An ICU Nurse’s Journey Through The Night
1:23am rolls around and five of us are seated in the back of an operating room staff lounge. We were the second of three organ procurement teams to arrive on site at a Podunk community hospital, and while time is, of course, of the essence — in the wee hours of the morning, it appears to stand still. Chopped is on the television and provides background noise for the motley crew of staff ranging from technicians to nurses to medical students to surgeons. While one sloppy contestant slices his finger on a jagged shard of lobster shell, my mind drifts into a state of wonder: I wonder about everything related to the process of harvesting and transplanting an organ, and what might be going through the minds of the others who share the quietly intense environment with me. Slicing and dicing: somehow that feels oddly appropriate given the circumstances.
While I am an ICU nurse — in this situation, I am merely a peripheral member of the prescribed list of attendees. I tagged along on the harvest of a human heart for transplant not as a clinician but as a curious observer. I convinced myself that my job was to ask questions; watch intently; and piece together the gaps in a process that seemed as familiar as it was foreign to me. Despite being something of a bookworm, I had little interest in neither the didactic nor the clinical component: rather — I had always wondered, with a sense of curiosity more meta than morbid — what does it feel like to be present for something as immensely saccharine and somber as organ transplantation seems to be?
For over a year, I’ve been harassing my attending transplant surgeon for permission to watch the loop close: from donor to recipient; from one life lost to a second chance gained. While the team was openly accommodating to my requests, somehow our stars failed to align. I wanted to write about a life-altering experience, dammit — and what was more momentous than retrieving an organ from one body and implanting it into the next?! However, as I quickly learned, heart transplants rarely happen during the day. As a matter of fact, organ procurement was often intentionally conducted overnight for a variety of reasons. And so after a year of trying and failing to accommodate my own work schedule to participate in the unpredictable and lengthy process that is harvest and transplant, my opportunity finally presented itself.
12:15am. I was on a strict timeline to meet the attending transplant surgeon near the emergency department entrance. I had worked the entire day in my hot and heavy surgical ICU, bobbing and weaving and working on caffeine and positive energy to help a critically ill patient…maintain. Sometimes, progress isn’t possible. Maintenance is the best you could hope for. Once I received word of a transplant looming in the near future, I caught the attention of the transplant surgeon between surgeries and received his blessing to join the team. The donor organ was relatively local, and this would allow me to ride with the team in a straightforward fashion. Any sort of air travel, be it via helicopter or private jet, might have required a bit more convincing on my end.
I left my thirteen-hour shift and returned to my home for just shy of two hours, jumping up and down like a kid on Christmas morning. If this sounds sadistic, I assure you, it isn’t. Well…I suppose it sort of is, but it’s not as black and white as it seems. As an ICU nurse, I exist every single day in the gray area. My job is to navigate those murky waters — the ocean of issues that lies between ethics and morality; prosperity and futility; acute and chronic; life and death. Does that sound dramatic to you? Like some fluffed up Grey’s Anatomy sh*t? I can assure you — minute-to-minute; hour-by-hour — I make no exaggeration.
After scaring and perplexing my husband with an unexpected burst of energy and excitement regarding the next eight or ten or twelve hours of my already exhaustive day, I opted to forego taking a cat nap in favor of cheap Mexican take-out and a hot shower. If ever there was a place for your brain to enter overdrive, it’s in the steamy sanctuary of your own bathroom. The list of questions and concerns that poured throughout the wrinkles of my mind included life and afterlife and complexes — both God and chemical — and even the unfortunate decision to eat black beans for dinner.
After tossing my freshly washed hair into a mop-top bun and throwing on blue surgical scrubs that were at least two sizes too big, I left the house with a minimalist approach to what I considered to be appropriate operating room observer essentials: a granola bar; six dollars in cash; a pack of gum; and a blank notebook.
With four shots of espresso in hand, I walked up to the entrance of my home base hospital at just shy of eleven-o-clock in the evening. I experienced a very severe and highly visceral moment of panic as I walked toward the security locked access that required special clearances after hours: what the hell was I doing? Was I seriously going to hop into some organ transplant wagon and stroll into another person’s operating suite, incapable of bringing anything to the table short of some annoying questions and a presumably obnoxious sense of awe? What gave me permission to witness the carving and emptying of one human being for the benefit of who knows how many people from God-knows how many places? What made me have the audacity to think that I would be accepted as a fly in the wall let alone have the balls to think I should write about it? Who even gives a sh*t? Would anyone even care?
Thankfully, I unlocked that door. Thankfully, I walked into that ICU. Thankfully, I took a ride in that SUV with red lights and blaring sirens and the smooth sounds of Sade and Mary J. playing on the sound system. Dissonance seemed to be a theme for the evening. The entire experience felt like a constant point of tension: like a strand of hair or a rubber band being gently tugged at both ends. At any point, the force could create a break…but with just enough tension, the circumstances remain taut.
The concept of organ donation is something that we as a society seem to discuss so infrequently that we flippantly consider nothing more than a stupid question at the DMV…that is, of course, until you and yours require someone else’s life to end for your second chance to begin. I have long considered the components of this transaction: the prospect that one life gone is another opportunity (or sometimes, multiple opportunities for many people) gained. I have laid awake at night reading about the legends and lore of cellular memory and how some component of an organ donor might be carried into its recipient. I have questioned the morality and ethics surrounding leaving a body intact and preserved versus understanding that we are merely all vessels through which souls and spirits are shipped. I have studied transplant drugs and learned the post-surgical protocols and cared for heart transplant recipients at every stage of their recovery. But that middle piece: that’s what was missing for me. The element of organ donation that went from Google searches and annual mandatories to the actual physical exchange from one being to the next. The theoretical: I got that. It was the literal that perplexed me.
Late that night…early that morning…stands as one of the only moments in life where I can recall questioning and thanking God all in the same breath.
I have seen many patients die. Some I have tried to prevent. Others, I have helped to transition. Some were bone-crushing and drug-pushing and blood-slinging efforts. Others were…quiet…calm…tastefully tearful. Regardless, nearly every patient I have seen pass away has done so through cardiac death. Heart stops beating. Lungs stop breathing. The sort of dying most of us are accustomed to. Brain death, however…that’s a confusing one: even for me, and I see people die regularly. Brain death feels wrong because it often looks more like the most peaceful sleep of your life than rigor mortis. Patients who meet brain death criteria are dead — legal; declarable; documentable. Yet the patients sometimes seem so…alive. They might be pink and warm and without a scratch on their bodies. Their chests move up and down in a rhythmic pattern and despite being set on a ventilator it appears very life-like. They generate vital signs, whether assisted by medicated infusions or not, and they maintain a pulse and a blood pressure and a godforsaken heartbeat. And so it can be confusing and conflicted for both professional and personal interests to accept the idea that brain death and cardiac death are immensely different endings.
Somewhere around two-o-clock in the morning, I felt conflicted. I felt confused. And I felt the calm before the storm. It was a surreal moment to watch a donor escorted into an operating suite and being draped and prepped in a sterile fashion. I have watched surgical procedures before — in fact, many routinely occur at the bedside of my intensive care unit — but there was such a sense of finality that plagued me. Who was this donor? Did the donor have a family? Friends? A profession? Why was this donor here, lying before me as I stood at the head of the bed with the anesthesia provider, and not in possession of some less tragic fate? My mind raced with possibilities. I fought from deep within to contain my sense of nausea and bewilderment and dread because I asked to be here! I volunteered to do this! I wanted desperately to understand the sea of emotions that come with this process yet the experience was about to knock me down like a ton of f*cking bricks. As surgeons scrubbed and nurses prepped and members of the organ procurement team double and triple verified whatever the hell it takes to allow the donation to proceed, I watched quietly on a six-inch high stepstool in anticipation of how this might end. I told myself to leave the room before my knees buckled or my stomach turned or I fainted and caused a scene. Up until this point, the entire evening had been a waiting game, but despite the downtime my heavy eyelids were losing the competition to my pregnant thoughts. This…this was so very different from the joy and excitement and fear experienced by my previous interactions with recipients. This felt…well, it felt f*cking morbid.
And then it all washed away. Then the inner turmoil shifted. Just as I questioned the morality and meaning of it all…just as I uttered one more, “Holy sh*t, this is insane,” under my breath…a moment of silence for the departed. It was in that moment that I watched a room of fifteen or so sterile and stoic professionals turn fundamentally human. It was in that moment that I felt the hair on my arms stand on end. It was in that moment — one of quiet reflection for someone out there’s dearly departed — that I remembered the gravity of the moment. The donor has already gone — much like loved ones grappling with grief, I had been tricked by the rise and fall of a chest wall before me. The donor was deceased, and it aligned with the individual’s own wishes to give another chance to someone who still here. And so with scrub caps and surgical instruments, a memento mori unlike any other lay before me.
There is a reason the heart is a symbol for so many things. To some, it represents love. To others, it indicates depth of meaning. In terms of purely scientific reasons, if your heart doesn’t function you’re pretty much screwed. It turns out; the heart is also the priority in an organ donation harvest situation. The word harvest, as a sidebar, feels significantly out of character given the nature of the circumstances. Once again, the dichotomy of a term that seems better paired with fruitful abundance than the procurement of human organs strikes me as odd. Perhaps “scavenging” doesn’t have the same feel to it…but really, it appears to be a sharply executed scavenger hunt with the ultimate prize at stake. Three teams of surgeons stood at the patient bedside amid a sea of blue drapes and silver scalpels that felt all-too fitting for the holiday season. At the periphery of the field there were coolers reminiscent of a backyard barbecue during the Fourth of July. They created a mismatch to the workflow of a cold and sterile environment, better suited for diet soda and lite beer than life-saving organs in an operating suite.
Tick-tick. On the clock. With the first cut of a surgical blade, the energy shifts from potential to kinetic. Not only is there constant coordination and communication with home-base hospitals and surgical teams, another element comes into play: just because one is deemed a donor, doesn’t mean they will be considered suitable. There are a million one reasons for donor organs to be rejected, and this can be a total mind-f*ck for the patient awaiting transplant. Whether a heart or a kidney or a liver or a lung, the entire process feels more like luck than odds. Even when you make it past finding a donor to match your blood type; even when you receive a phone call at home; even when you’re rushed to the hospital; and even while you’re lying under anesthesia on an operating room table; you still might not have a transplant. To add to the stress, just because you receive an organ doesn’t guarantee you’ll do well. Complications happen. Rejection is a potential. Science and medicine enable us to do amazing things every day, but even still circumstances can fall short of expectations. When you throw in the reality that someone else had to die for your chance to live…well…dissonance. A running theme.
Once the transplant surgeons affirm or deny procurement of whatever body part they came in search of, everyone must defer to the heart transplant team for further action. A heart is strong but it is sensitive: it has a limited shelf life on ice compared to other organs. That is to say, there is a tight window of time that the tissue of a heart is considered viable for transplant. Four hours from the time of harvest until the last stitch in another person’s chest cavity. Given the immense pressure to optimize this narrow timeline, no organ can be procured from a donor body until the heart transplant recipient is physically opened on the operating table. No seriously: that’s a literal statement. Like, the recipient’s chest cavity needs to be opposite of closed in the interest of time. If at this point you’re trying to keep track of how many doctors and nurses and technicians and team members are required to orchestrate this process: trust me, there are more than I could have imagined, and some that I never even knew existed.
Our home team would need approximately ninety minutes to begin the process of preparing the heart transplant recipient for the big show, and that called for more downtime at the donor hospital until the call was made. I didn’t realize just how many stopgaps were in place for this process — all, presumably, with very good reason. However, as we entered the witching hour of three-o-clock in the morning, I could feel the burden of being awake for nearly twenty-four hours start to settle in. Surgical residents snacked on stale graham crackers and sipped on black coffee to stay mentally sharp: this was, after all, only the beginning of the process…and the next phase was punctuated by a stopwatch and an ice box. I went to the ladies room and adjusted my scrub cap — my eyes appeared glassy and the bags started to show through. I thought about taking a short nap but worried that missing even a moment’s worth of the process would alter the experience. I pulled a chair up next to the television of the break room to lip-read what Benson and Stabler were up against in this episode of Law and Order. While most of the medical staff remained in the operating suite monitoring the donor, a nurse appeared at the door with a pile of scrub jackets. While I had taken to feverishly writing down my thoughts at a frantic pace, she offered us a semblance of comfort in the form of a warm coat and some dim lighting. The exhausted transplant surgeons all sat in a row behind a scratched brown table…backs against the wall…one snoring gently enough to make the tuft of hair on his head flutter gently like a fallen feather. I couldn’t help but consider the tremendous amount of pressure they must have felt: individually; collectively; not only as physicians with pride in saving lives but also as humans. We are all flawed. We all make mistakes. Yet for them and others in their shoes — there’s no such thing as an “oops.” Up until this point and for the remainder of this process…well, f*cking up is not an option.
I took a snapshot of this moment in my mind, and it will forever serve as a reminder of the humanity in medicine. Surgeons are trained to create a disconnect. They are not intended be lovey-dovey or mushy-gushy or become attached to the patients charged with their practice. And yet I watched as they sprung to action the moment a go-ahead was given, and I sensed the dynamic shift once again. The storm was here; the calm had passed; and now it was time to sink or swim. I find it difficult to believe that it’s possible to be a transplant surgeon and not care about your patients or their outcomes — the stakes are too high. The pressure is too great. The pride is too priceless. And the outcomes are as directly correlated to your capacity to slice and suture and anastomose, as they are your capacity to give a sh*t. Just moments before four in the morning, everybody gave a sh*t. Tension. Dissonance. Compassion. Man, transplants are f*cking crazy.
Imagine a game of Hungry, Hungry Hippos. Everyone stands around a board and battles the opponents for the last bites of whatever delicious white game pieces might remain on the playing board. Now imagine a chess match…thoughtful; calculated; strategic. Now marry these two ideals, throw in a human donor, an operating room, and numerous patients waiting for a new organ, and you’ve got the bizarre game of organ harvest. I don’t mean to minimize the process — in fact, I’ve never been so awe-struck in my entire professional life. But if you want a semblance of what it feels like to be standing at the head of the bed when a transplant team agrees to cross-clamp an aorta…short of being graphic, that’s the best I can muster. We as a society are so reliant on time: we check our smart phones and we mark our calendars and we plan ahead by days and weeks and months and years, and yet here I stood…completely transfixed by the idea that — quite literally — every second counted. Inherent to the time checks was the implied pressure of a tangible countdown: everybody knows when it’s 11:59pm on New Year’s Eve. Every single second felt like 11:59pm.
Before I knew it, between suction catheters and ice cubes and scalpels and Kelly clamps, the transplant surgeon declared with the same pride I imagine an obstetrician delivering a newborn baby, “The heart is out.” Where a heart pumped, an empty cavity remained. Heartless. Literally speaking, heartless. I stood…speechless…as the value of this gift of life felt immensely more tangible; literal; meaningful.
I give my heart to you.
It was in this very moment that I witnessed modern medicine flit between prose and poetry. It was in this very moment that all of my reservations fell by the wayside and my expectations lifted: amid tragedy, there can be beauty. In the face of loss, grace has potential. Where darkness lives, silver linings are always possible.
The rest of the evening feels like a blur. After the organ was prepared and secured, we rushed back to the SUV. The transplant surgeon made sure I was buckled up. While we weren’t especially far from the hospital, there wasn’t a moment to spare. The music that played on the sound system was quite a departure from the smooth sounds of Mary J. Blige on our initial ride: much as the mood has shifted, so had the soundtrack. I watched the speedometer needle move further to the right as we zipped by the start of early-morning traffic. Lights swirled and sirens blared and my brain was in a tizzy fitting of the mood. I noted the shift in the energy of the transplant surgeon: he seemed…invigorated. Adrenaline, it appears, is a drug quite unlike any other. Here I sat, buckled into a leather seat, listening to music, speeding down the highway…with a human heart in the trunk.
We made it to the side entrance of the hospital in what I would consider to be record time: after all, this was my first and only experience in the back seat of an organ procurement vehicle. Nonetheless, I followed the surgeon as he wheeled the Coleman cooler into the massive line of operating rooms. While the donor harvest had felt more intimate, the sense of urgency coupled with the sheer size of my own hospital by comparison immediately amplified the intensity. Once again I stood behind the curtain near anesthesia, this time feeling an entirely different sense of astonishment. My exhaustion faded when adrenaline coupled with fascination kicked in. I had always watched surgeries on television as a child: I felt a sense of intrigue regarding that in-between state of awake and asleep; conscious and sedated; alive yet dependent entirely on another to keep you that way. I watched blood flow through the bypass machine as the team carefully cut out the native heart of the recipient before me. Once again, I saw someone heartless — literally, devoid of a heart. The open cavity struck me once again, this time less as poetry and more as an epic saga. How would this story end? How could this journey unfold? Did one chapter end, and another begin — or is this…is this a book entirely re-written? And when I finally saw the last stitch in place…when I finally watched the heart begin to beat…when I finally witnessed the final moment of a loop I so desperately wanted to close…I understood that I had witnessed a series of events most could never even fathom.
Not every outcome will result as predicted. Sometimes, life throws you a curveball. Other days, you get the grand slam. There is no way to know what might come, for even the best-laid plans may fall through. But goddamn…this thing we call life? It is so f*cking precious. It is so tragic and so dark but that’s when the light can best shine. Donor. Recipient. Give. Take. Beginning. Ending. Sometimes…beginning again. I have never felt more human…I have never felt more humbled…than I did as a silent observer on that crisp autumn night. I walked to my car in the light of day — disheveled and functioning on some sort of an indescribable high…and I placed my finger on the inner aspect of my wrist. I felt my own pulse. My very heart beating. And I found new meaning in what it means to be alive.
Originally published at medium.com