experiences of an ICU nurse

A year gone by...

2010-12-07T05:16:00.001-08:00

It has been a while dear readers. This has been a fine year - with new experiences, and bold/insane challenges, I have enjoyed myself. I am also tired, but finally catching up with it.

I have just finished my first stint as an official clinical nursing instructor (Thank you Tarrah), in addition to my glamorous real job. This has been an excellent experience which is great for my resume, pocketbook, and ego - but my family does not recognize me anymore. My house seems to have a life of it's own; heaving and breathing with dust and piles of laundry - clean and dirty mixed together, in the corners of every room.

At the start of the year I made some resolutions. I wanted to follow up with some of these, and also let you know some other things. First, my friends I want to let you know that I am an overachiever volunteer. You may remember my moral dilemma about whether or not I was exempt from having to volunteer additional time and money for the sake of others, since all I do is nurse the sick, wipe their asses, cry with their families, and fight against administrative sloth and snobbery. Well, the answer the heavens gave to me, was "No, totally not exempt". I am actually not going to be fulfilled unless I dedicate a good portion of my time to enriching the lives of others - I shake my head in disbelief as I write this, as I really would like to just spend free afternoons drinking cocktails and watching movies. But, instead I coached my kid's baseball team for the spring, and volunteered as camp nurse for a week this summer, in addition to choosing not to get drunk at the school auction - and instead I volunteered as a registration/cashier person. The last one actually benefited me - as I saved $700, and was able to laugh at the drunkards, who were actually myself the year before...

Camp nursing is a lot like ICU nursing, only with lots of benadryl and ice. I was able to go for a week to beautiful Orcas Island and I read 3 novels in addition to my rigorous nursing duties. The draw was that my daughter was able to go for free, and I was able to spend an excellent week with one of my best friends as we giggled like girls, while we calmed the crying babes, and appreciated the strapping male 18 year old bodies... as an artist would of course - not like cougars... Also, the week was excellent as I got to give a series of the rabies vaccine to this kid who may or may not, have had a bat fly into his mouth when he was walking in the dark. Don't ask; only know that it was 4 intramuscular shots in a row, and the serum is hot pink - freaky!

I have not gotten more artistic, but I have made some delicious Thai curry.

TFMITW has died. He placed himself on comfort care, shortly after marrying his young Asian bride - truth is stranger than fiction, but I will let your imagination take flight here. He was stoic, and yet a child, and I said goodbye one afternoon, stroking his cheek as he wafted in and out of consciousness, sure in my soul that he couldn't actually die - but he did, three days later.

I have taken a more anonymous route with this blog, as my students are probably nosey, and may be looking for any kind of leverage. I have also been somewhat of a rabble-rouser at work. I am angry about many issues, and you know what? I won't fucking take it! We deserve a voice, and the ability to be progressive, move forward, be able to give the best care possible to our patients, and to be an actual part of the force that makes decisions for our facility. We get all the blame when things go wrong, God be damned if we shouldn't get the ability to self-govern, and have a vote - at least a little... And though I have no fear of being fired, I may try to take someone's job one day, and perhaps I shouldn't lay myself down as a martyr just yet in this forum - I mean really, I obviously still have some work to do, right?

On this note, I will inform you of my newest resolution for this coming year - Grad school. Yes, I am insane and masochistic, not to mention an absent parent, but I am compelled to do more I guess. I can not work in the same setting for 20 years, and I might as well get it over with while I have some of my youthful vitality and clever wit. This will assist me in contributing more to this online diatribe, as you will help me to promote dialogue, give me feedback, and also let me know if that's just the wine talking.

So now I offer you the title of my next entry: Palliative Care - Devil of Defeat, or Humane Patient Treatment?

Happy New Year.

Palliative Care - Devil of Defeat or Humane Patient Care?

2010-08-18T08:45:00.000-07:00

The word palliative comes from the Latin pallire which means to cloak. It means to alleviate symptoms or to make something less severe. Palliative care has been a quiet movement which surfaced as patients, families, and health care workers grew more and more uncomfortable watching their loved ones suffer for the sake of healing. The idea to cure at any cost has been ingrained into the psyche of our poor doctors. They are expected to figure out what the disease is, and treat it appropriately. If that doesn't work, they try something else. This process continues until all hope is lost, and the family is informed that nothing more can be done. They then, theoretically will kum by ya at the bedside, and kiss their loved one goodbye. This is a nice process on paper, and makes sense as you read it, and yes, you may even be lured into it's simplicity, until you are the one who has to sit in that room. You sit there watching your loved one get worse and worse, lay in pain because fentanyl will cloud their mental status. They also become grossly edematous and their skin starts to weep and tear everywhere. They loose control of their bowels, and are rolled and shoved from side to side as we change their sheets and rub thick paste on their bottoms. This is really the toned down version of what we do. Honestly, I can't begin to describe some of the physical deterioration I witness on a day to day basis. Sometimes I feel like a CIA waterboarder. Patients whimpering as I roll them, begging me with their eyes to stop as I clean away the feces from their macerated skin. This is the worst part of my job - and sometimes I hate myself for it.

(I will say this disclaimer: as some poor patient deteriorates into a wretched, decomposing life form - this is not always the fault of gung ho medicine, but just crazy ass families who refuse to accept the inevitable, despite a ridiculous count of family meetings, or sometimes a blatant refusal to even visit their loved one, who they claim to care too much for to let go. Just keep them alive at any cost. This is a segway that I wanted to avoid - but stay tuned for another blogpost in the future entitled: The Whole Enchilada?)

Palliative care is in essence, the backwater cousin of modern medicine. The herbal healer compared to the Pfizer magician. In short, the roots of modern medicine that were swept under the rug as microscopes and labs replaced thousands of years of oral tradition and observation. Older medicine focused on symptom management and trying to sustain the body as it fought illness, and if the battle was to be lost, the healers provided comfort measures to extend dignity and pain management. As time has marched on, and medicine has become more complex and miraculous, the focus on medicine is now fixated on The Cure. Finding the answer at any cost, despite additional pain and discomfort. Over the past few years, the Palliative movement has been quietly growing. A sprout of revolt from standard care, which also takes into account quality of life and symptom management. It is actually the same medical picture taken from a different angle. Palliative medicine looks through the eyes of the patient and family. The brush is very broad, but covers the bases that traditional modern medicine has missed. Concepts that Palliative care investigates include:

Goals of care - Tell me about your loved one. What are your goals now? What would they be if this or this happened? Has your loved one ever talked about what they would want in this situation? How far should we go? What would you want if you were in the same position?

Symptom management - pain, nausea, vomiting, constant diarrhea, constipation, inability to eat, edema, weight loss, dementia, hallucinations, delirium, depression, anxiety, anger, fear, crazy ass family who doesn't quit, crazy ass resident who doesn't quit - they are extensive, this list could go on - I won't bore you, but you get the picture.

Patient and family support - free psychologist!

Facilitator for family meetings - actually get doctors to talk with one another - Amazing!

Interdisciplinary liaison - actually gets doctors to talk to one another - Amazing!

Spiritual Guru - Gets you to talk to, and listen to the God which has forsaken you! Lord bless a good chaplain.

As you can see Palliative Care takes into account all if those things that people really want, but are afraid to ask for. And frankly, as Palliative Medicine continues with this incredible scope of practice, it is destined for failure in many ways since it encompasses so much. This is really a philosophy that will, over time, be integrated in modern medicine. I don't blame the doctors or other care providers for not being able to cover all these bases, it is now just starting to be routine in MD training, and there are many old school Attendings who are threatened by Palliative Medicine, and sadly, are a very poor example for their young Jedi. The culture is changing however, and soon, I foresee that Palliative measures will be enacted as soon as patients walk in the door.

I was talking to a resident about his patient getting a Palliative Care consult. He asked if nurses were allowed to place the consult, and why we would do it instead of the intern. I told him quite sincerely that sometimes residents and interns are "idiots". Nurses say over and over, "this guy is super sick and going to die here; Palliative Care maybe?". Doctors say: "It is too soon to tell, we are talking to the family, it's not time for Palliative Care." Essentially, they don't want to admit defeat, and really I think they don't want to deal with sticky, emotional situations. I explained that as nurses, we deal with a lot of shit already, and while we are trying to keep a patient alive and get all of our obnoxious charting done, we are not the right people to be an effective emotional support for our families. Taking care of sick people is hard. Nursing school barely trained me to handle a bedpan, much less a grieving soon-to-be widow and her disabled daughter who brings her drunk husband and his biker friends. With all the crying, questions, begging for a miracle, and "can I get a coke, his feet look cold, why are you giving him this medication, by the way he is allergic to pollen, why is he so swollen, I don't think he would want this...." - I am spread super thin. I am awesome, but I can't deal with all that! Give me a little back-up!

Give me a liaison to the emotional realm. The phenomena of human disconnect in the ICU and hospitals in general is very interesting and will be discussed in a later essay - but the point is that in order to function in such a visceral and intense environment, nurses and health care staff must essentially "turn-off" that state of "presence" which is in tune with a family's emotional and spiritual needs. I couldn't function with all of my physical nursing duties, as well as being a genuine soft shoulder to cry on - the RAS section of my brain may literally catch on fire or something from so much overload.

"Sometimes the Palliative Care consult is a cry for help from your nurses" I tell Dr J. (Cute resident who is a boy dressed in man's clothing)

He asked aloud if it was his own ego that was offended by a request for Palliative Care. Maybe he was hesitant to order the consult because he was afraid to admit failure... (Umm, duh) Maybe was because he didn't want to look stupid in front of the other doctors...(Umm, duh).

"OK, then. When is a Palliative Care consult inappropriate?" He asks me. Together we determined a PC consult may not be beneficial when:

- You already have an excellent primary doctor, like an oncologist who knows the family well, and whom the family trusts.

- You have a crazy ass family who doesn't trust anyone, and thinks you are trying to kill their loved one anyway, and then you send in the "death team". This is the family who will believe in a miracle till the bitter end. It sucks.

- You have a very well balanced family who has excellent communication skills and is adaptable to the changing situation. (1 in a million)

Overall, I can feel the current of medicine is changing. I envision true interdisciplinary rounds where Palliative Care, social work, dietitians, pharmacists, and nurses are utilized as resources and equals with the doctors, and a holistic patient picture can be developed. It is easy to imagine, because it is how it should be; it is the only thing that makes sense - and the catch is, it would be so much easier, and would save time, money, and would encompass a real view of our patient's health and wellness.

In the hospital, we are treated only for physical distress, and spiritual crises are passed over quietly. Patients avoid talking about this as our culture does not embrace emotional needs. In the real world, we all are getting Palliative Care in one way or another. We seek out therapeutic friends, who tell us how it is. We self medicate with chocolate. We go to the doctor when we are sick. The difference is, we choose our therapies, and we know what we need when we are outside the hospital. It would be nice if our patients were allowed some alternative and satisfying options that addressed all of their human needs, not just the physical ones.

My good day is someone's really bad day - Confessions of a bored ICU nurse

2010-08-18T08:44:00.002-07:00

Since I had too much time on my hands for most of the summer, I took time off from writing apparently. I was uninspired, bored at my job, and desperate for anything to take my mind off how sick I was of my workplace. We were a home for the chronically critically ill, and it almost drove me to insanity - I swear. I became desperate for any exciting event to happen - dreaming of car accidents, trauma hospitals, and even had been contemplating airlift nursing (that is still on my radar by the way). I started out as an ICU nurse - which has been great in many ways, but I sometimes go back to what this older ICU nurse said to me when I was graduating from nursing school: "You don't want to start out as an ICU nurse, because then you will have no where to go". I didn't really understand what she meant, until I have watched four people retire this year who had worked on my unit for like twenty years or something. Jesus Christ! Twenty years??! I know time flies, but please let me spend time away from these same dreary walls and fucked up management (No offense Nurse Manager - who has been fairly decent, and I'm not even just saying that). As I found myself increasingly dissatisfied with my work, and scouring want-ads, those nurses words came back to me, and I looked at my options.

More blood and gore; aka cool new challenges!
I could get my TNCC-Trauma Nurse Core Course, and how cool would that be? I could be in a functional ER with even - get this - a working MRI! (I think I hear angels weeping with joy).
I could also be an ambulance or airlift nurse. Or, I could get some crazy job being the nurse for some foreign dignitary, or even South American drug lords, the options are limitless! I do want my kids to be fluent in Spanish, and who doesn't want to work for the Mexican Mafia? But, my husband has already put his foot down on that one. Usually, it just comes down to the outfit, and I would look really hot in a jumpsuit like this. Admit it people...

This is option one for the bored ICU nurse; more drama and fun. (this sounds good, but I would definitely take a pay cut, and I get five weeks vacation a year - this is hard to give up. Plus, there might be little babies, and that is always hard.

Managing...to take on a whole pile of shit.

I have strong social justice issues. I can see a bigger picture at my workplace, and I see so many areas that we can improve, and it drives me absolutely crazy if I think about it too much. I know that I have strong leadership skills, and I am fortunate to have an ability to encourage groups, and make ideas happen. I am pissed that our nurses (and all other hospital staff) aren't seen for their potential, and that by increasing employee satisfaction and idea ownership, we could improve patient care tenfold. Our nurses are absolutely treated like crap at my work by the upper management. I will say this with not really a twinge of regret, because these people have no idea that I even exist. I got a fucking popsicle for nurses week (from the volunteers), and yet I take all the heat when the Joint Commission comes to town. There is minimal recognition for years of service, basically zero opportunity to participate in greater hospital decisions, and then they wonder why we can't keep staff. Maybe I am ridiculous for even thinking that there can be a better way, that we should just be happy to be working, to know that the man will never listen to the regular working people; but in my heart of hearts, I know that this is bullshit. I know that people who are motivated can accomplish anything, and that by enriching people's perspectives, we can be the best place to work, with the best patient outcomes. I have a passion for excellent patient care, and I want to bring in new research and modernization for our patients and families. I am an optimist, and I fear, dear readers, this will fade in time - especially if I go into management...
Plus, I am still in my youth, and I have energy - I am not ready for the desk job.

Hitting the books

Since I want more, and I don't just want to get stuck in the same place for twenty years, I could go back to school and get my Master's. It would buy me some time, help me make connections, and design the role that I want to have in caring for patients. I have been looking into the Clinical Nurse Leader role, and I think it could be pretty great. But, this is a very new type of position, and there is a lot of controversy about whether or not it will become mainstream. I would still have my degree though, and that never hurts. This would involve me actually reading a book that is not a sci-fi novel or vampire smut, and those are going to be hard to give up, but I might still have the summers to catch up...I have been coddled by my regular day job I suppose.

These are some of the thoughts that have been going through my head this summer. I have not written because I have been tired of being tired. Now, however, my work is indeed exciting again, and I have been able to to give really good care to challenging patients and families who have inspired me to write this and vocalize my ideas.

So, thank you for reading my thoughts, and please give any insights you have. I know that we are nothing without the inspiration of others and I am grateful for that. I am also thankful for the intubated patient who needs lots of blood and pressors, and for the fact we got him better in time for the next one coming in. Amen.

The last sense

2010-05-19T22:20:00.000-07:00

I have often heard that the last sense to go is hearing. I have also heard the same about smell and touch. I don't know really what is the truth. I have experience with the end of life, and I still really don't instinctively know what people can hear or taste at the end of life. I do know that I am a fanatic about patient oral care, and that I insist on music or the white noise of CNN with my sedated patients. But, I also know that I have no real qualms with taking shop while cleaning up a code brown when a patient is sedated and intubated. There is also a never-ending joke about how in the ICU we are happy to have sedated patients when there has been a large amount of bean dip or cruciferous vegetables consumed the night before - it is easy to blame the man in the bed. I refrain from talking about a patient's condition or prognosis, but am not inhibited when discussing another nurses sex life, or what my weekend plans are. I often take personal calls in sedated person's room, and will chat while drawing blood or giving meds. I like to think the personal commentary breaks up the monotony of unyielding beeps and alarms that are part of the ICU experience.

This is probably crap, and I am a horrible person for dehumanizing my patients, and I do get paid a fair amount of money per hour, so there is really no excuse for not maintaining strict professional standards. Still saying this, I don't really buy that my people are there enough to hear everything that is going on around them. Most will wake up after they are extubated and say that they don't remember anything, and I like to think that maybe I gave them some good dreams talking about my wicked hangover, and the fun love making I (I mean my fellow nurse - of course) had the night before.

boyfriend update

2010-05-12T23:21:00.000-07:00

A year or so ago I wrote a post about some of my boyfriends at work. I am sad to say that one passed away, and I am just stunned that he could actually be gone. I thought he would be around forever. He deserved a quiet demise like falling asleep after a cigarrette and a burger, and forgetting to put his oxygen back on. I will visualize that that is how he actually went.

You will not be forgotten, and you made me laugh so many times- Thanks. I know that you are going to enjoy the lightness of afterworld.

I wish I had bought him the ham sandwich he asked me for the other day.

A rant

2010-05-03T22:10:00.001-07:00

This is going to be a bitchy post.

I normally don't talk smack about people (aside from residents and administrators, who are obviously exempt from this, and just from their job description, need to be heckled occasionally), but I feel the need to express some anger and frustration - and that, I will do now, with you dear reader. I think that most professions generally protect their own. Unless someone is a total jackass; teachers, lawyers, doctors, and nurses will give one another the benefit of the doubt. Publicly broadcasting someones incompetence is a politician's job, and not mine, but, with discretion- I will share this complaint.

OK, yes, I talk about death a lot, and I promised only a few more posts (a lie), and here is another one. Not particularly about death, but more about dying and dignity, and not the political hot potato kind. Dying with dignity to me means: not dying alone, not being a carnival show, having privacy, being comfortable, and having an intuitive person watching over you. Some nurses and doctors get this, and some are fucking oblivious. In the ICU this is a scary/sad thing. I believe that for many nurses, when a patient dies, there is a big difference in care when they are alone, rather than with family present. This goes for physicians/nosey med students too. When there is no family we are more likely to poke and prod, take random blood pressures, talk about how pissed we are at our spouses, and gossip about hospital drama. I know that I am less sensitive when there is only my sedated or stuperous patient - but the key is that I KNOW I am not being delicate at that moment - when under it all, I still am in touch with the current of the room, the patient, and my role as advocate. I can get right back there, where often times I don't know if some other nurses can feel it at all.

I had an event the other day where a new orientee was being trained by and older, very experienced nurse. The patient was placed on comfort care over the phone by their DPOA. The family opted out/was not able to be present for his death, (Granted, he probably had a colorful life, any may not have been the most angelic character, as his ending diagnosis was Hep C and alcoholism) and he was going to die alone. We all knew this, and shortly before I came on shift, his medical care transitioned to comfort rather than cure. I was to assume his care four hours later at 8pm, and in the meantime I was the floating helper nurse. (I will admit that I did remark: "Christ, another trip to the God-damned morgue, fucking great.") (I am not a saint). I went by his room a couple times and noticed that his door was wide open, revealing the bright yellow, bloated form that he had taken. Making sure he had soft music in the background, I shut the door gently each time, only to find it wide open again later. I hear the two nurses in charge of him wondering aloud why is oxygen levels are so high, they thought he would die so much sooner. The new nurse was eagerly watching his monitor for cardiac changes, oohing and gasping when he would have a sinus pause or a bout of arrhythmias. This is pretty cool for a little while, but after a while got annoying, especially when I noticed that his blood pressure cuff kept going off, showing a BP of 30s/20s. I asked why they were taking his blood pressure, and they couldn't give me a good answer. I said "The guy is on comfort care, give him a break!" They said they would stop it, and I let it go - with an eyeroll, and a meaningful look at the nurse next to me. Finally, 8pm comes.

I am the charge nurse and also have this guy. After I make the rounds, I go into his room. I see this man alone, fairly obtunded, with all the bells and whistles attached to him. I call the covering doctor for a morphine drip, which all my comfort patients receive, even for a small dose per hour (which you had better do for me too). I take off all of his extra leads, his BP cuff, his oxygen monitor, and I wash his face. I notice that his oxygen is blaring 6 liters in his nose, and turn him down to 1 liter per minute (No wonder his sats were so high!! (dumbasses)). I hang out with him for a while, swaying to Kid Rock after I change it to the country station, since he is obviously not smooth jazz.

All of this should have been done before me. I notice that after he had been placed on comfort care, his vitals were still written down every fifteen minutes for the next two hours. This irritates me.

Soon his heart rate slows and I go into his room. I stand next to him and sing him a song as he dies.

I took him to the morgue with the goofy escort guy (It was swell. Yeah right, the morgue sucks. I should get paid hundreds of dollars an hour when I have to go there and shove bodies around). Whatever.

I pulled the nurses aside individually the next day and told them that this was not the way to do comfort care and that I was upset about the way that this patient had been treated. They both bristled and made excuses, and I know that we are not on our game all of the time, so I am letting it go now. However, if I am in that bed, please give me a different nurse.

This is a rant really saying that an expected death should be as peaceful as possible, and that the care of the patient shouldn't be lessened if they end up dying without friends or family present. They should have a sensitive hand stroke their hair, and someone there to dream a little of the good person that they were.

So I will leave you with the song I sang, by a lovely woman named Joules who lived on Lopez - I think my guy liked it.

My clothes are ragged and torn,
you know as sure as your born,
that they've been loved and worn for many years.
And from the mud on my toes,
to the way my hair grows,
I see that everyone knows I'm living free.

Cause living free is the only life for me.
Yeah living free is the only way I'm gonna be.

Some see the dirt on my hands
and they just can't understand
how I can live on the land, but that's OK.
I tried my hand at their schools,
but they was acting like fools,
restricting life with dumb rules,
that's not for me.

Cause living free is the only life for me.
Yeah living free is the only way I'm gonna be.

(Jazzy ending)

Puppy Love

2010-04-30T08:19:00.000-07:00

Just a few more posts about death, I promise.

When I was 19 and living in a van, with a really great ex, I adopted a little puppy. She was six weeks old, a little black fur ball, and was so small she couldn't go up stairs by herself. She grew up to be this incredible dog, who was always loyal and dependable. I didn't have to use a leash after she was four months old, she learned lots of tricks, and she got along with most dogs and kids, but wouldn't take any crap either. She barked at the door when people came over, and liked to pee in the basement sometimes, but these were her worst flaws. She was always so cool in public, I would take her to festivals and pretty much everywhere I went. She was so mellow, she got left at more than one garage sale; where we all jumped out of the car to check it out. After perusing and buying goods, we would drive away, realizing a mile later that Zu wasn't in the car. I would freak out, flip a u-turn, and there she would be, standing in front of some guys garage, waiting for me. I'd lean over and open the door, and she'd hop in. We'd speed off down the road, as a group of people would chuckle at the scene. Good times.

My dog is now 14 years old. She was diagnosed with heart failure a couple years ago, and her life was graciously extended with dignity by the modern marvels of an ACE inhibitor and a little blue hydrocodone pill. Her symptoms started with this random collapsing when she was exerted. The first time it happened I was walking with friends from the gym, and Zula just fell to the side, laying there, breathing hard. It happened a couple more times, and I thought that perhaps 12 years old was the end for her, and this was just a natural progression. My husband told me to take her to the vet, and she was prescribed some meds that gave us some more good years. (Thank God someone in the family has sense to see the doctor!) Her quality of life has been excellent, despite occasional exertion seizures and accidents, she is always happy and loving. She is the best girl.

Zu-zam has lost a dramatic amount of weight in the past month. She has stopped eating and when she stands up, she wobbles back and forth like a drunken sailor. Her time is near, and I am trying to make her as comfortable as possible. She needs to be carried down the porch stairs to do her thing, and I bring her up again, laying her on a blanket that belonged to my sister. She won't even eat bacon, and we all know this is an ominous portent. I would like her to die at home, in her sleep. But, I don't know how it will all play out.

I tell people at work about her, and they all are sympathetic. One person tells me to use propofol under the skin, another says phenobarbitol, and yet another tells me to bring home an IV kit and some potassium. This is all well meaning, and shit, yes, we all want to save some money, but I'm not going to kill my own dog. I want to be the griever, not the agent. My role is to love and cherish her, not plan for and give her the best death. This is a new arena for me. I have had personal losses, but most have been sudden and devastating. I have not had to watch anyone get weaker and more feeble, except my Grandma, who was comically proactive, planning her own wake from the music and the food, and finally passed away the morning of the event.

It makes me glad that she is not in pain, and still wags her tail when she sees me, but I still lay down on the floor and cry heavy tears thinking that soon she will be gone. I know that she is "just" a dog, but she is part of my family and she has been with me through the most fundamental changes and progressions in my life. As a nurse who deals with death all of the time, It is surreal to have this in my own home. I have been to the morgue twice in three days this week, wrapping the bodies of two people whom I was with when they died. Still, this exposure doesn't prepare me for the loss of my baby and best friend. At home, laying with her, I easily slip out of my day job, and envelope her with inconsolable arms. Thanking the Gods that there is someone else who can lead us through any tough choices we may have to make ahead.

the power of now

2010-04-10T17:41:00.001-07:00

0700
Me:'I hope I get someone super sick today...God, is that wrong?'
Husband:'No. But it's weird.'

Anyone who really knows me understands that myself and my family have been having a rough year or so. Tragic events, coupled with strained relationships, have made me very close to the self-help section at Barnes and Noble. It is a startling event when you realize that whenever you go to the library (after your therapy session), you are consistently drawn toward books about spiritual enlightenment, comfort food, and hot, teenage vampires. Anyway, my point is, that yes, I have had some Lifetime Channel moments, and I am pulling myself through, one trip to the bookstore, and one blog entry, at a time.

Along my journey of self reflection, I found the pinnacle of modern spiritual growth, Eckhart Tolle's The Power of Now. The point to this book is pretty simple and is not rocket science (Monica), but easily missed in our daily rat race. He says people in American society don't focus on the present, and instead, dwell on the past, or think about the future. He writes that the mind evolved as a helpful mechanism for humans to develop strategy, and assisted us in ultimate survival; but has since taken over. We think of our minds as our self, when really, many of the thoughts are crap repetitive tapes cycling through our head. This rang true for me in some ways, and I started to make an effort to sweep away nonessential thoughts, and to think of my mind as a tool, not as my true self. (My mind likes to talk a bunch of bullshit, and so do I in daily conversation)(ask anyone)

Being in the now takes the effort to quiet the mind, and just be aware of where you are. A section of the book mentioned that in emergencies, you have to be completely present, and that your mind is useful to get you through the event, but it doesn't throw out a lot of it's regular rambling. This struck me as I read. I realized that one of the reasons I like working in the ICU, is that I have to be present and in the now most of the time. I do well in that now. I like to call ahead to get challenging patients, and I want to fill my day running to catch up. Sometimes it can be overwhelming, and I don't need the action everyday, but I love that feeling. I am strong and useful, and am becoming expert at anticipation and reaction. I feel empowered when my movements are instinctual and correct: drugs, ACLS stuff, airway patency, arrhythmia's, knowing how to look calm in front of families. I feel at home with this self. When I was at the bookstore looking for meditational insight, I did not realize that I had already carved a niche at work where I did have some sense of self and inner peace. (You just have to ignore the blood, shit, and festering wounds - then, voila! - Nirvana)

In real life, I am still working on trying to swim through the constant chatter of shoulds, needs, wants, and all of the baggage that goes on in family life. Finding those quiet moments with kids as enthralling as my day job. Loving my kitchen again, really smelling and seeing the soil as I turn it over in the garden. Finding joy in the little things that don't involve gore and vasopressors. These are things I am working on.

TFMITW - The Foulest Man In The World

2010-04-07T09:26:00.000-07:00

Disclaimer - This entry may contain profanity. I have censored some of my recent posts as I have been publishing some of my stuff on nursing blog forums, which tend to be more scholarly, and try to be serious/conservative in nature. This is despite the fact that a lot of real life nursing deals with crap and bureaucratic bullshit. I for one, love swearing and crass commentary, and have felt, well, almost suffocated by these fucking boundaries of professionalism.

TFMITW lives in my unit. He won't die, but he also won't get better. He teeters on the edge of life and death all the time, and when he is doing ok, he is rude, is always on his fucking call light, and is always, hideously incontinent. His stench is unbearable and it permeates to your very core when you take care of him for the day. He also refuses to turn, refuses to cough and deep breath for pulmonary hygiene, always is screaming for pain medication, and worst of all, if he doesn't have his speaking valve or call light handy - clicks incessantly with his mouth like a horny Spaniard. He is now basically paralyzed, has an ever oozing trach, and needs everything done for him. Wiping his nose, feeding him, flossing his teeth, "milking" his rectal tube, changing the channels, and moving him repeatedly one inch at a time - "No! Too much, back toward you! Get the wrinkles out, Oh God I hate the wrinkles. Oh my rectum hurts, it burns! I need more dilaudid! Oh Christ, I just crapped again." This is your day with TFMITW. Oh God it burns.

He is the bane of the unit and we trade him off like canned spinach. I have to assign him to people, and will trace it back to the last time someone had him. Sometimes I have to go back over a month in order to make it fair. This whole junior high bullshit pisses me off. People will sigh heavily, whine uncontrollably, and beg to pass him off. I mean he isn't pleasant, but seriously, groveling?

The sad thing now is that he doesn't really bug me anymore. I actually feel bad for him, and have found out over time, that we actually get along pretty well. He calls me Nurse Ratchet. I set limits, tell him no, and say "Jesus Christ TFMITW, give me a fucking break!" He likes this. I am the one who got him out of bed for the first time in two months and took him outside - for a cigarette, of course. The light shone in his eyes as his son held the smoke to his crusty lips, and he winked at me as the sun played on his face. He was so grateful for that moment, and I felt pretty good about it. Then later, we had to go upstairs and replace the large rectal tube that he is always shitting out as he has no more rectal tone. sweet.

He always asks when I am coming back. He has a couple nurses who don't treat him like crap, and he wants to know who is coming on after my shift. He doesn't understand why he always gets a different nurse, and gets depressed and angry that no one listens to him. He doesn't mean to be TFMITW, but alas, it is his fate. He is an asshole, and if he was more proactive and nice, he probably would have gotten better care from everyone. People look at me in horror when I say that I don't mind him. "Well, why don't you just take him all the time then?" they ask smugly with sarcastic smiles. Well, for one thing, bitches, he is a patient and deserves care despite his physical and personal flaws. We all need to do our share and deal with backtalk and crap. So you too, can get off your ass, deal with his needs and find a way to communicate and help him so that he doesn't call you every five minutes. Plus, I am getting tired of coming home and taking a thirty minute shower which includes a complete nasal flush.

TFMITW is looking like crap again by the way. It is nice when he is stuperous and can't get his shit together enough to call for help. But it is sad listening to his confused and rambling hallucinations. He is half the asshole he was, and this is an ominous sign. He is on pressors and is dependent on the vent all the time now. I think that many people on our unit might be happy if he was listening to "smooth jazz", but I would miss him. (Well, I'd miss him as a person, not necessarily taking up a bed for god damned ever)

Good luck TFMITW.

The ugly cry

2010-03-28T23:56:00.000-07:00

The other day we let a patient die. He had been dependent on the ventilator for a couple months, and no matter what we tried, he still needed tons of extra oxygen and pressure (peep) to keep up his oxygen sats. He was always anxious and frequently requested anxiety medication. He had a trach but couldn't talk, didn't have the ability to write, and was literally trapped in his body. He was miserable, his family was torn apart, and his girlfriend was by his side all of the time with a look of heartbreak in her eyes.

He kept pulling out tubes, and over time it became clear that he did not want artificial nutrition or invasive lines. All the medical disciplines came to see him and he made it known that he wanted to be removed from the ventilator and for us to let him go. He had been fighting this for over two months, and it was clear that he would never leave his room. His family understood and accepted this, and his girlfriend was more hesitant, but ultimately, she accepted his decision, and a date was decided upon. I was charge nurse that day, and I was assisting in the comfort care process with a new-ish nurse. It is a trick to balance sedation and comfort with dying patients. You want to give them enough to sedate and comfort them, but you can't suppress breathing and actually be the death mechanism itself. (tricky). He had about eight family members and friends in the room when we started. He was given a bolus of versed and fentanyl and when he was comfortable, we disconnected him from the ventilator. We covered his trach site with some humidified oxygen, and watched him for signs of discomfort or fear. His family gathered around him, anxiously watching his face, waiting for the moment he would escape from his body. We gave him some extra sedation a couple times, but really it was a lovely passing. For his final and greatest journey, he was able to know when his time had come, all of his closest people were showering him unconditional love and support, and he was comfortable the entire time. What a blessing.

His oxygen sats slowly lowered over the next hour, his cardiac rhythm widened, and shortly after, he was in PEA. Soon had no cardiac activity. His family was told that he had passed, and it was an emotional time for them all. I was in and out of the room through the day, helping out and answering questions when I could. It was also taco day for the nurses, and I spent some time in the back getting the fiesta together while I oversaw the unit. Later, his nurse went for lunch and I stayed in the patent's room to act as family support and explain the process of what happens to his body after they leave. I stood close to his girlfriend on the side of the bed who was still holding his hand. Her eyes were red rimmed and moist, but she was calm. They had been high school sweethearts who reconnected fifteen years ago. They never married, but lived together and loved each other as life partners. She was the one who would go home to an empty house, clean out his belongings, and figure out how to carry on. His daughter began to gather up her family and say goodbyes to friends who came to be with them. I stood by the girlfriend and took in this scene of goodbye. I got weepy as they all took turns kissing the patient and waving in parting to his ladyfriend. She still sat by him holding his hand as they drifted out, the daughter was the last to leave, signaling to the partner that she would call her, her hand as the telephone to her ear, and she walked out the door into the hall. This moment was profound. This ritual of death, mourning, and goodbye. I was so there; I was both observer and participant. I found myself in the partners chair, holding his hand watching all of the others leave, and being left dreadfully alone. A flood of emotion welled up with me. My little tears turned to rivers, I began to literally heave and sob. This moment, that had been replayed over generations, centuries, since the beginning of humanity, was unfolding before my very eyes. I was hit with the full force of these very human emotions and experiences, and in that instant, I rolled in this emotional tsunami.

What a blessing.

I looked out the window and tried to pull myself together. I grabbed some tissue and dried my eyes, squeezed the girlfriend's other hand meaningfully, and walked out of the room, trying to keep these emotions in check. Then with red rimmed eyes, I went to the break room and ate a taco. My coworkers asked me if I was OK. I nodded and sat down. We all ate in silence for a while. The moment passed, I ate my tacos (delicious), dealt with the unit, wrapped up his body, and had the room cleaned. The day was done, I went home and had a beer or three. I kissed my family, read the kids books before bed, snuggled with my husband, and felt incredibly grateful. I slept without dreams.

I told my friend Jaime about this emotional experience I had, and my uncontrollable visceral reaction. She matter of factly said "Ahhh, that was the ugly cry". The spontaneous, overwhelming emotional response that possesses both body and mind. A labor pain of sentiment that strips away all personal discretion and composure, revealing the raw, pure soul within you. I was able to explain how real that moment was for me; how it symbolized humanity, mortality, unhindered love and loyalty, the true complexity and beauty of relationships. I tied it together with one encompassing word: Lovely.

It was amazing to witness such a power, such a time of incomprehensible sadness, mixed with love and hope, and to see this dance of human relationships. I was truly present for that striking moment, and it will stay with me forever.

What a blessing.

Jinx

2010-03-13T10:53:00.001-08:00

You really never know who is going to do well in the hospital and who won't. You can guess fairly easily based on vital signs and labs, previous experiences, a person's feeling of well being, and your own instinct, but really all of those things have failed me more than a couple times. People can have massive MI's suddenly, and they are just - gone. Despite your best efforts to stabilize them and get a cardiac rhythm back, you fail, and they are lost to you and their loved ones in an instant. Some people you can expect this of; they have been having chest pain, they have horrible cardiac disease, they look like crap, their mentation changes. But some people give you no warning at all. They come in for shortness of breath which clears quickly with a little lasix, and you send them to the floor with a cardiology consult, never guessing that they will code that night.

In a small hospital with limited ICU beds, we are constantly trying to shuffle patients in and out. There is a lot of pressure to move patients to the floor when we think that they may be (possibly/probably) stable. Many times this is a crap shoot - the truth is, when you only have two patients, you can detect subtle changes that are missed by the floor nurse who has 10 patients. You can see when their respiratory rate goes from 20 to 35, you are there to assist them cough out huge amounts of thick, sticky sputum, you run in when they are starting to throw up and begin to aspirate bile. The floor is a different animal; where questionable patients are left to fend for themselves unless they are aware enough to use the call light, or if someone happens to come into their room at the right instant. It is a toss up, and you just pray that nothing goes wrong with them when it is your call to push them out of the ICU. When I say push, I really mean push by the way. We use gentle pressure on the residents, saying: "We have no ICU beds in the hospital. If there is a code, we have no where to put them. Who can move out? Now." We look at the patients, determine who is the least sick, and send them out, sometimes crossing our fingers. This is the nature of the beast, (and inadequate staffing) and we just hope that everything works out ok.

Through these patient transfer experiences and my own personal adventures, I have found out an amazing thing. I have a gift/curse from God. I have a horrible talent for hexing people via words of reassurance and encouragement. Oh, you good people may scoff at this, but I swear to the higher power that it is true. I incite the fates by trying to tame patient/friends fears, and I have learned that to improve the odds of survival, I must be as noncommittal and vague as I possibly can, for the sake of others. I think doctors and tattoo artists have also learned this lesson, as they will never tell you what you should actually do as a patient/client. They give you scenarios, tell you the odds, but never, ever will come out and tell you what operation you should have, or what colors would work best for the Chinese dragon you want to place on your torso. Always the same damn thing - "These are your options, I can't decide for you, this is what has worked for some other people in your situation, but I can't say it is the right choice for you". They must be jinxes too, and are taught in their schooling the nuances of ambiguity.

So, since I have learned these lessons about myself and the nature of my job, I know a few things that I will never say again in order to protect the safety of others:

"That baby will slide out like a little seal" - Translation: That baby will be born breech and you will be in heavy labor for many hours.

"It's not like you are circling the drain or anything" - Translation: Actually, this is your last night to be alive, you should call your mother.

"God, you look great, you'll probably leave in the morning" - Translation: You look good now, but wait for a couple hours after I leave - not so much.

In the hospital, we are sometimes forced into difficult choices where we have to push the patient out of the nest, to see if they fly or not. Usually this goes off fairly well, other times they come back to us in a day or two. These "repeat offenders" usually will have a hard time ever leaving the hospital, and ultimately may be treated in a palliative fashion, keeping them comfortable, and out of the ICU because we can't actually make them "better". I will not worsen their chances however, by making a generalized, overly positive statement about their condition, which, as we have learned, would mean their demise. Instead, I will take a measured, cautious approach which is noncommittal, but warm - "Hey, I hope you get to leave, but if not, I have lots of jokes and obnoxious commentary to keep you occupied for a few days while we work on it, ok with you?".

Is that better?

patient advocacy - not as easy as you'd think

2010-03-03T20:57:00.000-08:00

I received my first, rather horrible, critique of my nursing practice the other day from a comment on this blog. As a person who is used to praise and commendation, I was first dismissive and cold when this person presumed to judge my nursing skills, my patient devotion, and overall ability to be a fabulous nurse. When I first read this comment, I was pissed. My unedited mind said: "Fuck you. You wish you could have a nurse like me. You don't know me. How dare you put me in this little box, focusing on out of context words, and trying to chop me at the knees. Get some fucking counseling and kiss my ass." This IS a rather extreme reaction, and I held myself from responding that evening, and instead, drank some wine and slept on it. Many days later, I take a deep breath and brood on patient advocacy. Could I have done more? Should I have done more? What prevents me from acting more, on what I believe are my patient's best interests?

There are many factors involved in being completely present for your patient, and I am not perfect people! I try to be the best patient advocate that I can be, but there are a few issues in my practice that fluster these intentions. First, I am the NURSE - I take orders, not give them. Second, people say "no" all the time - this doesn't mean that they "mean" it. Third, I am fucking busy, and do not have the resources it takes to research deep issues and have many heart-to-heart discussions. These three concepts will be further explored in this essay. Angry commenter, please accept this as a rebuttal and understand that I am not an evil sadist, but a person just like you - trying to get by, and do the best that I can with my time on this Earth. Peace.

I am a nurse. Not a doctor, soothsayer, or magician. I get orders and pretty much follow them unless they are totally stupid, totally wrong, or cause more pain than they are worth. The third reason is fairly subjective and frequently, if I suggest that this might be the wrong choice during rounds, I automatically seem to sprout two heads and am stared at without comment, and the interns return to their patient plan quickly so as not to embarrass me further. Nurses during rounds are really only worth anything when the Attendings are trying to look PC, or when all other ideas have failed. So yeah, I do say what is on my mind - "This person is sick and probably going to die, have we had a family meeting recently?", "Has Palliative Care been consulted?", "Is this invasive procedure necessary, and is it going to change our plan of care?". I say this stuff, and I hope for a meaningful response - but really am only effective if I take issues up with a resident in private, and they then present the idea as their own. They proceed to get a pat on the back, and then wink at me meaningfully when they are done rounding on my patient. nice.

People shout out "No!" many times during my day. They come into the unit with a GI bleed and are tachycardic and hypotensive. I explain what I am going to do beforehand, but they are of course upset and kicking away as I push a tube into their nose to go to the stomach in order to lavage the blood out. They say "No!" when I start IVs, restrain them from pulling out tubes, or putting in a foley because they are pissing all over themselves. These same confused/sick people tend to clear up within a couple days, and are sent off waving goodbye as they leave with a thank you, and I hope to never see you again. Coming into the ICU sucks, it is not a trip to the spa. It is hell to get better sometimes, and I walk the fine line of trying to figure out if the discomfort is worth it. Sometimes no means "I hate this, I hate you, but I don't want to die like this". During these times, my patient advocacy means putting the patient's long-term interest before what they may want at that particular time.

My third reason for not being a super patient champion is because I am stretched to the max sometimes. With two patients who should actually be one-to-one, I am running my ass off all day, and can't even sit down to review their chart. Maybe this is my fault for working in a hospital that doesn't provide adequate staffing. Maybe it would be different somewhere else where I wouldn't have days where I feel like a kicked dog when I leave. Is it different anywhere else though? I don't know. My work has great benefits, awesome staff, usually a good working relationship with the doctors, and I have good potential for the future. The patients are great; very colorful, rich histories, amazing families, and usually I feel very satisfied at the end of the day. Sometimes though, I know that if I had an ICU physical therapist, respiratory therapists who actually cared about vent weaning, or even a competent nursing aide, I would be much more effective at my job.

This is a depressing post.

As a nurse in a small hospital without much nursing support, I do the best that I can with the time I can afford. There needs to be a fundamental change in the way we view patient care at the ICU level, with a holistic focus and commitment to improving patient outcomes, and accepting when we are beyond our means of making some of them better. Probably, my best way to be a better leader in patient care is to move into administration and really push for greater resources and training. But, then I would be away from where I really shine - at the bedside, with the patients whom I really do appreciate, and try to either get them better, or help them leave this world peacefully with dignity, surrounded by someone who really does care.

Nursing: It's not just a job, it's a lifestyle

2010-02-08T13:48:00.000-08:00

Being a nurse, doctor, RT, or any bedside clinician means that you never really leave your job at the workplace. I am always asked random health questions from friends and neighbors, as well as doing the occasional dressing change for the diabetic old man across the street. I am the on-call assessor of allergic reactions, bug bites, and power tool wounds for the neighborhood. I also am approached for advice on hemorrhoids, vaginal elasticity, tooth abscesses, and the benefits of fish oil by strangers when they discover I am a nurse. This just comes with the territory, and usually I just try to lay low when in line at the grocery store.

My nurseyness is also displayed at the gym and the airport as I spot the AED placement around the facility. My ears perk up when the 88 year old grandma says she is dizzy during her AOA workout. I also travel with a resuscitation mask and many pairs of barrier gloves in my trunk. My first aid kit is ready for a mass shooting event, and I have many N95 masks in multiple sizes, in case of widespread swine flu outbreaks. I brought my kids home PAPR masks in case they wanted to be bee keepers for Halloween. These are some examples of how my work travels around with me.

My "nurse as a lifestyle" reality was further demonstrated last night when I was at a Super Bowl party, and the kids had a sign-up for a talent show. While the other adults put down: headstand, "olive trick", and yodel, I put down "CPR demo". This is in fact, a worthy talent that all people should know. And while I was thinking about rate and depth of chest compressions, I had many male volunteers who wanted to be the dummy, and not for the chest compressions. I had to explain that now the AHA recommends Hands Only CPR for the layman, and that Rescue Breaths are not indicated for the community - sorry guys. Granted, I had a couple beers in me and perhaps had poor judgement on appropriate "talents", I could really only think of this skill I could put down. We left before the talent show commenced, thank God, because I didn't really think of the whole up and down motion of chest pumping with a the mixture of drunk people and kids in this particular setting. Alas, I need to find another, more appropriate talent to come up with, maybe burping the alphabet?

So you can take the nurse out of the hospital, but you can't take the hospital out of the nurse; in fact most of the hospital is actually under my bathroom sink (I hope my manager doesn't come over).

Hey world, I just wiped your grandpa's ass, are we cool now?

2010-01-21T09:47:00.000-08:00

I have many moral dilemmas. I am constantly trying to find the balance between good and good enough. I feel obligated to do many unselfish social deeds, but then I think to myself; "Christ, don't I do enough?". You all know dear readers, that I usually give 100% of myself at my job. I serve mankind everyday. I understand that most jobs are serviceish and that they indeed benefit society as a whole. Teachers, doctors, garbage collectors, waiting tables for rich jerks, and countless other areas of employment, are all jobs that require you to put aside personal distastes and get the work done. Many times these employees will require deep breaths and personal time outs, in order to keep the patience one needs to be nurturing and understanding with the people you are supposed to be caring for. Being a nurse who really tries to be present and deliver the best care means I have to get downright intimate with my fellow man. I put on a smile and clean crap, listen to someone scream for Jesus all day, wash genitals, rinse festering, stinking wounds, work to fight for the best plan of care for my patient, and seriously - save lives. I ask you world: Is this enough? Should I feel obligated to volunteer and put forth community service during my days off?

This is totally a selfish question. I know in the pit of my gut that, yes Lisa, you dumbass, you get paid to do your job and since you are even having this moral questioning, you know that you should be giving more. But, I also know that most people don't even have this question on their radar, and they don't give to their fellow man the way I do! What makes some people give so much, and others don't even think about it? When I was younger, I had two goals: To be able to go anywhere and "make it"; meaning survive, find a niche, succeed anywhere in the world. The second, inspired by John Irving: "To be of use". I really believe(d) that to contribute things to this world for a greater good, is the most profound thing a person can do with their life. When I made these goals when I was 19, I had no idea that I would get into nursing. Years later, after I had been working as a nurse for a couple years, I revisited my long forgotten goals, and realized that I had made both of them a reality. What an epiphany! "How clever I am." I thought. But, as I patted myself on the back, I also had a deeper question, is this enough?

There are two sides to my thinking about this query. The selfish reaction: "Why should I donate to the leukemia foundation? I'm already the kidney failure/liver failure/cancer care/putrid leg ulcer turned septic foundation! No one donates to me!" Then the rational, compassionate side says that of course I am obligated to help others every day, using my time on this earth to really count for something is the most important thing.

Now, I don't want to give anyone the idea that I am actually an actual volunteer or anything, I show up for an hour at my kids school a few times a year, and donate to the Salvation Army a buck or two during the holidays. I am really saying that I would like to like to volunteer, just like I would like to like to be more artistic. So really this back and forth is that indeed I do want to do more, despite my knowledge that indeed I do serve people in a great way during my work week but obviously it isn't enough for me. I guess that by putting these words into written form, I will begin to make this a reality, no matter how much I may scream and kick on the way. Consider it a resolution, along with: cooking more Indian food, not screaming at my kids so much, going to the gym more than once a month, and yes, being more artistic.

I will do a volunteer update at the end of the year - (no commitments though...I might change my mind).

Sunday Paper

2009-12-21T19:57:00.000-08:00

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.

Incompetence is a four letter word

2009-12-18T21:00:00.000-08:00

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’.

Fun at the morgue

2009-11-09T10:39:00.000-08:00

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.

Road Trip!

2009-09-28T14:09:00.000-07:00

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)

Don't Love Me Too Much

2009-09-19T15:59:00.000-07:00

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)

To My Friend

2009-09-10T18:23:00.000-07:00

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.

Orientation

2009-08-05T16:16:00.000-07:00

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.

Smooth Jazz

2009-07-22T16:44:00.000-07:00

"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.

Homage to Friendship

2009-06-18T21:41:00.000-07:00

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.

Boyfriends

2009-06-14T23:37:00.000-07:00

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...

Fatballs

2009-05-28T22:15:00.000-07:00

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.

Code Whores

2009-05-09T20:54:00.000-07:00

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.

What do I want to be when I grow up?

2009-04-22T10:27:00.000-07:00

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?

Devotion

2009-04-15T09:40:00.000-07:00

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.

Enlightenment update

2009-04-11T19:56:00.000-07:00

My little guy passed at 1400 today.

Enlightenment

2009-04-10T23:29:00.000-07:00

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

A job I love, but don't get to talk about

2009-04-09T23:25:00.000-07:00

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.