.
“Yeah all good. The arterial line is positional.” Sarah sat back down and crossed one leg over the other. “So, what have you got planned for the long weekend?”
“I’m going to Birrangulla for Kate Kennedy’s wedding.”
Kate was a friend and former work colleague who had given up city life the year before and fled to the country after a long-term relationship disintegrated. She’d fallen in love with Joel O’Connor, an Irish barista, and after a whirlwind romance they were getting married. It was like something straight from the pages of the romance books she loved to read – the stuff of Mackenzie’s dreams.
Sarah smiled. “That’s right. I’d forgotten it was this weekend. Give her my love won’t you?”
Mackenzie opened her book and became so engrossed in it she jumped when an alarm sounded. She glanced at the screen. Noah’s oxygen saturation levels were only ninety percent. That couldn’t be right. They had been one hundred last time she’d looked. Mackenzie checked the probe, but it was still attached to his finger. Noah’s heart rate was slow too. Mackenzie felt his pulse. It was thready and weak. She hit the button to inflate the automatic blood pressure cuff and thirty seconds later the machine alarmed, alerting her to a low blood pressure. She frowned and silenced the monitor so it didn’t drive everyone else in the unit crazy.
“What’s up?” Sarah asked.
“Hmm, not sure. Heart rate and sats are both down. BP’s down too according to the machine, but it can’t be right. I’ll check it manually.”
Mackenzie tugged the cuff from the wall and wrapped it around Noah’s upper arm. The heat coming off his skin startled her. Jamming her stethoscope in her ears, she inflated the cuff and listened carefully as she deflated it, watching the needle on the gauge closely. Blood pressure was definitely down. Seventy systolic. It had been sitting at a hundred an hour earlier.
“Noah?” Mackenzie paused for one beat. “Noah?” Another beat. “Noah!”
She squeezed the muscle that ran from his neck down to his shoulder and he groaned and briefly opened his eyes. She caught a glimpse of dark brown irises before they rolled back in his head.
“Do you need help?” Sarah asked.
Mackenzie tried to hold back the panic. “Can you flick the light on for me?”
A second later, the overhead light came on and Mackenzie’s heart sped up. The skin around Noah’s mouth was ash gray. His eyes remained closed, but he groaned, moving his head from side to side. He was obviously in pain. His hair was damp and the pillow drenched from sweat. His legs moved restlessly beneath the crisp white sheet.
Mackenzie swore under her breath.
“What?” Sarah asked.
“He’s in pain.”
“So give him some morph.”
“I gave him some a couple of hours ago.”
“How much has he gotten written up?”
Mackenzie checked the drug chart. “Five to ten milligrams IV every hour. PRN.”
“How much did you give him last time?”
“That’s probably not even touching the sides,” Sarah said.
Mackenzie let out a frustrated sound. “You’re probably right but if I give him too much he won’t clear it from his system. His kidneys have just about shut down completely. It will just build up and suppress his resps even further.”
“So?” Sarah asked.
“So. I don’t want to be the one that causes him to stop breathing.” Mackenzie kept her voice low. “I know he’s in pain but his BP is already low. I’m afraid if I give him more morphine it’ll drop his pressure all the way out. And I’m not doing that. Not while his wife and family aren’t here.”
She rechecked his blood pressure. Still low. His respirations were shallow, his breathing ragged. The machine beeped loudly again.
“You need any help Mackenzie?” The nurse in charge called out from the other side of the room. Greg. Older, wiser, always calm.
Mackenzie twirled her ponytail around her index finger and watched Noah struggle to breathe.
Greg approached the bed. “What’s up?”
Mackenzie rubbed her eyes. She was so tired her brain was fuzzy. She explained her dilemma to Greg.
“You need to call Sophie and his parents,” Greg said evenly. He handed her the phone from his pocket. “Now.”
She sucked in a deep breath and exhaled, wishing again she hadn’t agreed to work overtime.
While waiting for the family to arrive, she gave Noah a quick freshen up. He was damp and had been incontinent. Mackenzie grabbed gloves from the box on the wall and removed his gown, covering his body with a towel. Greg returned with hot wipes and together they sponged him down. Rolling him to one side, Mackenzie washed his back and buttocks before spreading out the fresh linen on her side of the bed. They rolled him back over the bump of old linen and wet towels and Greg finished making up his side of the bed. Noah’s low moaning changed to a deep guttural groan as they moved him around in the bed.
“He needs more pain relief,” Greg said.
Mackenzie clenched and unclenched her teeth. “I know. But –”
“Don’t let him die in pain.”
“I don’t want him to die at all, Greg! I don’t want him to suffer, but I also don’t want to be the one who gives him the last dose of morphine that causes him to –”
Greg interrupted. “Helping patients get better is the easy part of nursing, Mackenzie, but we also have to help them die too. When death is inevitable, we need to make sure it’s as smooth and dignified as possible. For the patient and for their family.”
Mackenzie looked away and dashed the tears from her eyes with the back of her gloved hand. When she looked back at Greg on the other side of the bed, she saw the sadness crinkling his eyes.
“He’s going to die anyway, Mackenzie,” he said softly.
“Not on my shift he’s not!”
Mackenzie yanked off her gloves and balled them together. Aiming at the trash can, she wasn’t surprised when she missed and they landed on the floor. She scooped them up, washed and dried her hands and looked again at Noah. He was suffering. Why was life so unfair?
She pressed the heels of her hands to her eyes and willed herself not to cry. Was she just tired, or was something else going on? She didn’t usually get so emotional over dying patients. Maybe it was because Noah was so young and still in love. Or maybe after fifteen years of nursing, the emotional toll of her job was wearing her down.
Noah groaned again. He was in too much pain, and whether Mackenzie like it or not, she would have to give him more morphine.
Mackenzie followed Greg to the medication room. She didn’t want to do this, but there was no choice. Her hands shook slightly as she drew up the ampoule of morphine and then the normal saline in the syringe. Moments after administering the entire ten milligrams into his IV line Noah’s breathing settled and his restless movements ceased. By the time Sophie arrived with his parents fifteen minutes later, he was comfortable. It wouldn’t be much longer.
“They don’t put this into the nursing textbooks do they?” Sarah asked with a kind smile.
Mackenzie’s chest tightened. She turned to Sarah and allowed the unchecked tears to spill down her cheeks. “I can’t do this anymore,” she whispered.