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This site is for student nurses or nurses starting out. Letters to a Young Nurse are blog posts written like letters to help you find your way and make your journey as a nurse less difficult. 

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Clear Your Mind and LISTEN! Part One

Updated: Jul 20, 2023




On a Friday night a few summers ago, I was called to perform an apheresis treatment on an elderly gentleman at a VA hospital in Northern California. This man, who I will call Mr. White (MW), had an extremely high white blood cell (WBC) count due to a diagnosis of chronic lymphocytic leukemia (CLL). Many times, patients initially discover they have cancer from a freakishly strange phenomenon of abnormally high WBCs. The normal WBC is 4,500 - 10,000 cells/mcl. A majority of these patients with high white cells have a count of 500,00 to a million. The bone marrow goes crazy and starts churning out WBCs in response to cancerous cells in the body. The major problem with this condition is that WBCs are bigger than other blood cells and when initially released by the bone marrow they are immature in nature. The normal infection fighting capacity is not present due to their immaturity. And their size is so large that an accumulation of them can cause strokes in the brain or an embolism in other organs. It is a critical condition that must be treated emergently.

This night was different in that it was early evening when I got the message on my pager. (Usually whoever was on call got called out in the middle of the night or early morning). The sun was still shining, there was a cool breeze, and everyone seemed to be outside enjoying the weather and each other. Because of MW's extremely brittle immune system he was in isolation which meant I would have to gown, glove, mask and sit in a single room in the ICU for this treatment that could take anywhere from 2-5 hours. This particular ICU had rooms circling the nurse's station and the walls and doors were made of glass. Everyone called it the fishbowl. As I sat there in the ICU I felt like a tiny fish in a huge ocean. To make it worse MW's room was at the far end of the circle which meant I would be alone with him and my machine. Needless to say, I was feeling sorry for myself.



The procedure I was performing, leukopheresis, involves attaching two tubes to the patient's central line and slowly removing the patient's white blood cells blood while replacing it with Albumin as needed. A patient could have their entire blood supply cycled thru the machine 2-3 times. As the blood cycles thru (a technology based on an 18th century cream separator) the desired element WBCs is separated from the rest of the blood. The goal for each leukopheresis treatment is a reduction in WBCs by 5-10,000 WBCs. The machine is dependent upon the operator (usually RNs) peering into the window of the machine, down into the centrifuge and manipulating the levels to get a good layer built up in the centrifuge. It is an amazing technology that is relatively young in the medical world. It took many years to perfect the technology and some of the first clinical trials were done on Rhesus monkeys. The operator manipulates the speed of the centrifuge to pack a vertical layer of the elements of the blood. The heaviest element goes to the bottom, the lightest to the top. If the machine dips too far into the layer by going too fast, then other blood cells are picked up and less WBCs are removed. And vice versa if the speed is too slow. Taking too many WBCs off too quickly can leave the patient in shock. And not removing enough increases the risk of stroke and embolisms. I had performed the procedure so many times previously that I manipulated the machine well enough to get at least 10,000 to 20,000 WBCs off at a time. The goal after approximately 5-10 treatments is to get the patient started on chemotherapy and or hydroxyurea, a medicine that prevents WBCs from building up in the patient's system.


MW was sedated, on a ventilator and not doing well. Half-way through the treatment MW's regular nurse said she was going on a break and another nurse would be overseeing his care. While I am performing a patient's treatment there must be another nurse assigned to monitor and perform procedures not associated with Apheresis treatments. The covering nurse entered the room a few minutes later to deal with the zillions of IV's the patient had hanging. As she quietly worked she kept looking into MW's face. I sat next to the machine, peering in and feeling sorry for myself. Quietly Joyce looked at me and asked, "can I tell you a story?" Since I had a few more boring hours to go I gladly responded with a "yes!" For the next few minutes as she hung IVs and took down medications she told me a true story about her husband. Joyce was in her early 30's as was her husband and they had a daughter aged 8 years old. She told me about her husband's struggle with leukemia. As she told me about his diagnosis she looked at our mutual patient and softly and with tears in her voice said that her husband had the same diagnosis as this patient. She went on to tell me about her own father dying of leukemia when she was 8. The irony of it hit me and my first thoughts were how could I feel sorry for myself when this woman has been through such pain? Her husband was a paramedic and had been diagnosed with leukemia 2 years earlier after a routine physical revealed the diagnosis in a man who had not been sick a day in his life. He battled the disease for 2 years but during the last 6 months of his life he had to be hospitalized. Joyce worked nights and spent her days with her husband in the hospital. In the last few months of his life he asked Joyce to get him a video camera, so he could film messages for her and their daughter. There were days when he was too weak to film any messages so his daughter would pick up the camera and say "Daddy, just talk, it doesn't matter what you say, just talk". So that is how they spent his last few weeks. 4 weeks before he died Joyce realized that the treatments were not working and after discussion with her husband they decided it was time to go home with hospice. Joyce asked the oncologists how much time her sweet husband had if he stayed in the hospital. The consensus from many of the physicians involved were 5 months at best. "And how much time does he have if I take him home?" she quietly asked. One month was the answer she was left with and which prompted her to take him home. She took time off from work which depleted their savings but t was 0time she knew was priceless to all 3 of them. He passed away in the early morning hours of 9/11, not knowing that the world had changed for everyone that day including two people closest to him. But Joyce has hours of film and messages that they watch when grief encroaches too closely to them.


For some reason I was prompted by some unusual force in that room to ask Joyce a strange question. "Had she ever seen him since he died?" With a quick intake of air, she breathed out slowly and answered. "I have never told anyone this, but I have seen him 4 times since he passed". She went on to explain that she had seen him twice in her nighttime dreams and twice during the day. All 4 times were centered around an especially stressful time in her life when she REALLY needed him. He spoke to her with reassuring tones and calmed and grounded her during times of intense grief.

As she wiped the tears from her eyes she loudly and with great humor in her voice asked, "bet you never expected a story like that, huh?" And we both laughed. Before she left the room, she turned and while intently looking at MW said, "go home and hug your loved ones tight, spend as much times as you can with them because we have no idea how little time we have left with them!"


The most ironic part of this incredible encounter was that Joyce normally works on another unit but had been floated to this ICU when there were sick calls. The stars aligned perfectly so that I could learn a powerful lesson about living in the moment and being grateful for the time I have with those that I love deeply. It can be difficult with so many tasks we must do in our day to sit and listen to a patient. But those are the times that remain in your memory. Those are the times that keep us coming back day after day to help strangers (our patients) get better. But you cannot listen deeply when your mind is busy with the argument you had with your spouse earlier, or the hundred things you have left to do before you can go home, or if you are scrolling through your phone. I make it a practice to find a seat in my patient's room, even if it is the end of the bed. Getting down to their level makes the connection easier and deeper. Standing above them does not build connection, it keeps you separate from them. Try it and let me know if it feels different. And LISTEN.



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