I have never asked if other nurses are addicted to the obituaries like I am. Every day I go to the local news section and peruse the death notices. I look for people who I have taken care of, and usually find one or two a week. I like to spot them and read about their lives, and think about them before I knew them or their families. I like to hear about their careers, loved ones, and accomplishments. I like to see smiling faces, and think about the lives they have touched.
Most of my patients don't get obituary mentions. Some come from out of city or state, but mostly I think it is because obituaries are EXPENSIVE. It cost about $600 for a Sunday listing with a picture. I know this from personal experience, and it upsets me that people can't share the life of their loved one because of financial reasons. The obituary and burial/cremation expenses can run in the thousands or ten thousands if you can swing it. Death sucks enough without adding up a numeric value to the life of someone you can't imagine living without. So, it short, I do not fault my families for not sharing more details with me in the print notice - I just appreciate it when I can.
If I do not see any of my people, I still read about dear Aunt Mabel, and 23 year old Brandon. I take in the stories and sadness and bring it all close to my heart. As common as death is for me, I still am at times overwhelmed by it. The last memories put to paper are a poignant part of the grieving process, and allow me to connect with people in a way that I have to restrain at work. While I am always comforting and understanding when I am with a patient and family when death is near, I always hold myself apart, still ready to react and intervene if crisis arrives.
Drinking my coffee, laying in bed, and locking the kids out of my room; the Sunday paper lets me relax with death, and more importantly, appreciate the wonderful living people have done.
Monday, December 21, 2009
Friday, December 18, 2009
Incompetence is a four letter word
Recently a nurse from another unit and I were talking. He is a good work friend to me. We get lunch sometimes; hang out in the hall and chit-chat. We talk about relationships, bad managers, and gripe about the political bull that we have to endure at our lovely hospital. ‘I’m going to go to the yellow team room and ask out one of the residents.’ He announces. ‘Which one?’ I ask. ‘The R2, I think her name is (blank)’. He replies with a glint in his eye. I flashback to my previous week with her and cringe. In the ICU you get to know your residents very well. ‘Oh God, not her’ I say rolling my eyes. He gets a worried look on his face and asks ‘What’s wrong with her?’ I go over some of my recent experiences with her and the team she is supposed to be overseeing, ‘Frankly my friend, she is incompetent’. He lets out a sigh and looks down. This is the worst insult of all.
I feel bad as I write this. If someone called me incompetent, I would be horrified. This is a label that cuts to your very foundation if you have a Type A personality like I do. Most professions are important enough that to be incompetent would be unacceptable. You want your mechanic to be qualified, childcare to be safe, a bartender who takes care of you, and an accountant who will keep the IRS away. Some professions only require adequacy, where there isn’t much to loose. Depending on how well the job is done, you may or may not get called on again. Healthcare is different. You don’t get to choose your doctor or nurse in a hospital. You are at the mercy of people you hope to God won’t forget about you. People you pray will optimize care for you, working tirelessly to get you better faster, and let you go on with your life in the real world.
Not all healthcare workers have the same philosophies. Some strive for excellence, some adequacy, and the others just try to stay under the grid, not really caring, hoping no one notices. It seems that many nurses and doctors are satisfied if their patient is alive at the end of the day. I guess that this would be adequate performance by some standards, but for me is not quite enough. The far side of the spectrum is the resident (or nurse for that matter), who looks good from the outside in the morning during rounds, saying the right things, nodding emphatically and writing down the plan for the day, and then walks away as if all patient care has been completed. They don’t check on the patient, respond assertively when a nurse calls with issues and questions, nor do they make measurable goals with solid outcomes, change care plans, call for back-up when the patient is circling the drain, and then they are surprised when they get reprimanded the next day. They are children who have no sense of obligation or duty it seems. Maybe they are intimidated by critically ill patients and use denial and rose-colored glasses to camouflage the true nature of the patient’s condition. Whatever the reasoning, there is no excuse for letting your patient crumple in front of you and then failing to respond. That is when I call the fellow. Too late, unfortunately in this case. But, of course the doctor still fails to take any responsibility the next morning, instead blames nursing for not putting in IVs, or relaying patient condition information, when really, they were on call all that night, and failed to make plans for your patient before midnight and it was too late for such and such procedure. So my friends, I did what any assertive ICU nurse would do, I got even with her for trying to make me look bad. Yes, vindictive I know, but it felt really good.
The attending who has known me for over three years became very informed of all the team’s shortcomings, and how the inability to have any accountability was an affront to the nursing staff which has shown repeatedly to have excellent patient care skills and intuition. He nodded in agreement with me, and with his jaw set, said he would have a talk with her/them.
The best residents and nurses who can see a holistic vision of their patient. They see beyond the hospital stay. They see the patient before he came, and what it might be like when they leave. They work for the benefit of the patient everyday, not just keeping them alive, but making their lives better. Getting them stronger physically and emotionally, giving dignity and understanding throughout the patient’s stay.
Incompetence for me is a four letter word, and I hope that I never have to be a patient of someone who doesn’t understand this. However, you can try to date and screw one who is apparently. As my friend so succinctly put: ‘Well whatever, she’s hot’.
I feel bad as I write this. If someone called me incompetent, I would be horrified. This is a label that cuts to your very foundation if you have a Type A personality like I do. Most professions are important enough that to be incompetent would be unacceptable. You want your mechanic to be qualified, childcare to be safe, a bartender who takes care of you, and an accountant who will keep the IRS away. Some professions only require adequacy, where there isn’t much to loose. Depending on how well the job is done, you may or may not get called on again. Healthcare is different. You don’t get to choose your doctor or nurse in a hospital. You are at the mercy of people you hope to God won’t forget about you. People you pray will optimize care for you, working tirelessly to get you better faster, and let you go on with your life in the real world.
Not all healthcare workers have the same philosophies. Some strive for excellence, some adequacy, and the others just try to stay under the grid, not really caring, hoping no one notices. It seems that many nurses and doctors are satisfied if their patient is alive at the end of the day. I guess that this would be adequate performance by some standards, but for me is not quite enough. The far side of the spectrum is the resident (or nurse for that matter), who looks good from the outside in the morning during rounds, saying the right things, nodding emphatically and writing down the plan for the day, and then walks away as if all patient care has been completed. They don’t check on the patient, respond assertively when a nurse calls with issues and questions, nor do they make measurable goals with solid outcomes, change care plans, call for back-up when the patient is circling the drain, and then they are surprised when they get reprimanded the next day. They are children who have no sense of obligation or duty it seems. Maybe they are intimidated by critically ill patients and use denial and rose-colored glasses to camouflage the true nature of the patient’s condition. Whatever the reasoning, there is no excuse for letting your patient crumple in front of you and then failing to respond. That is when I call the fellow. Too late, unfortunately in this case. But, of course the doctor still fails to take any responsibility the next morning, instead blames nursing for not putting in IVs, or relaying patient condition information, when really, they were on call all that night, and failed to make plans for your patient before midnight and it was too late for such and such procedure. So my friends, I did what any assertive ICU nurse would do, I got even with her for trying to make me look bad. Yes, vindictive I know, but it felt really good.
The attending who has known me for over three years became very informed of all the team’s shortcomings, and how the inability to have any accountability was an affront to the nursing staff which has shown repeatedly to have excellent patient care skills and intuition. He nodded in agreement with me, and with his jaw set, said he would have a talk with her/them.
The best residents and nurses who can see a holistic vision of their patient. They see beyond the hospital stay. They see the patient before he came, and what it might be like when they leave. They work for the benefit of the patient everyday, not just keeping them alive, but making their lives better. Getting them stronger physically and emotionally, giving dignity and understanding throughout the patient’s stay.
Incompetence for me is a four letter word, and I hope that I never have to be a patient of someone who doesn’t understand this. However, you can try to date and screw one who is apparently. As my friend so succinctly put: ‘Well whatever, she’s hot’.
Monday, November 9, 2009
Fun at the morgue
Going to the morgue is one of the most nasty parts of my job. I pawn it off on new orientees and escort services when I can. The morgue is not a place like they show in TV shows. Our morgue is this weird, cramped space with stainless steel tables set up with overhead shower sprayers. It has fluorescent lighting, sloped tile floors with a central drain to wash away bodily fluids. Walls are lined with shelves of glass containers that contain various organs, labeled with names of people I have taken care of. There are tables with cutting devices, pliers, hammers, and saws. It is straight out of a Frankenstein movie, and it really freaks me out.
Of course the times that I do go, it is at night when there is no other staff to force into it. I walk down with the escort, pushing the draped and wrapped body. We don shoe covers and go into the dark morgue past all the jars and dissecting equipment, to the body refrigerator. We open it, and look for an open shelf to place the body. The floor has a small pile of various wrapped limbs. Legs and arms wrapped in hospital sheets. The worst part of this experience is transferring the body to our archaic, rickety lift that deposits the body on our chosen shelf. We must slide the body onto this metal tray and use a manual lever to lift the body up to the proper elevation. This lift was designed for a 175 pound person, not the 300 pounders that frequent our establishment. The tray wobbles back and forth, barely making it to the needed height, and yes, it has almost tipped someone out. We reach up with gloved hands and shove the tray in place. Our friend is deposited with the other six for either autopsy or delivery to the funeral home. I wash my hands twice as I leave. I shudder at the thought of going there.
Despite the distaste I have for the morgue, one of my favorite lunch breaks is spent on Fridays at the weekly autopsy review. This is usually the haunt for doctors and eager medical students. Nurses don't much come to these briefings, but I always feel welcome, and some doctor who knows me will pat the stained cloth seat for me to sit next to them. The debriefing that follows consists of a medical history, circumstances during hospital stay, and a run down of the death events. The radiologist pulls up CT's and x-rays, and then the fun begins. The resident step up eagerly and a large metal tray is pulled out of the fridge across the room. The organs of importance are unveiled and I see the patient I took care of in smaller pieces. The forensic doctor, or whatever he is, stands by and talks about the cool findings during the autopsy. He is a pudgy short man wearing a plastic apron and boy, does he love his job. He picks up each organ and carefully plys away at the intricate dissection. he shows blocked arteries, enlarged livers, and even the surprise necrotic brain tumor they never expected. He encourages the residents to put on gloves and feel the rubbery nature of the spleen, inviting them into his magical world. The last time I came however, he stood by without touching, and let the forensic medical students do the displaying. He was instead holding his miniature terrier dog lovingly against his white apron. The dog was well behaved, as this is commonplace apparently, and did not once try to take a nibble.
I don't really know how to end this after that visual, but I will say that I will try to attend next week.
Of course the times that I do go, it is at night when there is no other staff to force into it. I walk down with the escort, pushing the draped and wrapped body. We don shoe covers and go into the dark morgue past all the jars and dissecting equipment, to the body refrigerator. We open it, and look for an open shelf to place the body. The floor has a small pile of various wrapped limbs. Legs and arms wrapped in hospital sheets. The worst part of this experience is transferring the body to our archaic, rickety lift that deposits the body on our chosen shelf. We must slide the body onto this metal tray and use a manual lever to lift the body up to the proper elevation. This lift was designed for a 175 pound person, not the 300 pounders that frequent our establishment. The tray wobbles back and forth, barely making it to the needed height, and yes, it has almost tipped someone out. We reach up with gloved hands and shove the tray in place. Our friend is deposited with the other six for either autopsy or delivery to the funeral home. I wash my hands twice as I leave. I shudder at the thought of going there.
Despite the distaste I have for the morgue, one of my favorite lunch breaks is spent on Fridays at the weekly autopsy review. This is usually the haunt for doctors and eager medical students. Nurses don't much come to these briefings, but I always feel welcome, and some doctor who knows me will pat the stained cloth seat for me to sit next to them. The debriefing that follows consists of a medical history, circumstances during hospital stay, and a run down of the death events. The radiologist pulls up CT's and x-rays, and then the fun begins. The resident step up eagerly and a large metal tray is pulled out of the fridge across the room. The organs of importance are unveiled and I see the patient I took care of in smaller pieces. The forensic doctor, or whatever he is, stands by and talks about the cool findings during the autopsy. He is a pudgy short man wearing a plastic apron and boy, does he love his job. He picks up each organ and carefully plys away at the intricate dissection. he shows blocked arteries, enlarged livers, and even the surprise necrotic brain tumor they never expected. He encourages the residents to put on gloves and feel the rubbery nature of the spleen, inviting them into his magical world. The last time I came however, he stood by without touching, and let the forensic medical students do the displaying. He was instead holding his miniature terrier dog lovingly against his white apron. The dog was well behaved, as this is commonplace apparently, and did not once try to take a nibble.
I don't really know how to end this after that visual, but I will say that I will try to attend next week.
Monday, September 28, 2009
Road Trip!
Traveling with the critically ill is an art. I am a master at few things; but I will say that parallel parking, and moving the sick and intubated patient are amongst my top skills. Some of this is from instinct and most of it is from practice. I also am a perfectionist, and I try to be prepared for any situation. As I write this, I am acutely aware that the art of preparation is an exercise in both instinct and practice. Whichever came first is unimportant, as they all are intimately intertwined.
Patients need to move through the hospital for different types of procedures and scans, and the patient's nurse is usually solely responsible for their care as they are pushed through the halls.
Road trips are an exercise in preparation, focus, assertiveness, bravery, and well...exercise. These trips can take forever, and that bed is flipping heavy. You struggle to keep the IV poles together and kick visitors out of the elevator, and by the end, you are sweaty and disheveled. When you take a patient out of the ICU you are leaving the safety of staff support, an alternate oxygen supply, and unlimited resources. You are a lone wolf wandering the halls with with a sick patient, a lumbering hospital bed, a portable monitor, and your instinct to guide you. Traveling can be either a quick uneventful trip, or it can be a harrowing experience that makes you wonder if you are in the right profession.
Moving through the hospital with a sick patient is, I believe, the best way to gain confidence and experience as a new nurse. You learn how to be on your game; preparing for the worst to happen, being able to adapt to difficult circumstances, and learning who to call when all hell breaks loose. All orientees should go on as many traveling procedures that they can. This is the most basic ICU nursing, because all you have is you and the tools you bring to the table. You strip your patient to the basics, since you want to travel light. I put a few vials of emergency meds in my pocket, make sure I have an IV start, put an ambu bag on the bed, and get ready to roll. Some nurses tie themselves down with a crapload of equipment and IV poles; they are the wost kind of traveler. They are unable to adapt, freakout at every inconvenience, and they end up turning a stressful situation into a traumatic event for all involved parties. Road trips with the frantic are not fun. They are loose cannons with no focus or discipline, and if you are a patient, you are lucky to make it back unscathed.
I have learned many lessons through these patient expeditions. Always confirm IV access and patency. Nothing is worse than losing your access when your intubated patient is thrashing during a CT scan. Always bring an additional oxygen tank when your patient is on a non-rebreather mask, least the tank runs out while you are waiting for the elevator and your patient starts to turn blue. Be prepared to be a guinea pig in IR, where you are requested to disconnect your unstable patient from the vent over and over, while hiding behind a radiation blocking barrier. Know how to call anesthesia stat when your patient won't respond to sedation and is bucking while a hole is being punched and stented through his liver during a TIPS procedure(I have has to do this twice). These trips are in the extreme, but they do happen frequently. I have learned to not be optimistic, and always assume that when the shit hits the fan, it will be with me, on this particular road trip.
These experiences can be frightening, but you learn to take in your surroundings, know who your allies are, and know when you are in over your head. You also learn how to get the job done when it counts. An example is when I was traveling through the hospital with a very sick patient and making stops to CT, MRI, and to Nuclear Med for a VQ Scan to rule out a pulmonary embolism (PE). This poor man was tortured all day by me. Transferred back and forth from his bed to testing areas. He is old, in pain, and going to die any day. Who fucking cares if he had a PE? It doesn't make a difference in his treatment, seriously, I know. But, in order to provide the most thorough care we must turn over every stone, despite the discomfort of our elderly dying patients. The VQ scan looks at ventilation vs perfusion in the lungs. One has to breath in a radioactive gas, and then get transferred into a horizontal tube where they continue to breath in this toxic gas and sit until it permeates all of the lung spaces. This scan can take an hour and it sucks. It is uncomfortable, confining, and you have to keep wrapping your lips around this tube and breathing in this gas like it is the Devil's houka. I can understand how this would be unbearable. My poor old guy started to cry. Tears rolling down his cheeks. He started to scream "No more, No more!". My heart moved in my chest, I almost went to call it off, but then I thought of how I was working for three more days, and how I would have this guy again tomorrow. I didn't want this trip again. "Mr. So and So, you will finish this test. I am sweaty and tired, I look like hell, and I will not do this again. Put your mouth around this tube and breath. Breath deep and breath hard, and we will be done. I am not screwing around, and I will not take you back until we finish!" He looked at me first with fear, and then with understanding. He wrapped his lips around the tube and finished the test. We both got a resolution to get this bullshit test out of the way and be free from traveling to this hellhole again. I felt kinda bad, but I knew what needed to be done. I think he forgave me.
I like road trips for a few reasons. You are autonomous, intuitive, MacGyverish, and fluid. I get to be a better nurse for these experiences. Meeting and depending on new people, discovering my own strengths, and hopefully being able to make a difference in someones life. It is a fun break-away from the unit, and we need that sometimes. By taking ourselves out of our comfort zone, we are able to grow in ways that we could never imagine. I found that I was able to rely on gut more than monitors, and experience more than security. Most important though, I have learned to trust myself and my patients more. I was once so scared to go out of the unit by myself with my patient. I did the same thing with my daughter when she was first born. We tried to go for a walk in her jogger stroller when she was five days old. I got about fifty feet from the house, and immediately turned around and ran her home. I felt like a fool to be so scared of something so easy. It took me a while and I was finally able to move through this fear. I began to take my kid to the zoo, not unlike taking my patient to CT really. So, all and all, traveling is a necessary evil, though while uncomfortable, will ultimately be a benefit to you, and possibly to your patient.
(Plus, I haven't been to the gym in a while, and I can use the workout)
Patients need to move through the hospital for different types of procedures and scans, and the patient's nurse is usually solely responsible for their care as they are pushed through the halls.
Road trips are an exercise in preparation, focus, assertiveness, bravery, and well...exercise. These trips can take forever, and that bed is flipping heavy. You struggle to keep the IV poles together and kick visitors out of the elevator, and by the end, you are sweaty and disheveled. When you take a patient out of the ICU you are leaving the safety of staff support, an alternate oxygen supply, and unlimited resources. You are a lone wolf wandering the halls with with a sick patient, a lumbering hospital bed, a portable monitor, and your instinct to guide you. Traveling can be either a quick uneventful trip, or it can be a harrowing experience that makes you wonder if you are in the right profession.
Moving through the hospital with a sick patient is, I believe, the best way to gain confidence and experience as a new nurse. You learn how to be on your game; preparing for the worst to happen, being able to adapt to difficult circumstances, and learning who to call when all hell breaks loose. All orientees should go on as many traveling procedures that they can. This is the most basic ICU nursing, because all you have is you and the tools you bring to the table. You strip your patient to the basics, since you want to travel light. I put a few vials of emergency meds in my pocket, make sure I have an IV start, put an ambu bag on the bed, and get ready to roll. Some nurses tie themselves down with a crapload of equipment and IV poles; they are the wost kind of traveler. They are unable to adapt, freakout at every inconvenience, and they end up turning a stressful situation into a traumatic event for all involved parties. Road trips with the frantic are not fun. They are loose cannons with no focus or discipline, and if you are a patient, you are lucky to make it back unscathed.
I have learned many lessons through these patient expeditions. Always confirm IV access and patency. Nothing is worse than losing your access when your intubated patient is thrashing during a CT scan. Always bring an additional oxygen tank when your patient is on a non-rebreather mask, least the tank runs out while you are waiting for the elevator and your patient starts to turn blue. Be prepared to be a guinea pig in IR, where you are requested to disconnect your unstable patient from the vent over and over, while hiding behind a radiation blocking barrier. Know how to call anesthesia stat when your patient won't respond to sedation and is bucking while a hole is being punched and stented through his liver during a TIPS procedure(I have has to do this twice). These trips are in the extreme, but they do happen frequently. I have learned to not be optimistic, and always assume that when the shit hits the fan, it will be with me, on this particular road trip.
These experiences can be frightening, but you learn to take in your surroundings, know who your allies are, and know when you are in over your head. You also learn how to get the job done when it counts. An example is when I was traveling through the hospital with a very sick patient and making stops to CT, MRI, and to Nuclear Med for a VQ Scan to rule out a pulmonary embolism (PE). This poor man was tortured all day by me. Transferred back and forth from his bed to testing areas. He is old, in pain, and going to die any day. Who fucking cares if he had a PE? It doesn't make a difference in his treatment, seriously, I know. But, in order to provide the most thorough care we must turn over every stone, despite the discomfort of our elderly dying patients. The VQ scan looks at ventilation vs perfusion in the lungs. One has to breath in a radioactive gas, and then get transferred into a horizontal tube where they continue to breath in this toxic gas and sit until it permeates all of the lung spaces. This scan can take an hour and it sucks. It is uncomfortable, confining, and you have to keep wrapping your lips around this tube and breathing in this gas like it is the Devil's houka. I can understand how this would be unbearable. My poor old guy started to cry. Tears rolling down his cheeks. He started to scream "No more, No more!". My heart moved in my chest, I almost went to call it off, but then I thought of how I was working for three more days, and how I would have this guy again tomorrow. I didn't want this trip again. "Mr. So and So, you will finish this test. I am sweaty and tired, I look like hell, and I will not do this again. Put your mouth around this tube and breath. Breath deep and breath hard, and we will be done. I am not screwing around, and I will not take you back until we finish!" He looked at me first with fear, and then with understanding. He wrapped his lips around the tube and finished the test. We both got a resolution to get this bullshit test out of the way and be free from traveling to this hellhole again. I felt kinda bad, but I knew what needed to be done. I think he forgave me.
I like road trips for a few reasons. You are autonomous, intuitive, MacGyverish, and fluid. I get to be a better nurse for these experiences. Meeting and depending on new people, discovering my own strengths, and hopefully being able to make a difference in someones life. It is a fun break-away from the unit, and we need that sometimes. By taking ourselves out of our comfort zone, we are able to grow in ways that we could never imagine. I found that I was able to rely on gut more than monitors, and experience more than security. Most important though, I have learned to trust myself and my patients more. I was once so scared to go out of the unit by myself with my patient. I did the same thing with my daughter when she was first born. We tried to go for a walk in her jogger stroller when she was five days old. I got about fifty feet from the house, and immediately turned around and ran her home. I felt like a fool to be so scared of something so easy. It took me a while and I was finally able to move through this fear. I began to take my kid to the zoo, not unlike taking my patient to CT really. So, all and all, traveling is a necessary evil, though while uncomfortable, will ultimately be a benefit to you, and possibly to your patient.
(Plus, I haven't been to the gym in a while, and I can use the workout)
Saturday, September 19, 2009
Don't Love Me Too Much
Advanced directives are a basic form that people fill out sometimes about what they would want in case they are not able to make their own medical decisions. Usually, everyone says the same thing: "I don't want to be a vegetable". Well, I am here to say no one want to be a vegetable, but that rarely helps families and medical personnel guide ones care. Everybody is different when it comes to his/her personal limit when it comes to invasive medical treatment. The goals of someone who is 50 verses 93 years old are immeasurably different. There are ways to quantify and specify the amount of medical care a person wants, and what health impairments are acceptable in defining a quality life. Unfortunately, many of these tools have come under scrutiny by the right-wing media by declaring that this is an open invitation to assisted-suicide when a persons health problems exceed the parameters that they have specified in their advanced directive. The VA Hospital has a detailed AD form that is an excellent tool, but has caused an uproar among conservative groups, and has been officially suspended by the Obama administration until flames have died down. This document spurred a backlash against progressive medical groups and the Obama administration, despite the fact that it was created and brought into use during the time Bush was President. See the example shown, and do your own exercise following the link, if you like.
http://stevebuyer.house.gov/UploadedFiles/Your_Life_Your_Choices.pdf
The point of all of this is to discuss some end of life issues that I have observed during my short career in the ICU. Please ignore any blatant political commentary that you might unearth, as my intentions are not about right and wrong, they are just feelings that have bubbled forth. Please feel free to share your own observations/feelings as appropriate.
Some themes:
The right to choose or decline medical care
The sticky issue of family in interpreting what is appropriate for their loved one
The view of medical care during end of life as a medical professional
My own Advanced Directive - which may or may not be ignored - titled: Don't Love Me Too Much
The right to plow ahead with every medical intervention possible is reoccurring theme in my work environment. This is done by both patients and families during their time of crisis. We really give them everything we have to give, but ultimately, despite our best efforts, the fight is between the patient and God. When a patient is unresponsive, or unable to participate in medical decisions, we assume that everything must be done, unless the family otherwise declines. This could be due to a terminal illness, a very poor prognosis, or the statistical indicators that this person will never return to a quality of life that is acceptable for them. These lines are very blurry, and in fact, quite subjective. As we learned from looking at the VA Life Choices pamphlet, where one person would be all right with being disabled, completely dependent, and having to spend their remaining days in a hospital; another person may find this unbearable and would want us to, in effect, pull the plug. Many times we do not know which way the chips may fall, and we can only speculate about outcomes. I have seen miracles my friends. People who should have died, being rolled out in a wheelchair for the cabulance home. That said, they seem (to me)to be a shell of what they once were. Not only do they require years of rehab, possible penile reconstructive surgery due to edema, God knows how much therapy, and the financial and emotional turmoil of the family; they will undoubtedly come back to me as a patient with some glaring infection, and we will start the process over again. I do not judge, this is what was meant to be, as it has already happened.
Some patients are scared and want everything done, even though we tell them that they will never leave the ICU. They succumb to an infection, and when they cannot communicate, a family member will assume responsibility and agree to let them go. (This has caused an ethical debate, as we knew full well what the patient wanted, and this decision would be unacceptable to them. Fortunately, we can always argue medical futility, and understand that no one wants to die, but ultimately we know everyone does.)
Some patients are stoic, and greet death as an inevitable occurrence, and these people go with grace, and the morphine drip is hung, and they are able to peacefully return to their origin. This is a rare occurrence. I had an experience where we knew this guy was going to die, but we could give him an extra week if we continues aggressive care. We could give him seven more days of torture. The pain was unbearable for him. The daily lab draws, being forced to turn every two hours, these fucking 20 year old doctors making decisions and changing their minds every day. "Screw you" the patient thinks, "I would rather die". So what do we do? Order a God-damned psych consult, cause this guy must be suicidal. Seriously, this was done. This is the dumbest crap I have ever heard. We are hypocrites for accepting a families wishes to withdraw care when someone is unable to say so, but when a patient says that it is time to stop, we gawk and feel ethically compelled to decline. This has happened to me, and I coached the family and patient on what to say in order for the doctors to allow us to stop treatment. This I felt, was my moral obligation. The patient and family were accepting, were able to say goodbyes, and the patient died the next day. I was glad for him.
Some families are not ready to let go. This is usually the case, and it is very difficult for all of us to come to terms with the mortality of both the patient, and our medical efforts. I think that it is hard for these young blossoming residents to accept defeat. They will try everything, and even try some more, though the statistical evidence is staggering that the patient will not make it. This drive from the residents, fuels the family belief that all will be well, until the inevitable moment where defeat is called and the families are blown away that all of their hope was for nothing, and their loved one should be let go. Sometimes this still does not sink in and we are forced to keep these poor bastards alive to the point of morbid horror, when either they code and have a traumatic end, or we finally convince the family that it is over, and the patient dies within a minute of removing life support.
Sometimes we are able to have a therapeutic and peaceful death, where families and medical personnel work together. This is the most gratifying part of my job.
The point of these scenarios is to demonstrate that rarely Advanced Directives are actually followed, and the fact that they are so vague with the resignation of "I don't want to be a vegetable", they are worthless without thorough thought and disclosure. The ultra-conservatives that are against in-depth death discussions want us to believe that every medical intervention should be made possible for all patients. This is a careless waste of resources, and it does not help families make educated decisions about how to manage the medical care of their loved one. Many of the interventions and ways to prolong life are not what doctors and nurses would have done for themselves. An example of this is the mundane flu shot. Doctors and nurses recommend this all the time. I myself gave over 50 flu shots in one day last year. If however, you do an informal poll like I did last week, you would find that the only nurses who get the flu shot are in management, or are kiss asses. The same goes for the doctors. It is not that we don't think the flu shot is beneficial, or that it can be lifesaving for certain individuals, we all have a deathly fear of rare complications. It is stupid, we all know, but if anyone is going to get some crazy Guillain-Barre, it will be us. We see enough weird shit, that as a superstitious measure, we protect ourselves from a 1:1,000,000 chance of drawing the short straw. The same goes for all of the other things we do. I am scared of needles. I am scared of doctors. I am scared to get my blood pressure taken. I urge all politicians to poll medical staff about how they rate quality of care before shoving it down the throat of average citizens simply because they are afraid to face their own mortality and that of the people they love. Bam.
This is a long, drawn out morbid topic I know. I will edit and condense for the book version, I assure you.
In conclusion, I will tell you my own personal advanced directive. Please do not take this as medical advice, as I am full of it, and frequently, a hoppy fermented beverage. I will also say, as another older nurse has said to me a few times before:"just wait till you get to be 83, you will feel a lot different than when you are 33" Well, thanks for the wisdom, this is my disclaimer, and I will reevaluate my goals of care through the years, and I urge you all to do the same.
I will first say that all of us nurses and doctors are scared of many things that we hope to Christ we don't get. These will act as indicators to guide my care, if I have these, I am pissed. The first is liver failure. The worst, bloody, metamorphosis a person can have. The rest in no particular order: MS, cystic fibrosis, oral cancer, severe heart failure, pancreatic cancer, severe dementia, crazy bowel problems, and renal failure. Oh, and severe COPD, leukemia, lymphoma, Tourettes...the list keeps coming. OK poor exercise. Nobody wants to get sick. Exercise more, smoke less.
If I have more that 3 organ systems failing, with less than a 30% chance of leaving the HOSPITAL, not just the ICU, please let me enjoy my time with my family and friends. Sneak me in a margarita and put it in my feeding tube. Give me lots of drugs, and play some Bonnie Raitt while I listen to the laughter of those who know me best. Let me keep my dignity, my joy for life, and don't make me haunt you. To sum up: Don't Love Me Too Much. (I promise to do the same for you)
Thursday, September 10, 2009
To My Friend
We weren't together long, but I came to care for you. You came in with respiratory distress, and you got worse by the day. I helped you out the other week, and six days later, when I was your actual nurse, you remembered my name. You joked and flirted. Told me Viagra was more than just for pulmonary hypertension. You told me stories from your youth, your short career in the Air Force. How you were screwed by those good ol' boy bastards. You told me your wife of 24 years, and how she had died 14 years before. She was the love of your life. Now you had a new girlfriend 20 years your junior, but your wife was always going to be the one.
I sat on your bed with you and held your hand when I saw tears well up in your eyes, after I told you that you weren't going to get better. You looked right at me and said, "I'm dying Lisa, I am going to die." I nodded, and we cried together, our heads on each others shoulders.
I was able to be with you for three more days after that. I called every morning before work to reserve you for the day. Your eyes would brighten when I walked into the room, you would tell me that you dreampt of me the night before. "Shut up old man, you're embarrassing me!" I would say. But I grinned; this was all that you had right now. I sent a pretty nurse in to talk to you, to make you smile. She loved to be there for you.
I called Palliative care and social work for you. They came and got you signed up for hospice. You talked about going home, but we knew that wouldn't happen so you resigned to finishing out your days in a nursing home. Maybe a year you said, but we all knew your time was much shorter. I sat with you again, and held your hand.
One week ago, I was leaving for a long weekend. You had transfer orders out of the ICU. We couldn't do anything more for you. You were chipper, and asked me to come visit you. "Of course I will" I said. I kissed his cheek and hugged him for a long time.
I was giving report that night, and you were shaving. I got you set up with a hot basin of water, shaving cream, razor, and towel. I sat with the night nurse and started my update. You had visitors at the main door and I invited them in. I looked at the monitor, and your oxygen sats were very low. I went into the room and saw you. You had taken off your oxygen to shave and had passed out when it got too low. You looked peaceful. But you had visitors, and I couldn't look bad. I ran over, put your mask on, smacked your cheek and told you to wake up. You awoke with a start; confused, but easily reoriented. You had a lovely visit with your neighbors, and then I had to go home.
I kissed you one last time, walked to my car, and drove away. I thought of you over the weekend. I wondered if you were able to get out of the ICU, and sit and talk with other old dying men. Talk about dreams, and love, and share memories forgotten until then.
I looked you up this morning. You had left the ICU the next morning after I had left, and you died that night. You were found with your oxygen off, unresponsive, without a heartbeat. You had decided against resuscitation and intubation, so you were let go. I wish I could have visited you one last time. Seen the light in your eyes. Let you know that you weren't alone, and most of all, that you touched my heart.It was a peaceful death. I know that you just fell asleep, and felt no pain. That is a lovely blessing, and I am glad that you didn't have anxiety or fear.
Safe journey my friend. I hope you are in the arms of your sweet lady, and you will never have to leave her again. I will think of you with great fondness and smile when you come into my thoughts. You help me strive to be better every day, and to be present when it really matters.
I sat on your bed with you and held your hand when I saw tears well up in your eyes, after I told you that you weren't going to get better. You looked right at me and said, "I'm dying Lisa, I am going to die." I nodded, and we cried together, our heads on each others shoulders.
I was able to be with you for three more days after that. I called every morning before work to reserve you for the day. Your eyes would brighten when I walked into the room, you would tell me that you dreampt of me the night before. "Shut up old man, you're embarrassing me!" I would say. But I grinned; this was all that you had right now. I sent a pretty nurse in to talk to you, to make you smile. She loved to be there for you.
I called Palliative care and social work for you. They came and got you signed up for hospice. You talked about going home, but we knew that wouldn't happen so you resigned to finishing out your days in a nursing home. Maybe a year you said, but we all knew your time was much shorter. I sat with you again, and held your hand.
One week ago, I was leaving for a long weekend. You had transfer orders out of the ICU. We couldn't do anything more for you. You were chipper, and asked me to come visit you. "Of course I will" I said. I kissed his cheek and hugged him for a long time.
I was giving report that night, and you were shaving. I got you set up with a hot basin of water, shaving cream, razor, and towel. I sat with the night nurse and started my update. You had visitors at the main door and I invited them in. I looked at the monitor, and your oxygen sats were very low. I went into the room and saw you. You had taken off your oxygen to shave and had passed out when it got too low. You looked peaceful. But you had visitors, and I couldn't look bad. I ran over, put your mask on, smacked your cheek and told you to wake up. You awoke with a start; confused, but easily reoriented. You had a lovely visit with your neighbors, and then I had to go home.
I kissed you one last time, walked to my car, and drove away. I thought of you over the weekend. I wondered if you were able to get out of the ICU, and sit and talk with other old dying men. Talk about dreams, and love, and share memories forgotten until then.
I looked you up this morning. You had left the ICU the next morning after I had left, and you died that night. You were found with your oxygen off, unresponsive, without a heartbeat. You had decided against resuscitation and intubation, so you were let go. I wish I could have visited you one last time. Seen the light in your eyes. Let you know that you weren't alone, and most of all, that you touched my heart.It was a peaceful death. I know that you just fell asleep, and felt no pain. That is a lovely blessing, and I am glad that you didn't have anxiety or fear.
Safe journey my friend. I hope you are in the arms of your sweet lady, and you will never have to leave her again. I will think of you with great fondness and smile when you come into my thoughts. You help me strive to be better every day, and to be present when it really matters.
Wednesday, August 5, 2009
Orientation
The other day I made a bunch of food and brought it to work for a welcome luncheon for our new orientees. New staff that will go through the ICU consortium and have an experienced staff preceptor for 3-4 months. Most have hospital nursing experience and are moving up into the ICU arena. I myself, came a a new graduate out of nursing school. I was fortunate to have had 10 weeks in the Harborview CCU for my last quarter of nursing school, and I was welcomed with open arms in my current workplace. My unit has been through drastic changes over the past 2+ years that I have been there. There was seriously a "Nurses Eat Their Young" attitude when I started. Older, bitter nurses who greeted every new person with a rude, hazing process that would only end after you either proved yourself, or told them to fuck off. Over time, our nurse manager left and the bitter staff moved up the ladder. We were left with basically zero direction or feedback for many months. We were a unit with very little experienced staff and had only ourselves for guidance and praise. Over time our culture has evolved into one of welcoming, acceptance, loyalty, sacrifice, and true friendship. These new orientees will be lucky to work in this unit - if they make it through.
We have a poor record for ICU training survivorship. I was one of three, the next group had one of three, but this last batch had 3/5 make it. There is a lot of pressure, you have to be anal, thorough, be willing to screw-up and take the heat, deal with family and death, handle crises while your hands are shaking and people are screaming at you whilst there are wailing loved ones in the background. There is a lot of shit. A lot of bodily fluids, really fat people, genital warts, and other unpleasantries. You also have to have focus, see a holistic picture, be able to stand scrutiny, residents, whole team rounds where they try to make you seem stupid and invisible. Most of all you can't be a fucking idiot either.
There has been death my friends. I will not go into too much detail, as my coworkers have discovered this blog, but take me out for a beer sometime... New orientees can have the power of life and death in their hands, and sometimes make stupid choices. Not maliciously, just a really morbid learning curve. You don't send people to the bathroom when they need 100% oxygen, you don't infuse whole bags of sedation within 10 minutes, you don't follow every order you are given blindly, especially when is is by the med student who is actually thinking about another patient. A while ago, I was out for drinks with coworkers talking about some orientees. My coworker said the "newbie" was very smart, but was not able to get the big picture. She had the skills, but lacked the judgment to be safe. "Lisa, look at me. She will kill someone. I mean it. She will see an order on the computer and just do it. I love her and she will be a good nurse, but she just isn't that smart yet. I'm telling you, someone will die because of it." Maybe I will have someone else watch my patients when I go to lunch...
I have almost killed someone. I will admit it, I went through the proper channels, had to write a report, call the doc, I paid my dues. I have learned, when you are done with a bag of medication, you get fucking rid of it. You don't leave it hanging to be accidentally hooked up and bolused in quickly like it is an antibiotic, when it is actually heparin (anticoagulant) and your patient is a GI bleeder, shitting out bright red blood like there is no tomorrow. I was on orientation. My preceptor was fantastic, always proud of me, made me feel smart, capable, and comfortable. He called me out of the breakroom to check out this guys IVs. I went in cocky. "What?" After a minute, I realized my error. My heart dropped, my face fell, and I could see he was thinking: "She's going to kill someone". I learned to trace my lines carefully, get rid of the shit that I was not going to use, and to always second guess my self.
These new orientees, like myself when I started out, will come into work everyday, sweating, praying that they won't kill someone. New staff should be scared, 'cause if they aren't, they're fucking scary. These are the ones who will hurt someone, not really care, and do it again. Then, they are shamed back to the floor, and out of the ICU, hopefully.
I have a new orientee myself. My first one is now on her own, and I couldn't be prouder. She calls herself a Code Whore too, and is doing fantastic. She was always excruciatingly meticulous and didn't really mess up once. Her time will come I am sure, but at least it isn't on my watch (We are all human N..). My new one is just starting consortium. He will then follow my schedule for 3-4 months. I will work with him everyday. Christ. He will get to know my very soul and I will see his. I will yell at him, make him feel stupid, build him up, maybe cry with him, and if he pans out, send him on his own. Precepting can be a bitch. You have no space, they have to follow you around like a dog and do what you say, you always have to be on your game, and be responsible for everything they do. By the end, you are so happy just to be alone with your sedated patient, enjoying the silence. "What are the benefits?" you may ask. Initially, I just get to hear myself talk all the time. You all know that I love that. We fight for the sickest patients and get to have cool experiences. They get to see me talk in rounds, stand up to the attendings, handle families and emergencies. And later, they will take over the care and I will be the back-up. Wingman. They have to do all the charting, talking to families, and practice skills. You become like a mother, wanting them to succeed and do well. You want them to be better than the other orientees. Like a play that you are in, or a song that you get to sing; they become a reflection of you.
We have a poor record for ICU training survivorship. I was one of three, the next group had one of three, but this last batch had 3/5 make it. There is a lot of pressure, you have to be anal, thorough, be willing to screw-up and take the heat, deal with family and death, handle crises while your hands are shaking and people are screaming at you whilst there are wailing loved ones in the background. There is a lot of shit. A lot of bodily fluids, really fat people, genital warts, and other unpleasantries. You also have to have focus, see a holistic picture, be able to stand scrutiny, residents, whole team rounds where they try to make you seem stupid and invisible. Most of all you can't be a fucking idiot either.
There has been death my friends. I will not go into too much detail, as my coworkers have discovered this blog, but take me out for a beer sometime... New orientees can have the power of life and death in their hands, and sometimes make stupid choices. Not maliciously, just a really morbid learning curve. You don't send people to the bathroom when they need 100% oxygen, you don't infuse whole bags of sedation within 10 minutes, you don't follow every order you are given blindly, especially when is is by the med student who is actually thinking about another patient. A while ago, I was out for drinks with coworkers talking about some orientees. My coworker said the "newbie" was very smart, but was not able to get the big picture. She had the skills, but lacked the judgment to be safe. "Lisa, look at me. She will kill someone. I mean it. She will see an order on the computer and just do it. I love her and she will be a good nurse, but she just isn't that smart yet. I'm telling you, someone will die because of it." Maybe I will have someone else watch my patients when I go to lunch...
I have almost killed someone. I will admit it, I went through the proper channels, had to write a report, call the doc, I paid my dues. I have learned, when you are done with a bag of medication, you get fucking rid of it. You don't leave it hanging to be accidentally hooked up and bolused in quickly like it is an antibiotic, when it is actually heparin (anticoagulant) and your patient is a GI bleeder, shitting out bright red blood like there is no tomorrow. I was on orientation. My preceptor was fantastic, always proud of me, made me feel smart, capable, and comfortable. He called me out of the breakroom to check out this guys IVs. I went in cocky. "What?" After a minute, I realized my error. My heart dropped, my face fell, and I could see he was thinking: "She's going to kill someone". I learned to trace my lines carefully, get rid of the shit that I was not going to use, and to always second guess my self.
These new orientees, like myself when I started out, will come into work everyday, sweating, praying that they won't kill someone. New staff should be scared, 'cause if they aren't, they're fucking scary. These are the ones who will hurt someone, not really care, and do it again. Then, they are shamed back to the floor, and out of the ICU, hopefully.
I have a new orientee myself. My first one is now on her own, and I couldn't be prouder. She calls herself a Code Whore too, and is doing fantastic. She was always excruciatingly meticulous and didn't really mess up once. Her time will come I am sure, but at least it isn't on my watch (We are all human N..). My new one is just starting consortium. He will then follow my schedule for 3-4 months. I will work with him everyday. Christ. He will get to know my very soul and I will see his. I will yell at him, make him feel stupid, build him up, maybe cry with him, and if he pans out, send him on his own. Precepting can be a bitch. You have no space, they have to follow you around like a dog and do what you say, you always have to be on your game, and be responsible for everything they do. By the end, you are so happy just to be alone with your sedated patient, enjoying the silence. "What are the benefits?" you may ask. Initially, I just get to hear myself talk all the time. You all know that I love that. We fight for the sickest patients and get to have cool experiences. They get to see me talk in rounds, stand up to the attendings, handle families and emergencies. And later, they will take over the care and I will be the back-up. Wingman. They have to do all the charting, talking to families, and practice skills. You become like a mother, wanting them to succeed and do well. You want them to be better than the other orientees. Like a play that you are in, or a song that you get to sing; they become a reflection of you.
Wednesday, July 22, 2009
Smooth Jazz
"Is it ok if I turn on the smooth jazz station?"
"Of course" she says. "I can't believe that they got rid of the oldies station" I say, as we gown up. Double gloves, plastic gown. "Yeah, what a fucking bummer" she says. as we head in and start our work.
"How was your day?" my husband asks? We are on a rare date night. He is trying to be nice and inquisitive. "Fine" I say. "you know, sick guy, mourning family, trying to keep him going so he makes it through this. My other patient was stable though, transferred him out in the afternoon. pretty good day I guess."
0900 that morning. I see this guys heart rate in the 30s. He was put on comfort care the day before. I know it's time. I go to his room and the chaplain and his nurse are there. He is taking his last breaths. I go to him and hold his hand and stroke his hair. I hum under my breath. He dies as we surround him, blinds closed. I kiss his forehead. He looks peaceful finally. He had been struggling to breath over the past few days. The monitor is turned off.
"So what else happened today?" He is fishing for conversation. It is a couple hours later and there is a break between bands. He wants to be interested in my work and ask the right questions. "Well..." I think about my day. I don't think about work when I am not there. It may be a self-protection mechanism, but really, I am able to leave it behind usually. You do the best you can, and know that most things are not in your control. "Oh yeah, this morning when I came in, I was with this man as he died. It was peaceful. I held his hand, and then helped his nurse with the body." My sweet husband of 8 years looks shocked. I can see it on his face. he is thinking "I just asked you earlier how your day was and you said "fine", this is not fine." He is speechless and looks almost betrayed. I don't have any words for him. I don't know why this even didn't come to me right away when he asked. It was just part of my day.
We go in and start to wash the body. I always need some background music to take away the awkwardness. I have goose bumps the whole time. It is not natural to clean a body. I go piece by piece, trying not to take in the whole situation. A foot, the leg. an arm, nose, an eye. "Look at his feet!" I marvel. He has small, perfectly clean manicured feet. Very rare in this institution. They gleam white, without blemish. "Yeah" she says "who would have thunk..." She looks pointedly. "Jesus Christ" I say laughing under my breath. And I do give a conciliatory nod. Noting that indeed, this old guy is fairly well endowed. Leave it to her to state the obvious. However, the blood caking his lips takes away from the picture. We finish cleaning him, take out the foley and his IV's and wrap him in plastic. She doesn't like to bind hands and feet with silk tape, so I just put on the toe tag. We call for escort and drape his body with the American flag as we wait. They take him away to the morgue. And I give meds to my other patients.
"How can you do that?" My husband and friends ask. "You do what you have to I guess." I reply. "Doesn't it bother you and keep you up at night?" "Not really. I guess if I really fucked up and hurt someone it would." They question me about families and the emotional turmoil. I tell them that I do the best I can do, and try to be present for all of the situations I may have to face. I remember talking to a daughter in Germany, telling her that I would take her place, and be there as a daughter when he passed. Telling spouses that I will care for this patient as if he was my own father. Acting as a angel of death as I bolused morphine when a patient is struggling to breath, as his family looked at me in with terror in their eyes. Saying prayers with families as tears cascaded down my face.
"I am calling about my Uncle, Mr so and so. I wanted to see how he was doing." "Oh" I reply slowly. "Have you talked to your Aunt? Umm, your Uncle was very sick, and I am sorry to say.." Horrible silence. "Is he dead?" "Yes, he just passed." I state, trying to be sensitive. "Thank you for taking care of him..." He starts to wail in the background. sobbing heartbreaking sobs. "I'm sorry, I'm sorry. Good bye" he says and hangs up. It is 1000, I answered the phone for her when she went to smoke. I breath deeply and sigh a little. I hear and alarm go off and figure I should check on it. Just another "no big deal" experience to have. I guess.
"Of course" she says. "I can't believe that they got rid of the oldies station" I say, as we gown up. Double gloves, plastic gown. "Yeah, what a fucking bummer" she says. as we head in and start our work.
"How was your day?" my husband asks? We are on a rare date night. He is trying to be nice and inquisitive. "Fine" I say. "you know, sick guy, mourning family, trying to keep him going so he makes it through this. My other patient was stable though, transferred him out in the afternoon. pretty good day I guess."
0900 that morning. I see this guys heart rate in the 30s. He was put on comfort care the day before. I know it's time. I go to his room and the chaplain and his nurse are there. He is taking his last breaths. I go to him and hold his hand and stroke his hair. I hum under my breath. He dies as we surround him, blinds closed. I kiss his forehead. He looks peaceful finally. He had been struggling to breath over the past few days. The monitor is turned off.
"So what else happened today?" He is fishing for conversation. It is a couple hours later and there is a break between bands. He wants to be interested in my work and ask the right questions. "Well..." I think about my day. I don't think about work when I am not there. It may be a self-protection mechanism, but really, I am able to leave it behind usually. You do the best you can, and know that most things are not in your control. "Oh yeah, this morning when I came in, I was with this man as he died. It was peaceful. I held his hand, and then helped his nurse with the body." My sweet husband of 8 years looks shocked. I can see it on his face. he is thinking "I just asked you earlier how your day was and you said "fine", this is not fine." He is speechless and looks almost betrayed. I don't have any words for him. I don't know why this even didn't come to me right away when he asked. It was just part of my day.
We go in and start to wash the body. I always need some background music to take away the awkwardness. I have goose bumps the whole time. It is not natural to clean a body. I go piece by piece, trying not to take in the whole situation. A foot, the leg. an arm, nose, an eye. "Look at his feet!" I marvel. He has small, perfectly clean manicured feet. Very rare in this institution. They gleam white, without blemish. "Yeah" she says "who would have thunk..." She looks pointedly. "Jesus Christ" I say laughing under my breath. And I do give a conciliatory nod. Noting that indeed, this old guy is fairly well endowed. Leave it to her to state the obvious. However, the blood caking his lips takes away from the picture. We finish cleaning him, take out the foley and his IV's and wrap him in plastic. She doesn't like to bind hands and feet with silk tape, so I just put on the toe tag. We call for escort and drape his body with the American flag as we wait. They take him away to the morgue. And I give meds to my other patients.
"How can you do that?" My husband and friends ask. "You do what you have to I guess." I reply. "Doesn't it bother you and keep you up at night?" "Not really. I guess if I really fucked up and hurt someone it would." They question me about families and the emotional turmoil. I tell them that I do the best I can do, and try to be present for all of the situations I may have to face. I remember talking to a daughter in Germany, telling her that I would take her place, and be there as a daughter when he passed. Telling spouses that I will care for this patient as if he was my own father. Acting as a angel of death as I bolused morphine when a patient is struggling to breath, as his family looked at me in with terror in their eyes. Saying prayers with families as tears cascaded down my face.
"I am calling about my Uncle, Mr so and so. I wanted to see how he was doing." "Oh" I reply slowly. "Have you talked to your Aunt? Umm, your Uncle was very sick, and I am sorry to say.." Horrible silence. "Is he dead?" "Yes, he just passed." I state, trying to be sensitive. "Thank you for taking care of him..." He starts to wail in the background. sobbing heartbreaking sobs. "I'm sorry, I'm sorry. Good bye" he says and hangs up. It is 1000, I answered the phone for her when she went to smoke. I breath deeply and sigh a little. I hear and alarm go off and figure I should check on it. Just another "no big deal" experience to have. I guess.
Thursday, June 18, 2009
Homage to Friendship
I may go off the beaten track with this one, but I will talk about work also.
Today I was struck with the number of times this week I felt an overwhelming gratitude for the wonderful people that I work with. I caught myself saying for the fourth time: "I think you are amazing, and I am so happy to have you part of my life". My work peeps are an awesome bunch of people. From the freaky, sweaty ward clerk, to the hot Asian nurse, we are this ridiculous unit of people who make it work so right, even when it goes terribly wrong. We are this group who, like a family, is forced to see each other 40+ hours a week and work as a combined force. I learn everyday from them, and I truly appreciate all that they have to offer. Even when they drive me crazy and I am ready to scream "back the fuck off!". They are there for me, and I know they know that I will back them up till the bitter, bloody, sometimes twitching end. I don't cry at work unless I am with families, but I have never laughed so hard, as I do when I am at work. Even the residents, for all of their aloofness, are part of this revolving group.
I see the residents through the years, starting out and then really being actually smart, I grow to love them.
In my "real" life away from work, I am equally blessed. The best of friends from when I was five years old, to ones I have seen every Monday for almost three years. My husband, soulmates, unconditional confidants, sounding boards. There are more loves than I can name, but you know who you are. I am surrounded with this amazing support, and I don't know why I deserve it. As an awkward middle schooler with poor self-esteem, an emotionally mutilated family, and confused set of values, I have come to find that I am strong now, and most of that is because of the people who have helped to build me up.
I am still totally confused. I question my sanity daily. I don't know how I deal with these really sick people, giving them questionable hope. Holding daughters of men who have just passed, as I gave them the morphine relief to let their souls float away. I have had great loss myself. My sister, father, all my grandparents are gone. I have a a crazy mother, a fractured family, and yet I persevere. So this is my time to say: thank the goddess for all the love that I have, because I know that I would be nothing without it.
Today I was struck with the number of times this week I felt an overwhelming gratitude for the wonderful people that I work with. I caught myself saying for the fourth time: "I think you are amazing, and I am so happy to have you part of my life". My work peeps are an awesome bunch of people. From the freaky, sweaty ward clerk, to the hot Asian nurse, we are this ridiculous unit of people who make it work so right, even when it goes terribly wrong. We are this group who, like a family, is forced to see each other 40+ hours a week and work as a combined force. I learn everyday from them, and I truly appreciate all that they have to offer. Even when they drive me crazy and I am ready to scream "back the fuck off!". They are there for me, and I know they know that I will back them up till the bitter, bloody, sometimes twitching end. I don't cry at work unless I am with families, but I have never laughed so hard, as I do when I am at work. Even the residents, for all of their aloofness, are part of this revolving group.
I see the residents through the years, starting out and then really being actually smart, I grow to love them.
In my "real" life away from work, I am equally blessed. The best of friends from when I was five years old, to ones I have seen every Monday for almost three years. My husband, soulmates, unconditional confidants, sounding boards. There are more loves than I can name, but you know who you are. I am surrounded with this amazing support, and I don't know why I deserve it. As an awkward middle schooler with poor self-esteem, an emotionally mutilated family, and confused set of values, I have come to find that I am strong now, and most of that is because of the people who have helped to build me up.
I am still totally confused. I question my sanity daily. I don't know how I deal with these really sick people, giving them questionable hope. Holding daughters of men who have just passed, as I gave them the morphine relief to let their souls float away. I have had great loss myself. My sister, father, all my grandparents are gone. I have a a crazy mother, a fractured family, and yet I persevere. So this is my time to say: thank the goddess for all the love that I have, because I know that I would be nothing without it.
Sunday, June 14, 2009
Boyfriends
As a nurse in an average sized hospital, I get to meet many nice looking men. Some of these guys I see fairly often become "boyfriends". I don't see them often, but we like to flirt and say hi. There is Kevin in CT, a handsome IR attending, some random residents, and some random male nurses from other floors. They are cute and easy to flirt with, but we are always just easy ways to pass the time. They compare nothing to my REAL boyfriends. The men I see up close and personal, and become intimately involved with.
I will see the name on the board and start singing "My boyfriend's back and we're going to be in trouble..."
Lately there is my sweet boyfriend, that no one else understands but me. He saves all his requests, demands for attention, tiny details of comfort, for me. He is a quad, can't talk. speaks only with his eyes, and lives for my attention. I know his every thought. We both like the sci-fi channel, we both like to breath comfortably, we hate drool, laying in shit, head turned awkwardly, being too hot, being too cold, we hate it when people talk like we are not there. We are a perfect match. A symbiotic system who will not rest unless the other one is comfortable. At this time, trapped in a hospital, I am the one who can give him release. He shows me his true side. Frustration, anger, loyalty, devotion, unrestrained joy. These are the feelings we both share. He loves it when I swear, sweat heavily, tell nasty jokes, and tell him to fuck off. I love it that I am the only one who gets what he is saying. I also hate it. I am possessive and defensive of him. I hate to see his head twisted uncomfortably when someone else has him. They are not as thorough and detailed as I am. He is miserable. And sometimes, I just walk by.
My other boyfriend that comes to mind is the opposite. He is the fattest and most nasty fucker you could ever meet. He is Jabba the Hut. Fat, ugly, hides food in his many skin folds, stinks, rubs his ass and then licks his fingers. He is so foul that EVERYONE knows him. To me, whatever, I could do worse. He may be 400 lbs. He may be the most disgusting person ever, but we are kindred spirits. Fuck what they think! "I like to be naked in bed, with only a pillowcase covering my (hot) crotch" He has to heave on his belly to pull it back to reveal his tender hidden areas. Sweaty and dank his folds of flesh are flashed. I may turn my head, and gag just a little. But, fuck it, I have seen worse. I hand him 4 alcohol wipes when I come in the room, tell him to wash his hands and nails. Laugh at his stupid jokes, and try to get him better so he can get the hell out. He is "the man who won't die", and he is my boyfriend for the day.
We finally get him out. The ambulance drivers call for back-up since they are afraid to lift my chunk of a man. I wave goodbye, but know soon enough I will sing my favorite song..
In the hospital, "boyfriends" can take on many forms. I hope I can go to CT soon...
I will see the name on the board and start singing "My boyfriend's back and we're going to be in trouble..."
Lately there is my sweet boyfriend, that no one else understands but me. He saves all his requests, demands for attention, tiny details of comfort, for me. He is a quad, can't talk. speaks only with his eyes, and lives for my attention. I know his every thought. We both like the sci-fi channel, we both like to breath comfortably, we hate drool, laying in shit, head turned awkwardly, being too hot, being too cold, we hate it when people talk like we are not there. We are a perfect match. A symbiotic system who will not rest unless the other one is comfortable. At this time, trapped in a hospital, I am the one who can give him release. He shows me his true side. Frustration, anger, loyalty, devotion, unrestrained joy. These are the feelings we both share. He loves it when I swear, sweat heavily, tell nasty jokes, and tell him to fuck off. I love it that I am the only one who gets what he is saying. I also hate it. I am possessive and defensive of him. I hate to see his head twisted uncomfortably when someone else has him. They are not as thorough and detailed as I am. He is miserable. And sometimes, I just walk by.
My other boyfriend that comes to mind is the opposite. He is the fattest and most nasty fucker you could ever meet. He is Jabba the Hut. Fat, ugly, hides food in his many skin folds, stinks, rubs his ass and then licks his fingers. He is so foul that EVERYONE knows him. To me, whatever, I could do worse. He may be 400 lbs. He may be the most disgusting person ever, but we are kindred spirits. Fuck what they think! "I like to be naked in bed, with only a pillowcase covering my (hot) crotch" He has to heave on his belly to pull it back to reveal his tender hidden areas. Sweaty and dank his folds of flesh are flashed. I may turn my head, and gag just a little. But, fuck it, I have seen worse. I hand him 4 alcohol wipes when I come in the room, tell him to wash his hands and nails. Laugh at his stupid jokes, and try to get him better so he can get the hell out. He is "the man who won't die", and he is my boyfriend for the day.
We finally get him out. The ambulance drivers call for back-up since they are afraid to lift my chunk of a man. I wave goodbye, but know soon enough I will sing my favorite song..
In the hospital, "boyfriends" can take on many forms. I hope I can go to CT soon...
Thursday, May 28, 2009
Fatballs
So something funny...
I am helping another nurse with a patient that she just admitted. His heart rate is 30, but he's talking and thinking fine - he is asymptomatic - big word I know. He tells me his heart rate is always like that, and "everyone makes a big deal about it" "Jesus Christ, they always do this, fucking idiots! I came in here for these fat balls!"
Hmm. I tilt my head to the side and take this in.
Later, I was helping again and casually mentioned "Ahh, so what's up with your fat balls? Do you have heart failure or kidney problems?" He looks at me quizzically. "Why are your balls all swollen up?" I ask.
He looks taken aback - "My balls are fine, what I have are all these fatballs under my skin, and ohhh they are so painful. Feel 'em, I mean it! They don't ever believe me. Right here.. Do you feel it? Right here too, deeper, deeper, ahhhh there"
He has fatballs, not fat balls!
He says that he has lumps of tissue in between his joints. They are very painful for him, but I can't feel crap. I feel weird and apologetic, and he later convinces me to rub some numbing lotion around his fatballs. "Oh yeah, around the right side, oooh a little higher. Do you feel that, feel how big they are? I just want them to take 'em out. Ohh a little more lotion, my wife really layers it on... ohhh just a little longer"
He comes in for fatballs, gets treated for bradycardia. Maybe they will be back...Ahhh fatballs. I shant forget you.
I am helping another nurse with a patient that she just admitted. His heart rate is 30, but he's talking and thinking fine - he is asymptomatic - big word I know. He tells me his heart rate is always like that, and "everyone makes a big deal about it" "Jesus Christ, they always do this, fucking idiots! I came in here for these fat balls!"
Hmm. I tilt my head to the side and take this in.
Later, I was helping again and casually mentioned "Ahh, so what's up with your fat balls? Do you have heart failure or kidney problems?" He looks at me quizzically. "Why are your balls all swollen up?" I ask.
He looks taken aback - "My balls are fine, what I have are all these fatballs under my skin, and ohhh they are so painful. Feel 'em, I mean it! They don't ever believe me. Right here.. Do you feel it? Right here too, deeper, deeper, ahhhh there"
He has fatballs, not fat balls!
He says that he has lumps of tissue in between his joints. They are very painful for him, but I can't feel crap. I feel weird and apologetic, and he later convinces me to rub some numbing lotion around his fatballs. "Oh yeah, around the right side, oooh a little higher. Do you feel that, feel how big they are? I just want them to take 'em out. Ohh a little more lotion, my wife really layers it on... ohhh just a little longer"
He comes in for fatballs, gets treated for bradycardia. Maybe they will be back...Ahhh fatballs. I shant forget you.
Saturday, May 9, 2009
Code Whores
Fresh in at 0730, and joyous day, I am handed the code pager. This beeps a loud obnoxious beep and a voice directs me to a location when somewhere in the hospital a code is called. Some poor patient has become pulseless and/or stopped breathing. 2 ICU nurses respond to the call along with countless doctors, a pharmacist, and respiratory therapists run to the rescue.
Another nurse looks at me and we give each other a knowing smile, saunter over to one other and give a low high-five. We are whores. Code whores. I love a good code. I must be going to hell, because sometimes I get so bored with my patients, or on night shift, I just wanted to stay awake. I am wishing the code pager would go off.
The initial call sends a thrill through me. I drop everything and rush out of my patients room. I yell for someone to take over, grab my red box of emergency supplies and run where I am directed. The pounding of all our feet on the stairs, recognizing and appraising the responders. Cracking a joke, or giving a quick summation of recent life events, we rush to the scene. People point us to the room, and we run in, grabbing gloves as we go. Someone is already doing compressions, another is bagging. I slap on the pacer pads to get a rhythm, as a doctor takes the lead in the code and begins to give orders. I am the ICU nurse, there to make sure we have IV access, push drugs, take over compressions if needed, and my greatest role personally, is as the code nazi. Delegating to the floor nurses and med students, I become a goal-oriented force of nature. Typically we are able to get a pulse and intubate the patient, and then transfer them to the ICU. My energy transforms into the nurturer as I see family members looking on with tears in their eyes and horrified faces. I encourage them to come with us, hold their loved ones hand, as we rush together to the unit.
Now, if I was in pediatrics, or an OB nurse, a code would be my worst nightmare. I am not so ravenous for adrenaline that I would hope for that. If it makes you (or I) feel better, I will say that people typically have cardiac arrests for a reason. They are usually very sick or have sick hearts. The chances outside the hospital of resuscitation are 25%, inside the hospital are not much better. We can usually get a pulse back, but actually leaving the hospital, chances are actually like 5%. Really poor. We are typically giving families a chance to say goodbye. The patients have chronic illness, are on a ventilator, have enough heart or brain lost to be permanently damaged, and I help families let their loved one go.
I go from code whore, to a supportive, intuitive nurse who is protective of my patient and family. I help families to understand the events and many times we will go down the path of making the patient DNAR, and then eventually to transitioning to comfort care. The lights get turned down low. Machines are taken away and morphine drips are hung. Comfy chairs and warm blankets are brought in, and the endotracheal tube is taken out. Families gather around the patient and stories are told. The heartbeat slows and we gather closer. Families are lead in prayer and I hold hands with them all. I cry tears with them and hug them when I leave.
I go home, and as I walk to my car, I have the same elated feeling in my heart from the successful code, as I do with the loving family. My day was productive, I helped people in the best way that I could. Whether that was as a code whore or as a family advocate, I did my job, and I did it as best I could. And I can only be satisfied with that.
Another nurse looks at me and we give each other a knowing smile, saunter over to one other and give a low high-five. We are whores. Code whores. I love a good code. I must be going to hell, because sometimes I get so bored with my patients, or on night shift, I just wanted to stay awake. I am wishing the code pager would go off.
The initial call sends a thrill through me. I drop everything and rush out of my patients room. I yell for someone to take over, grab my red box of emergency supplies and run where I am directed. The pounding of all our feet on the stairs, recognizing and appraising the responders. Cracking a joke, or giving a quick summation of recent life events, we rush to the scene. People point us to the room, and we run in, grabbing gloves as we go. Someone is already doing compressions, another is bagging. I slap on the pacer pads to get a rhythm, as a doctor takes the lead in the code and begins to give orders. I am the ICU nurse, there to make sure we have IV access, push drugs, take over compressions if needed, and my greatest role personally, is as the code nazi. Delegating to the floor nurses and med students, I become a goal-oriented force of nature. Typically we are able to get a pulse and intubate the patient, and then transfer them to the ICU. My energy transforms into the nurturer as I see family members looking on with tears in their eyes and horrified faces. I encourage them to come with us, hold their loved ones hand, as we rush together to the unit.
Now, if I was in pediatrics, or an OB nurse, a code would be my worst nightmare. I am not so ravenous for adrenaline that I would hope for that. If it makes you (or I) feel better, I will say that people typically have cardiac arrests for a reason. They are usually very sick or have sick hearts. The chances outside the hospital of resuscitation are 25%, inside the hospital are not much better. We can usually get a pulse back, but actually leaving the hospital, chances are actually like 5%. Really poor. We are typically giving families a chance to say goodbye. The patients have chronic illness, are on a ventilator, have enough heart or brain lost to be permanently damaged, and I help families let their loved one go.
I go from code whore, to a supportive, intuitive nurse who is protective of my patient and family. I help families to understand the events and many times we will go down the path of making the patient DNAR, and then eventually to transitioning to comfort care. The lights get turned down low. Machines are taken away and morphine drips are hung. Comfy chairs and warm blankets are brought in, and the endotracheal tube is taken out. Families gather around the patient and stories are told. The heartbeat slows and we gather closer. Families are lead in prayer and I hold hands with them all. I cry tears with them and hug them when I leave.
I go home, and as I walk to my car, I have the same elated feeling in my heart from the successful code, as I do with the loving family. My day was productive, I helped people in the best way that I could. Whether that was as a code whore or as a family advocate, I did my job, and I did it as best I could. And I can only be satisfied with that.
Wednesday, April 22, 2009
What do I want to be when I grow up?
Ahh...the teaching hospital. A place where residents grow and blossom. Coming out fresh from school in July - they plunge head-on into the real hospital world of writing orders, dealing with crisis, and being completely responsible for his/her patients. It is a step into the unknown - they learn through trial and error, and hone their craft through the 2+ years of residency.
Rounds with the Attendings in the morning are a teaching moment for all. In the ICU I am able to hear all about pathologies, differentials, potential paths of care, and ultimately the logic and plan for my patient. I usually have an input and am typically seen as a resource in this process depending on who the Attending is. I am blunt and to the point. We have a limited number of repetitive Attendings; I am seen as a nuisance, a gatekeeper, a partner, and as a cute nurse who likes to get her way. Many times I am all of these at once. Usually I am a babysitter. I am babysitting the residents.
Many times a helpful prod or push will awaken them to the realization that I have been here for a couple years, I have seen this type of patient before, I know the Attending, I know this hospital, I have a fairly good ideas how the dots connect. I can make your job easier, and I can save you from looking like an idiot.
Sometimes they just are idiots, and I get an evil pleasure out of watching them drown. Horribly, I call a superior physician, to come and assess my patient. I would never let my patient suffer for negligence by someone who is incompetent, though I think many times the residents would rather see how the dice roll, than be held accountable for anything.
So instead of telling you what bad residents do (the list would be endless) - I will tell you what good residents are like and what good role models they can be.
A good resident is always attractive - even if they started out ugly, by the end of their residency they have the self-confidence, humility, critical thinking, and good judgment to be attractive to anyone. I mean this - men and women, bald and not. When they can run a code, ask you for things by your name, and remain cool - they are attractive.
A good doctor always checks in at the end of the day - I mean it. Post-call or not.
Always sits down (at least once) to talk to a family member. I mean literally sit.
Calls the family to give updates
Knows good nurses by name, says thank you to nurses who give exceptional care, and tells the patient they have a good nurse when they do. (I don't just mean this in a shallow good-nurse way. There is sometimes this weird animosity b/w doctors and nurses. The nurse wants power (even if it is bitchy power), the doctor wants recognition for his $100,000 debt, and they treat each other with contempt)Telling a patient he is being well taken care of is a renewing cycle. The patient is grateful and reassured, and the nurse thinks "I am a good nurse - let's go give some good care". The Dr-nurse relationship has become a partnership and the patient benefits.
Doesn't act like they already know what you are trying to tell them.
Is humbled, and can say they are sorry.
On this note, there is also a list of nursing do's and dont's.
I work with some amazing nurses. I work with some lazy nurses. There are good nurses with exceptionally poor communication skills. I also work with some nurses who want to retire, and really don't give a rats ass. I feel like I aspire to the first category.
A few things:
Shoot me if I ever say: "Just go in the bed and we will clean it up later"
A good nurse will call the family with an update, before they go on craigslist.
A good nurse will question Drs orders if they seem amiss
A good nurse is always wary in July
A good nurse will admit mistakes and apologize - to the patient.
A good nurse will tell residents and others if they did a good job.
I love a nurse who can cry
I love a nurse who can laugh at inappropriate times
crude humor is a must.
A good nurse and a good resident has a good heart, which more often cares than not.
So, the question is, what kind of nurse or resident do you want to be?
Rounds with the Attendings in the morning are a teaching moment for all. In the ICU I am able to hear all about pathologies, differentials, potential paths of care, and ultimately the logic and plan for my patient. I usually have an input and am typically seen as a resource in this process depending on who the Attending is. I am blunt and to the point. We have a limited number of repetitive Attendings; I am seen as a nuisance, a gatekeeper, a partner, and as a cute nurse who likes to get her way. Many times I am all of these at once. Usually I am a babysitter. I am babysitting the residents.
Many times a helpful prod or push will awaken them to the realization that I have been here for a couple years, I have seen this type of patient before, I know the Attending, I know this hospital, I have a fairly good ideas how the dots connect. I can make your job easier, and I can save you from looking like an idiot.
Sometimes they just are idiots, and I get an evil pleasure out of watching them drown. Horribly, I call a superior physician, to come and assess my patient. I would never let my patient suffer for negligence by someone who is incompetent, though I think many times the residents would rather see how the dice roll, than be held accountable for anything.
So instead of telling you what bad residents do (the list would be endless) - I will tell you what good residents are like and what good role models they can be.
A good resident is always attractive - even if they started out ugly, by the end of their residency they have the self-confidence, humility, critical thinking, and good judgment to be attractive to anyone. I mean this - men and women, bald and not. When they can run a code, ask you for things by your name, and remain cool - they are attractive.
A good doctor always checks in at the end of the day - I mean it. Post-call or not.
Always sits down (at least once) to talk to a family member. I mean literally sit.
Calls the family to give updates
Knows good nurses by name, says thank you to nurses who give exceptional care, and tells the patient they have a good nurse when they do. (I don't just mean this in a shallow good-nurse way. There is sometimes this weird animosity b/w doctors and nurses. The nurse wants power (even if it is bitchy power), the doctor wants recognition for his $100,000 debt, and they treat each other with contempt)Telling a patient he is being well taken care of is a renewing cycle. The patient is grateful and reassured, and the nurse thinks "I am a good nurse - let's go give some good care". The Dr-nurse relationship has become a partnership and the patient benefits.
Doesn't act like they already know what you are trying to tell them.
Is humbled, and can say they are sorry.
On this note, there is also a list of nursing do's and dont's.
I work with some amazing nurses. I work with some lazy nurses. There are good nurses with exceptionally poor communication skills. I also work with some nurses who want to retire, and really don't give a rats ass. I feel like I aspire to the first category.
A few things:
Shoot me if I ever say: "Just go in the bed and we will clean it up later"
A good nurse will call the family with an update, before they go on craigslist.
A good nurse will question Drs orders if they seem amiss
A good nurse is always wary in July
A good nurse will admit mistakes and apologize - to the patient.
A good nurse will tell residents and others if they did a good job.
I love a nurse who can cry
I love a nurse who can laugh at inappropriate times
crude humor is a must.
A good nurse and a good resident has a good heart, which more often cares than not.
So, the question is, what kind of nurse or resident do you want to be?
Wednesday, April 15, 2009
Devotion
I have had both the pleasure, and an exercise in patience this week taking care of two sweet people and their families. It has been some cruel hazing technique apparently at my work. For three days in a row - 12 hour shifts - I have been taking care of two men who can not move at all, both are totally alert and with it, and both communicate with an alphabet board. Moving row by row down the board, they nod when I have the right one, and then nod when I hit the right letter. It is a tedious task, but always a satisfying moment when I get a word right - arm, tv, suction, hot, up.
At home, both are able to use the computer. One uses a sensor on his glasses and can move his head around, the other can use his thumb to navigate the mouse. They send e-mail, surf the net---really cool. really sad. The computer is their life.
One has been like this since an accident 25 years ago. The other has had a rapid onset of ALS over the past 2 years.
Both have trachs, one is fresh and he is having complications.
Both of these men have amazing wives who care for them at home. They pick them up, put them on the toilet, clean them, feed them through a tube in their stomach. As a nurse I do this stuff everyday, but not living the same day over and over. These women have stepped up and given up everything for their husbands. Freedom, flexibility, time, privacy. I am blown away when I think of them.
One has limited time with her husband, the other has been doing this for 25 years. 25 years! They were only married a year before the accident, she said she doesn't really remember what they were like together before then. What devotion. What kind of lesson are they supposed to learn in this life? What the hell is God thinking?
But, they seem to be a perfect symbiotic match. He smiles softly to her, she anticipates his every need. They have adapted. They both have pain etched in the corners of their eyes that shows with their soft smiles.
I wonder how many tears were shed. I wonder if I could do the same. How would I change as a person? To lose so much in so short a time, and then have to live with it everyday. Praying that your care is good enough, that you don't let him down. So many emotions.
I wonder if I could do the same.
At home, both are able to use the computer. One uses a sensor on his glasses and can move his head around, the other can use his thumb to navigate the mouse. They send e-mail, surf the net---really cool. really sad. The computer is their life.
One has been like this since an accident 25 years ago. The other has had a rapid onset of ALS over the past 2 years.
Both have trachs, one is fresh and he is having complications.
Both of these men have amazing wives who care for them at home. They pick them up, put them on the toilet, clean them, feed them through a tube in their stomach. As a nurse I do this stuff everyday, but not living the same day over and over. These women have stepped up and given up everything for their husbands. Freedom, flexibility, time, privacy. I am blown away when I think of them.
One has limited time with her husband, the other has been doing this for 25 years. 25 years! They were only married a year before the accident, she said she doesn't really remember what they were like together before then. What devotion. What kind of lesson are they supposed to learn in this life? What the hell is God thinking?
But, they seem to be a perfect symbiotic match. He smiles softly to her, she anticipates his every need. They have adapted. They both have pain etched in the corners of their eyes that shows with their soft smiles.
I wonder how many tears were shed. I wonder if I could do the same. How would I change as a person? To lose so much in so short a time, and then have to live with it everyday. Praying that your care is good enough, that you don't let him down. So many emotions.
I wonder if I could do the same.
Saturday, April 11, 2009
Friday, April 10, 2009
Enlightenment
Chapter 1 - Denial
I have been taking care of a sweet, very sick 65 yo man admitted for lung CA with mets. His prognosis is for only weeks of life, and he was desperate to hold onto hope of survival. He said that he wanted to remain full code, "do anything you can". He was subsequently intubated (put on a ventilator) one early morning for respiratory failure, and I came in that day to start my four day week (44 hours).
He was sedated initially, but I was able to ease off the second day or so. Soon he was intubated without sedation, just a little fentanyl. He was animated, able to communicate easily, making eye contact, completely intact. He was not able to speak of course, but he made his needs known. He said again that he wanted everything done, chest compressions, paddles, you name it. Even if he were in a coma forever, he wanted to be kept alive. Jeez, now that is hardcore.
Chapter 2 - The Prologue
Ready to extubate today, day 4.
I came in, sats were 86% (you and I are 99%). He was on a breathing trial, the vent started alarming, his tidal volumes had dropped to 18 from 500, he started turning color, sats dropping to 70s, I call for assistance, he was taken off the vent and bagged, tons of secretions. Back on vent, doing better. He was coughing a lot, copious secretions through the am. Not going to extubate right now anyway...
Later the floors were being waxed with industrial waxing chemicals-- in the ICU -Nice. My room was one of the last, so I had to move my guy to the next room, uneventful, RT (Respiratory Therapist) (Frank) bagged him over. Shortly after, his daughter calls, I go to put the phone to his ear and he starts coughing out a lung (literally), he coughs out his ETT (breathing tube). ("Can you call us back in just a little bit?") It isn't as dramatic as it sounds because this sucker is strapped on like like a helmet on his face. It just tweaked enough that it was not under his vocal chords anymore and he was losing air from the system. We tried to push it in position to no avail. We called his medical team and decided to extubate and see how he fared. His sats were ok, but he wasn't coughing much out junk, we called anesthesia for possible reintubation, but decided to hold off and see how he did through the afternoon.
Chapter 3 - The Meeting
I had to go to this kiss-ass administrative meeting in the afternoon for 1 hour. I had 2 nurses watching my sweet little don't-let-me-die patient. When I came back, I found my guy on his side, mask on, sats 72, completely unresponsive- you have got to be kidding me -- "Call Anesthesia!" I rolled him over, started to bag him, my other nurses ran in. The noise from the f-ing waxing fans were so loud they couldn't hear the alarms, we got his sats back up, he is not withdrawing to pain, totally obtunded. Anesthesia intubates, my guy starts to come around.
Chapter 4 - Enlightenment
It is now 1700, my patient is totally alert. He loves me. I am the light of his world right now. I have talked with his whole family, I have led him through the last 3 days and kept him alive - barely. The Docs and I are talking in his room and he writes "I want to dirzz"(can't make out the last one). One dr writes "die" on the paper, "yeah right" I scoff. My patient looks at me and nods his head. He then writes legibly "I want to die". He motions for the tube to come out. After and hour of discussion, questions, him writing, "I don't want pain", "will it be easy?" - we allow his choice to be made after he repeats over and over that he does not want to wait till tomorrow. He has realized that he can't be saved, and he would rather go in peace.
Chapter 5 - Transition
It is now 1850, RT is called, morphine is hung, the drs ask me if I would be willing to call some family members as I am close with them. I do, then we extubate him, titrate up the morphine, and Sandy and I sit with him on the bed, holding his hands.
(Sandy and I are alike in many ways when it comes to patient devotion. We are both exceptionally loyal, not afraid to stick it to the drs, and we treat all patients as if they are our own. We have sung patients through death together, where we are the only support they have - and they are hardly ever our assigned patients. We gravitate toward families, loss, and death. We are also the loudest, funniest people on our unit. Also, we both like to drink a lot, go figure.)
1945- end of shift. I give report on my other patient (did I mention I have another guy on a vent?) I go back and sit with my little guy. He is quiet, breathing with raspy deep breaths, I give him another 5 of morphine, he is asleep and doesn't move as I spot check his sats - they are of course an ironic, laughable 97%. I said good-bye and went home.
I'll probably see him on Monday.
Hilarious
I have been taking care of a sweet, very sick 65 yo man admitted for lung CA with mets. His prognosis is for only weeks of life, and he was desperate to hold onto hope of survival. He said that he wanted to remain full code, "do anything you can". He was subsequently intubated (put on a ventilator) one early morning for respiratory failure, and I came in that day to start my four day week (44 hours).
He was sedated initially, but I was able to ease off the second day or so. Soon he was intubated without sedation, just a little fentanyl. He was animated, able to communicate easily, making eye contact, completely intact. He was not able to speak of course, but he made his needs known. He said again that he wanted everything done, chest compressions, paddles, you name it. Even if he were in a coma forever, he wanted to be kept alive. Jeez, now that is hardcore.
Chapter 2 - The Prologue
Ready to extubate today, day 4.
I came in, sats were 86% (you and I are 99%). He was on a breathing trial, the vent started alarming, his tidal volumes had dropped to 18 from 500, he started turning color, sats dropping to 70s, I call for assistance, he was taken off the vent and bagged, tons of secretions. Back on vent, doing better. He was coughing a lot, copious secretions through the am. Not going to extubate right now anyway...
Later the floors were being waxed with industrial waxing chemicals-- in the ICU -Nice. My room was one of the last, so I had to move my guy to the next room, uneventful, RT (Respiratory Therapist) (Frank) bagged him over. Shortly after, his daughter calls, I go to put the phone to his ear and he starts coughing out a lung (literally), he coughs out his ETT (breathing tube). ("Can you call us back in just a little bit?") It isn't as dramatic as it sounds because this sucker is strapped on like like a helmet on his face. It just tweaked enough that it was not under his vocal chords anymore and he was losing air from the system. We tried to push it in position to no avail. We called his medical team and decided to extubate and see how he fared. His sats were ok, but he wasn't coughing much out junk, we called anesthesia for possible reintubation, but decided to hold off and see how he did through the afternoon.
Chapter 3 - The Meeting
I had to go to this kiss-ass administrative meeting in the afternoon for 1 hour. I had 2 nurses watching my sweet little don't-let-me-die patient. When I came back, I found my guy on his side, mask on, sats 72, completely unresponsive- you have got to be kidding me -- "Call Anesthesia!" I rolled him over, started to bag him, my other nurses ran in. The noise from the f-ing waxing fans were so loud they couldn't hear the alarms, we got his sats back up, he is not withdrawing to pain, totally obtunded. Anesthesia intubates, my guy starts to come around.
Chapter 4 - Enlightenment
It is now 1700, my patient is totally alert. He loves me. I am the light of his world right now. I have talked with his whole family, I have led him through the last 3 days and kept him alive - barely. The Docs and I are talking in his room and he writes "I want to dirzz"(can't make out the last one). One dr writes "die" on the paper, "yeah right" I scoff. My patient looks at me and nods his head. He then writes legibly "I want to die". He motions for the tube to come out. After and hour of discussion, questions, him writing, "I don't want pain", "will it be easy?" - we allow his choice to be made after he repeats over and over that he does not want to wait till tomorrow. He has realized that he can't be saved, and he would rather go in peace.
Chapter 5 - Transition
It is now 1850, RT is called, morphine is hung, the drs ask me if I would be willing to call some family members as I am close with them. I do, then we extubate him, titrate up the morphine, and Sandy and I sit with him on the bed, holding his hands.
(Sandy and I are alike in many ways when it comes to patient devotion. We are both exceptionally loyal, not afraid to stick it to the drs, and we treat all patients as if they are our own. We have sung patients through death together, where we are the only support they have - and they are hardly ever our assigned patients. We gravitate toward families, loss, and death. We are also the loudest, funniest people on our unit. Also, we both like to drink a lot, go figure.)
1945- end of shift. I give report on my other patient (did I mention I have another guy on a vent?) I go back and sit with my little guy. He is quiet, breathing with raspy deep breaths, I give him another 5 of morphine, he is asleep and doesn't move as I spot check his sats - they are of course an ironic, laughable 97%. I said good-bye and went home.
I'll probably see him on Monday.
Hilarious
Thursday, April 9, 2009
A job I love, but don't get to talk about
I had no idea what I was getting into when I became a nurse. They don't tell you in school what it is really like, they save that surprise until after you graduate (and owe $40,000).
The brutal reality of nursing intertwines with the sweet reward of knowing that this day was meaningful. It is comical and tragic. Gross and sterile. Loving and really hard-assed. Painful and euphoric. A rush and a day that goes on for-God-damned-ever.
These writings are a log of my interesting, sad, hilarious, and meaningful adventures in a small Medical ICU. Nurses have amazing stories that are many times inappropriate for the untrained ear. I feel trapped when I come home because most of my day, experiences that have enriched my life and my patients and families, are not able to be told in their entirety. There is an unspoken wall between our world and that outside of the hospital. People get uncomfortable with death and sick people, and I feel like many of my best stories are left untold.
So without being narcissistic, I will try to relay some events and treat this as a journal, and people who are interested can catch up with me whenever they desire.
The brutal reality of nursing intertwines with the sweet reward of knowing that this day was meaningful. It is comical and tragic. Gross and sterile. Loving and really hard-assed. Painful and euphoric. A rush and a day that goes on for-God-damned-ever.
These writings are a log of my interesting, sad, hilarious, and meaningful adventures in a small Medical ICU. Nurses have amazing stories that are many times inappropriate for the untrained ear. I feel trapped when I come home because most of my day, experiences that have enriched my life and my patients and families, are not able to be told in their entirety. There is an unspoken wall between our world and that outside of the hospital. People get uncomfortable with death and sick people, and I feel like many of my best stories are left untold.
So without being narcissistic, I will try to relay some events and treat this as a journal, and people who are interested can catch up with me whenever they desire.
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