Ode to Elsy

“Dr. Fuller – my little man’s kidneys aren’t very happy. May I please give him 20 mg of lasix?”

When I was an Intensivist in a very busy cardiac surgical ICU for those many years, Elsy was one of my favorite nurses.

She was experienced, rather tall, very confident, and somewhat Brazilian.

But Elsy was…’different.’

Elsy often operated from the right side of her brain, leaving a reluctant, easy going left side of her brain sitting comfortably nearby, eating banana bread, and observing us.

To be sure, the left side was very competent and worked just fine. It’s just that there were times (many times) when Elsy sort of gave the right side ‘free reign’ to rule her decision making.

As an example, if a patient’s urine output wasn’t what it should be, most highly trained ICU nurses would call me, give me a concise overview of the most recent biologic data, and suggest their recommendation that would support the data.

But that just wasn’t Elsy.

Elsy would simply ask: “Dr. Fuller – my little man’s kidneys aren’t very happy. May I please give him 20 mg of lasix?”

It would be confusing to her right brain if I didn’t just follow her recommendations without further questioning on my part. After all, she knew how busy (and exhausted) I was during my nonstop 24 hour shift, and she was only thinking of me. She was just trying to expedite my decision making so that I could continue with balancing the life and death decisions I was endlessly making for the other 14 patients I was simultaneously managing in the cardiac surgical ICU as well as 1 or 2 patients in the ER and 2 more in the medical ICU.

But it was equally confusing to me, as I operated almost exclusively from my brain’s left side with embarrassingly little regard for people’s feelings about almost anything. And so I was oblivious to Elsy’s kind intentions.

When Elsy would call, my brain’s left side was fully engaged and would begin with its usual analysis.

First, I would require Elsy to regurgitate all of the biologic data on her very complicated ICU flow sheet so that I could make an informed analysis and dictate a course of action.

·      Maybe we needed to increase renal perfusion by beefing up a sagging blood pressure and therefore reduce the vasodilators or increase the vasoconstrictors (e.g. levophed).

·      Maybe the patient is functionally dehydrated and needed a fluid bolus and not the fluid reduction that would result from lasix.

·      Maybe we need to make the heart pump stronger by:

o  Increasing the dose of dopamine or milrinone, or

o  Stop weaning the intra-aortic balloon pump (if present) and increase the firing ratio from 1:2 to 1:1, or

o  Reducing the PEEP on the ventilator, if the lungs would tolerate it.

·      Maybe we need to reduce the dosage of any nephrotoxic medications.

·      Or maybe we should just give it another hour or 2 and see if the trend continues.

And then, after all of that, I must admit…in the end, most of the time, I would agree with Elsy and instruct her to give the patient 20 mg of lasix.

Now duly exercised, my left brain felt fine.

Elsy’s right brain was still confused.

And the next time we worked together a couple of days later, we’d start all over again.

Today I received an e-mail from Elsy, wishing me a Merry Christmas. For some reason, maybe because of everything that all of us have been experiencing this past year, this simple and heartfelt greeting from Elsy nearly made me cry. The reality is, as life so often dictates, I will probably never ever see Elsy again.

Merry Christmas, Elsy.

I miss you.