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?
Wednesday, April 22, 2009
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.
Subscribe to:
Posts (Atom)