1. Davis, Charlotte BSN, RN, CCRN

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As I drove into work, I prepared myself for the busy night shift. I had kissed my husband and teenage daughters goodnight. Leaving them at home watching a family night movie without me was always difficult. However, I had a job to do and I loved that job. I was well rested, in a positive mood, and ready to take on any Level I trauma patient that rolled through the doorway. Or so I thought...


As I opened the doorway into my trauma unit, I immediately sensed that we were preparing for a bad arrival. It was in the air-a sense of hyperalertness and a flurry of meticulous activity evolving. The respiratory therapist was pushing a ventilator into the room. Nurses were methodically setting up a vacant ICU patient room with a rapid volume infuser and a therapeutic hypothermia device and monitoring system. Both were only used in specific, life-threatening cases of massive blood loss and severe brain swelling. The rapid volume infuser could quickly infuse 1 L of I.V. fluid or 1 unit of blood in less than 1 minute. The central venous cooling monitor would cool the critically ill patient's body temperature down to 33[degrees] C to slow the cerebral metabolic activity and preserve neurologic and cardiovascular tissue. I had seen this medical device save many patients' lives and also preserve their brain functioning. I also knew as I put my personal items away in my locker that no doubt this would be my patient. The bad ones were always my patients.


I was one of the senior-most experienced trauma nurses on duty that night. I was the one who other nurses turned to in critical situations. I would share both my knowledge and my hands without the nasty comments or demeaning looks that often made young nurses fearful of asking others for assistance. Although this worked out well for my coworkers and patients, it usually meant that I left physically exhausted by the end of my shift.


As I walked out of the locker room onto the unit, I saw and heard the familiar voices of my coworkers pointing at me and saying, "Unrestrained driver ejected from a vehicle less than 45 minutes ago. Patient is on the way up. ETA is less than 2 minutes." I snapped on my gloves and without a second to ask who, what, where, and why, the trauma doors bolted open.


The patient had arrived, only 16 years old with beautiful long, cascading blonde hair that hung in curls framing her face. That's what struck me first-the blonde curls. Her eyes were closed as if she were sleeping. Upon closer inspection, I noticed the ominous trickle of blood and fluid from her left ear that was steadily dripping into a larger pool of blood under the cervical collar. It had saturated all of those lovely curls. She had been intubated in the field by emergency medical service workers.


We quickly stabilized her BP with multiple vasopressive drips and I.V. fluids. Then off to radiology we went. A traumagram was performed to scan her from the top of the head to the bottom of the pelvis looking for injuries. My heart sank as I watched the images of her head splash across the computer screen. Quietly, we watched as image after image showed a severe midline shift to her brain and bleeding around the pontine. This shift was caused by massive swelling and shearing injuries to the fragile blood vessels of the brain. Silently, we knew that this young girl wouldn't make it-this injury was too severe.


We tried everything, of course. Extraventricular drains were placed to shunt cerebral spinal fluid off the brain to give it a little room to swell without damaging the fragile tissue. As the physician prepared for placing the drain into the ventricles of the patient's brain, he shaved off a large section of her hair. This was a common procedure I had assisted with many times before. But today, something was different. I watched as curl after curl gently cascaded to the floor. Soon they would be swept away and discarded by environmental services. When I looked at her, she resembled my eldest daughter. I couldn't leave the curls there. I quickly picked up three large handfuls of the locks and placed them in a biohazard lab specimen bag. I secured the lab bag to her side rail with silk tape. I knew if things progressed, as my experience told me that they would, the family and funeral home might need these beautiful tendrils to prepare her for viewing by family and friends.


We administered concentrated 3% sodium chloride I.V. fluid to decrease the circulating water content of the brain to hopefully allow the brain additional room to swell. We cooled her body down to a chilly 92[degrees] F (33.3[degrees] C) to slow the brain swelling. But, sadly, her intracranial pressure continued to rise from 22 to 31 to an unbelievable 45 despite all of our aggressive efforts. Every few moments, I adjusted her I.V. drips to control her BP or erratic heart rate. We tried every aggressive treatment that was available and nothing was working. I prepared myself for the family visitation hour.


Her mother and father quickly took a seat beside the bed. Her father stroked her forehead and bent down to gently place a kiss there. His eyes closed painfully as he kissed her forehead. Tears were silently streaming down his face. Her mother had grasped her hand. She asked, "Can I hold her hand? Can I talk to her?" I didn't have the heart to tell her that the last head scan revealed massive damage to the temporal area of her brain, likely rendering her deaf. I looked at her mother's pained eyes, grasped her hand, and said, "I think she would like that. I think it might bring her peace to hear your voice, so please do." Her mother and father had already been told that she would likely die in the next few hours. And who knows, perhaps this young girl could still faintly hear her mother's voice or recognize a loving hand stroking her hand. Perhaps, it did bring her some peace.


It was almost like a chess game. We kept making strategic, aggressive moves, using every heroic intervention medically available to save her life. We monitored her heart rate, pulmonary artery pressure, arterial pressure, heart rhythm, BP, serum lab values, cooled body temperature, urine output, and pupillary response. We administered aggressive medications to lower her racing heart rate, reduce the brain swelling, and raise her failing BP. With each move our healthcare team made, it seemed that her body made a more aggressive move. We were losing this battle despite all of our efforts.


Seizures were racking this poor child's body despite our aggressive loading and maintenance dosages of neuroleptics and benzodiazepines. Her pupils were unequal and she was exhibiting decorticate posturing. My mind was working overtime contemplating what else our team could possibly do to help this patient. The chief physician came and sat beside the patient's bed surrounded by our healthcare team: "Does anyone have any other suggestions?" Silence followed his question because our team knew; we had fought the good fight, but this battle we were losing. We all watched as her heart rhythm erratically raced despite the maximum dosages of powerful cardiac medications. Sadly, the chief physician shook his head and grasped the patient's hand in his as if he, too, wanted to silently tell her, "I'm so sorry, we've tried everything."


The patient's mother asked if her younger sister could visit. She said that her sister was really struggling with incapacitating grief and she didn't know if it would be too traumatic to see the patient with all of the invasive lines, tubes, machines, and drains. I talked to my other team members and asked the mother to give us 20 minutes to prepare the patient for her sister's visit. After they exited the room, we quickly sprang into action and bathed the patient, removing all traces of dried blood and betadine. I then placed a new white towel under her head and gently folded it into a makeshift turban that hid the drain in her head. I placed crisp white sheets over all of the equipment in the room. I then placed a light green surgical blanket over her body from her toes to her shoulders, gently placing one hand on a crisp white pillow. The room now staged, we allowed the younger sister in.


Her mother and father gasped when they saw the room. Every monitor and medical device was either covered or adjusted to where only the physician and I could see them. Tears filled the mother's eyes as she quickly grabbed me for a tight hug. The patient's younger sister looked at her, all draped in white and said, "Look, mommy, you're right, she's already turning into an angel. She's so pretty." The mother began crying and hugging her youngest daughter as they said their goodbyes. She turned to me and said, "Thank you, we prayed for an angel to take care of our daughter and God listened and he sent us you. Thank you. Thank you for all of this and all you've done for both of our children."


I remember thinking that I was an experienced critical care nurse; I was supposed to experience empathy, not sympathy. These tears weren't supposed to be filling my eyes as I watched this family struggle to say goodbye to a 16-year-old child. As my shift ended and I left for the day, I said a silent prayer for both my patient and her family. I prayed that she either begin her return to health or that she have a peaceful end to her short life. When I returned, she had been declared brain-dead after experiencing brain stem herniation 9 hours after I left.


I entered through the trauma doors for my second night and found the physician waiting for me. He informed me that the patient's family opted for the gift of organ donation and that they had only one request. They wanted me to accompany their daughter to surgery and stay with her during the procedure so that she wouldn't be "alone." This was highly unusual because nurses never accompanied patients during organ donation. They said it brought them peace to know that I would be there with her because they knew I would make sure she was handled with great care and dignity. They informed me that their daughter always had a fear of being alone and expressed how important it was that someone who truly valued her accompanied her to the OR. Their choice was me and I was honored.


I worked with the organ procurement team to ensure all interventions were made to maintain organ viability. Betadine was instilled in her nasogastic tube to preserve her kidneys, saline was gently instilled as eye drops, and saline-soaked bandages were padded over her closed eyes to ensure her corneas remained viable. I made sure all of the forms were signed and that we had a funeral home contact number. The time had come to take her to the OR.


I scrubbed in and stood in the corner of the operating suite. One of the organ procurement nurses stood beside me. I think she could read my mind as I tried to find the reason for such a loss. "What good could possibly come from this?" I thought. Quietly, I heard the procurement nurse say, "One kidney is going to save the life of a mother of four children. The other kidney is going to help a 13-year-old girl. One lung is going to a veteran, the other to a college student. The corneas will help a young father see his children. The liver will go to a mother of two. The pancreas is going to a 20-year-old art student. The heart is going to a 12-year-old boy who says he wants to be able to go camping with his Boy Scout troop. He had to quit the Boy Scouts last year after an infection left him with profound heart damage. He has been on a cardiac balloon pump for over a month because his heart is failing. So much good is going to come from this."


I felt someone grasp my gloved hand and squeeze it. I realized that tears had begun cascading down my face minutes before. "Thank you for sharing that with me," I said. "I needed to hear that." I don't know how she sensed that I needed to hear it, but she did. So many lives would be saved from this one family's final gift.


We're taught to model empathy and not sympathy. I had crossed that line because all I saw was the loss of another beautiful young life. I wiped the tears away and true to my word, I stayed for the entire procedure. Afterward, I waited for the funeral director to arrive to transport the young girl's body. Moments later, I was filled with both a great sadness for the loss of life and an intense sense of hope for the patients and their families who would be forever changed by this family's heroic gift. I thought about the family's concern that their daughter not be left alone because she feared being alone. Through their loss, they had given the ultimate gift-the gift of life.


On that incredibly difficult day, I was so honored to be the nurse providing care for this family. On that day, I would've RN (rather not) been anywhere else in the world. Albeit difficult, this was the place that I was meant to be...right this moment in time.