PixelRN

There was a 26 year old patient that I took care of the night before I left for a long weekend in San Francisco. She was found unresponsive in her home with her 18 month old baby running around the house naked. Her insulin pump was off. She had a history of poorly controlled diabetes and she was 12 weeks pregnant. It was unclear how long she had been unresponsive, it could have been as long as 48 hours. The night that I cared for her, she had just had an MRI which showed cytotoxic edema and  a good portion of her brain was no longer functioning. In short, not a good prognosis. The death of brain cells is almost always permanent. And the fetus was simply too young to be sustained, even if the woman was kept alive on life support. Although interestingly enough, this had just happened with a Virginia woman.

So it was a very sad night. Her husband and some family members were at the bedside. They had been explained the MRI results and the poor prognosis, but it hadn't seemed to sink in yet. For myself, that was the most heartbreaking. I watched them trying to wake her up and falsely interpret her eye movements as hopeful signs that she would get better. Later the husband slipped her baby's shirt under her still hand and went to the waiting room to try and sleep. The shirt had a tiny little baby food stain on it.

On the upside, I got to perform neuro checks on her every two hours and was able to see some features of brain injury that I had never seen before including decerebrate posturing, doll's eyes, and positive Babinski reflex.

So I went to San Francisco for a few days and when I came back to work I was given this patient again, only she had died fifteen minutes before the start of my shift. This meant that I was responsible for her post-mortem care. I was somewhat apprehensive, as I had not done post-mortem care during my orientation and so this was, in fact, my first time. The unit was somewhat busy but I managed to find another nurse to help me lift the patient onto the stretcher to take her to the morgue. When we entered the room to do this there was a strange but somewhat familiar odor. We pulled away her sheets and saw that she had expelled the fetus. The site was both disturbing and mesmerizing. How often do you get to see a perfect thirteen week old fetus? I certainly had never seen one. The perfection of it was amazing. So tiny, and yet each little toe and finger were perfectly formed.

Then the troubles started. No one really knew what to do about the situation. In the whole history of my unit this had never happened before. What do you do with the fetus? I told the team of physicians who were rounding at the time. The matter was further complicated by the fact that they hadn't yet asked the family if they wanted an autopsy. And this factor would determine where I sent the fetus – either to pathology, or to the morgue. And what do I put the fetus in? One senior nurse said to just wrap it up with the mother and take it down. But what if the fetus was missed, or got thrown away by accident? What if the family wanted to bury the fetus? All of these issues had to be dealt with and yet I had never even done post-mortem care on a regular deceased patient! And I was caring for another patient the whole time this was happening. Everyone involved from the charge nurse to the attending was quite unsure what to do, and it wasn't exactly a priority considering the rest of the unit was filled with patients who were still alive. I was frustrated, confused and kind of in a state of shock.

Finally, like an angel, the palliative care nurse swept through the unit, came and grabbed my hand, looked me in the eyes and said, "You shouldn't be going through this alone. Let me get you some help." I almost burst into tears. I felt like a small child who doesn't cry when they fall if no one is watching, but the minute someone takes notice, they cry. I did not cry, however. Not at that particular time, anyway.

One by one, all of my questions were answered, and I was able to properly take the mother and the fetus to the morgue.

24 hours later, a very good friend of mine gave birth to a beautiful, healthy, baby boy in the same hospital, 5 floors below my unit.

And on that note, I'll end with a lovely picture I took at Big Sur.

PS: Tommy died in the MICU last week with his headphones on, listening to Radiohead.