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I back away from her. “Let me call the doctor,” I say, which I do and, in time, he comes. He does an exam and orders tests to check different aspects and function of the brain and her awareness. He orders continuous infusions of a sedative as needed to keep her comfortable until she’s ready to be weaned from the ventilator.
Caitlin doesn’t open her eyes again for the rest of the day, at least not that anyone sees.
What I know about coming out of a coma is that it’s a process, split seconds of awareness and lucidity followed by a slip back into the dark void of unconsciousness. This is the way it often happens and is the way it will likely happen with Caitlin. But then—if I’m lucky—there are things like locked-in syndrome, which is so much worse and is what I hope for every time I think of her and her marble-like eyes staring blankly up at the ceiling: that she will be locked in.
It’s rare but it happens. Locked-in syndrome is when a person’s mind might function to the full extent, their cognitive abilities are still intact—they can hear everything happening in the room around them; they feel pain and all external stimuli—but their muscles don’t work right. They don’t work at all. The person is paralyzed, wholly incapable of movement except for the vertical movement of the eyes. In other words, a fully functioning mind is trapped inside a nonfunctional body. It’s hell when you think about it, to be able to hear and think, but not scream. To have an itch but not be able to scratch it. I’ve read accounts of people suffering from locked-in syndrome, of them listening to doctors and nurses and loved ones talk openly about taking them off life support, letting them pass peacefully away because no one knows, no one understands that there is still life behind the eyes. Most don’t ever recover. Many don’t survive it. There are often complications, like aspiration or sepsis, and if I’m really lucky, she will be locked in and something like that will happen to her: she’ll aspirate, get pneumonia and die.
I shouldn’t think like that. I’m not a monster.
It doesn’t have to be that way.
She could live too and, if that were the case, she would eventually be transferred to a skilled nursing facility for care because she couldn’t stay here in our ICU for the rest of her life. That wouldn’t be so bad, not for me, not for her either, not when the alternative is death. A skilled nursing facility could better meet her needs. I think about her living out the rest of her life like that, with the ability to hear and feel, blink and think, but not much more, and there is some satisfaction in it, imagining how she could ruminate for the rest of her miserable life on what she did to me and others, and live to regret it. The staff at the skilled nursing facility might be able to teach her to communicate with her eyes, but even if they could, it could be elementary, rudimentary at best. She would never be able to tell them what I’ve done and, even if she could, it would be so easy for me to dispute it, to say that she’s mistaken or that someone misinterpreted what she was trying to say.
I’m in the room with her. It’s early the next morning, before visiting hours have begun. Caitlin’s eyes are closed and, at first glance, she looks unconsciousness.
But then I think of everything I know about this woman, about everything I’ve learned over these last few weeks, and wonder if it’s possible she’s bluffing, if she’s only trying to pass for being unconscious. I wouldn’t put it past her.
We assess patients’ brain function and consciousness using the Glasgow Coma Scale, which I have done at every shift that I’ve cared for her. The Glasgow Coma Scale measures things like motor responsiveness, verbal performance and eye opening, though verbal performance can’t be assessed on an intubated patient and so the highest she can score is 10 out of 15.
I start my assessment. Caitlin doesn’t open her eyes like a fully conscious person would, and so I have to speak to her, to see if she responds to the sound of my voice, though I’m reluctant. I don’t want her to respond. I want to pretend for as long humanly possible that she’s completely unconscious and unresponsive.
I blame myself. I got complacent. I got too relaxed. I took for granted that she would never wake up, but she has.
“Caitlin,” I say in a forced whisper, standing by the edge of the bed. There is no response and so I lean closer and say it again, unhesitatingly this time, not expecting her to respond.
“Caitlin.”
Her eyes fly open. I jerk suddenly back, plowing into the medical cart behind me, where items get jostled but nothing falls.
My heart pounds, a blast beat on the drum.
From two feet away, I watch Caitlin’s face. Her open eyes stare up at the ceiling tiles.
The next step is to assess whether she responds to pain. I don’t want to touch her, but I drag myself back to the bedside to pinch a couple inches of the trapezius muscle between my thumb and index finger. I pinch lightly at first and then gradually harder, and this time she reacts, her arm subconsciously flexing, bending at the elbow as if to pull away from the pain. I step back again, letting go. She can move, which comes as a letdown because it means she’s not locked in.
I tally the results in my head. Today she scores a seven on the Glasgow Coma Scale.
She was at a three when she came in, which is as low as a person can get.
She’s getting better.
In the break room alone, I try to catch my breath, to think.
Caitlin Beckett is improving. It’s only a matter of time now until the respiratory therapist comes to try and wean her off the ventilator. Once Caitlin can breathe on her own, she will be able to speak, and I wonder what she will say and if her memories are still intact.
The TV on the break room counter is on; it’s the midday news and they’re saying how the police are getting closer to finding the man who has been attacking women in the city, and I should be relieved, grateful—I should turn the volume up so I can hear it better—but my mind is somewhere else, and though I notice the voice of the reporter, I have my back to the TV and am only hearing her words at surface level. I don’t mentally absorb them because I’m thinking about Caitlin and what I’ve already done and of what I need to do, because I can’t take any chances. The latest victim fought back. Scratched him. Debris from fingernails. DNA.
I need to kill her.
I need her dead.
It’s not that I want to do this. I’m not a killer. I save people for a living. The idea of taking a human life is unthinkable. I can’t imagine anything worse, but I have so much to lose if she lives.
That said, it’s possible. I can kill her. If you work in a hospital long enough you know that some medical mistakes are inevitable. Every nurse has made them in his or her career. I certainly have. We used to hear horror stories back in nursing school, and I remember when I first started working at the hospital, how I went into every shift just hoping and praying I didn’t accidentally kill one of my patients that day. We’re human, and everyone makes mistakes, but some mistakes are worse than others, more egregious, things that range from improper documentation to administering the wrong medication, maybe one meant for another patient, and sometimes it’s okay, there are no adverse effects, but sometimes someone might have an allergy to a certain medication and die as a result. Even something like improper documentation can have fatal consequences if a nurse doesn’t document a medicine a patient takes and someone else also administers it. Some mistakes have ripple effects like that, and then before you know it, a patient has overdosed and died.
There is a shortage of nurses in the workforce these days. Burnout from the pandemic is real. In the last few years, it’s led many to rethink their career choice and to leave the profession en masse, which puts even more pressure on the rest of us. While the number of critical care nurses has been depleted, the number of patients continues to grow. They still come, despite the fact that we don’t always have enough room or resources to care for them as well as we should. It’s a known fact that inadequate nursing staff is directly aligned to patient mortality. The fewer nurses we have, the more responsibilities we have. We’re spread thin. We’re physically exhausted and emotionally drained. As a result, mistakes happen. It’s not necessarily due to bad doctors and nurses, but systematic health-care problems. It wouldn’t be my fault. It would be the fault of the system. What people don’t know is that fatalities from medical errors are one of the leading causes of death in America, though they don’t tell you that. Instead, it’s misrepresented as something else like cardiac arrest, when in reality it was something like a fatal drug mix-up; a programming error; the injection of air into the arterial line to cause an embolism or infusing something like potassium too fast.
What I wonder is if a nurse makes a mistake that results in the death of a patient, is she criminally liable?
