The last few weeks saw me taking on patient's who were extremely difficult to handle- not medically, exactly, but emotionally. They demand your constant attention, they are uncomfortable and painful and miserable every second and there's nothing you can do about it. In one case, I had a patient crying out "I'm dying I'm dying" every few seconds (he later coded and died), and on another day I had a guy in 4 point leathers begging me to just let him go down to the police station.
Finally, on my first night of 4, I got every ICU nurse's dream patient: sedated, intubated, no talking, no struggling. It was a GOOD four nights.
Monday, November 8, 2010
Saturday, October 9, 2010
drawing the line on compassion?
The other day I was taking care of an 82-year-old male who had been intubated for a couple of procedures and was quite agitated in the bed, requiring restraints. His son was very concerned and always stayed with him to comfort him and watch over his care. Everyone kept saying that the son was extremely annoying and high-maintenance, but as the ICU nurse who admitted the patient, I had no trouble with him at all and thought the patient was lucky to have such a caring and concerned son. I took him back a couple days later and was informed that he had been asked not to come in at night and his chair had been removed. The day nurse was annoyed with him, saying he "kept coming out of the room to ask questions".
This night, I allowed him to sit in the room all night if he wanted. I didn't want to undermine the other nurses, but he wasn't DOING ANYTHING WRONG. He sat quietly and asked an occasional question, as a family member should. He stepped out when I asked him to step out. He was grateful for everything I did. He did come find me once to inform me that his dad was very agitated again, and I appreciated it because the patient was in pain and uncomfortable and was unable to speak for himself, so I prefer to do something about it! The son was getting very teary-eyed, and trying to hide it, and said to me "please, don't leave me alone". He was sincerely upset and overwhelmed, and my job is not only to keep a patient alive and as comfortable as I can, but also to help the family members cope. So I was singled, doing nothing but watching Lost episodes on Hulu.com, and I pulled a mobile computer up to the room and sat just outside the doorway. It was an act of kindness that I had the time to perform, and I don't regret it.
However, the day shift nurse immediately says to the day charge nurse: "Look what she did! She put the chair back in the room! She sat outside the door!" So sue me. This was a family member who was not being inappropriate or interfering with care, and I chose to give him the comfort that other nurses presumably didn't have time to. I don't think that just because it's an ICU we have the right to treat family members as if they have absolutely NO rights to be there, to ask questions, or to express their concerns. The other nurses told me it's about "setting limits". I sometimes think those "limits" are really limiting our compassion and the other people we are supposed to be caring for- the family members.
What do you other ICU nurses think?
This night, I allowed him to sit in the room all night if he wanted. I didn't want to undermine the other nurses, but he wasn't DOING ANYTHING WRONG. He sat quietly and asked an occasional question, as a family member should. He stepped out when I asked him to step out. He was grateful for everything I did. He did come find me once to inform me that his dad was very agitated again, and I appreciated it because the patient was in pain and uncomfortable and was unable to speak for himself, so I prefer to do something about it! The son was getting very teary-eyed, and trying to hide it, and said to me "please, don't leave me alone". He was sincerely upset and overwhelmed, and my job is not only to keep a patient alive and as comfortable as I can, but also to help the family members cope. So I was singled, doing nothing but watching Lost episodes on Hulu.com, and I pulled a mobile computer up to the room and sat just outside the doorway. It was an act of kindness that I had the time to perform, and I don't regret it.
However, the day shift nurse immediately says to the day charge nurse: "Look what she did! She put the chair back in the room! She sat outside the door!" So sue me. This was a family member who was not being inappropriate or interfering with care, and I chose to give him the comfort that other nurses presumably didn't have time to. I don't think that just because it's an ICU we have the right to treat family members as if they have absolutely NO rights to be there, to ask questions, or to express their concerns. The other nurses told me it's about "setting limits". I sometimes think those "limits" are really limiting our compassion and the other people we are supposed to be caring for- the family members.
What do you other ICU nurses think?
Thursday, July 29, 2010
Mr. Grouchy Pants
I admitted a patient from the floor in "respiratory distress". I was excited to get a hit, hoping it was something juicy, something challenging.
Well, challenging it was, but not in the way I had anticipated.
First of all, the patient in respiratory distress, was brought up on room air. Room air people! No trach mask, no nothing. His sats when we plopped a pulse ox on his finger? 76%. He recovered nicely to 96 though once we got his trach mask on. On 50% trach mask he was fine. He was fine alllll night long.
So besides not being appropriately sick enough for the ICU, our biggest problem was that he kept throwing his O2 and pulse ox off. He refused to wear them, even after threatening to be restrained, explaining the grissliness of a code (including cracked ribs). He wrote on his paper "leave me alone" and "this is a 3rd rate ICU". Meanwhile, the O2 mask he kept throwing on the floor left him satting somewhere around 75%. You know, if someone really doesn't want our most basic care, let him check himself out, right? I mean, he was totally with it (arguably, I suppose), and even wrote our names down along with our positions (he's a practicing attorney), I guess so he can sue us later for trying to save his life.
At the end of the night, I was SO DONE with this man. If you want to die, fine. Make yourself a DNR/DNI, we'll make you comfortable. Don't call us names, threaten to sue us, and just basically act like a total ass. Just sign yourself out AMA and get the hell out. I'm not going to bend over backwards anymore to be nice to someone who is so obviously a jerk.
Well, challenging it was, but not in the way I had anticipated.
First of all, the patient in respiratory distress, was brought up on room air. Room air people! No trach mask, no nothing. His sats when we plopped a pulse ox on his finger? 76%. He recovered nicely to 96 though once we got his trach mask on. On 50% trach mask he was fine. He was fine alllll night long.
So besides not being appropriately sick enough for the ICU, our biggest problem was that he kept throwing his O2 and pulse ox off. He refused to wear them, even after threatening to be restrained, explaining the grissliness of a code (including cracked ribs). He wrote on his paper "leave me alone" and "this is a 3rd rate ICU". Meanwhile, the O2 mask he kept throwing on the floor left him satting somewhere around 75%. You know, if someone really doesn't want our most basic care, let him check himself out, right? I mean, he was totally with it (arguably, I suppose), and even wrote our names down along with our positions (he's a practicing attorney), I guess so he can sue us later for trying to save his life.
At the end of the night, I was SO DONE with this man. If you want to die, fine. Make yourself a DNR/DNI, we'll make you comfortable. Don't call us names, threaten to sue us, and just basically act like a total ass. Just sign yourself out AMA and get the hell out. I'm not going to bend over backwards anymore to be nice to someone who is so obviously a jerk.
Saturday, July 24, 2010
night shift takes its toll
For the first time, I got in trouble. The day shift nurse who took my patient made a list of complaints of things I didn't get done and submitted them to our supervisor. I got an email asking me why I "failed" to change expired tubing, ET tube tapes, and a bag of insulin that had expired. I have no excuse or good reason, either. I should've done all three things, and the honest truth is that I just forgot to check expiration dates all the way around. I told my supervisor exactly that, and that it will not happen again, I will add expiration dates to a list of reminders for myself on each shift. Maybe he will still write me up, I don't know. I feel horrible, like I should be sitting in the corner of the unit with a dunce cap on my head.
See, I always try really hard to do everything at night so that day shift doesn't have to: baths, IV dressings, tubing changes, new yaunkers, new feeding tube bags, new EVERYTHING with a new date. I take pride in handing patients over to the next shift completely caught up. This is seriously the first night I forgot to check tubing dates, and OF COURSE, a tattletale has to take the patient.
I'm just not a big fan of running straight to managers with complaints about other nurses. It was a huge problem on my last floor, and I didn't expect to see it here. I was hoping that if I made a mistake, my co-worker could talk to me about it first. I thought I would at least be given the benefit of the doubt... but I guess not.
I have been miserable on nights since my last post. Extremely tired, cranky, emotional... brought to tears many times by practically nothing. I feel sick when I leave. It's hard to concentrate and I feel like I'm moving around in a fog. I feel like it's hard to be a good nurse because I get so annoyed at little things. I'm glad I switched to ICU, but I don't LOVE my job like I thought I would.
Is it even possible to have a job you love?
See, I always try really hard to do everything at night so that day shift doesn't have to: baths, IV dressings, tubing changes, new yaunkers, new feeding tube bags, new EVERYTHING with a new date. I take pride in handing patients over to the next shift completely caught up. This is seriously the first night I forgot to check tubing dates, and OF COURSE, a tattletale has to take the patient.
I'm just not a big fan of running straight to managers with complaints about other nurses. It was a huge problem on my last floor, and I didn't expect to see it here. I was hoping that if I made a mistake, my co-worker could talk to me about it first. I thought I would at least be given the benefit of the doubt... but I guess not.
I have been miserable on nights since my last post. Extremely tired, cranky, emotional... brought to tears many times by practically nothing. I feel sick when I leave. It's hard to concentrate and I feel like I'm moving around in a fog. I feel like it's hard to be a good nurse because I get so annoyed at little things. I'm glad I switched to ICU, but I don't LOVE my job like I thought I would.
Is it even possible to have a job you love?
Sunday, July 11, 2010
that was good times!!!
I'm on night shift now, and it's not as terrible as I thought. I had a crazy day when I was withdrawing on one patient (only 53, very sad) and he was quite difficult to sedate, the new interns don't know which orders to write and need hand-holding, and he wanted to die NOW. I asked him if he wanted me to put him to sleep, and he said yes. I didn't have orders for fentanyl or versed drips, so I kept pushing them plus ativan and morphine. While I waited for pharmacy to make me drips (after I insisted the docs write for them), I had to keep running in there and push more because he kept waking up. It was horrifying, really, because who would want to wake back up and see your loved ones all hovering around crying???
In the meantime, my other patient was in respiratory isolation way down at the other end of the hallway, and I couldn't really keep my eye on both of them at the same time. To make matters worse, this patient was very unstable, and I would get stuck in his room for long periods of time and couldn't tend to the grieving family or dying patient the way I wanted to. The unstable patient had a blood pressure that bounced around from 60s systolically up to 220 in a heartbeat. I was chasing my tail all night with pressors on, pressors off. I got very frustrated by the end because I kept thinking, am I doing something wrong?? But another nurse came and looked over everything and assured me I wasn't.
The last three nights I took care of one patient, mainly, who wasn't quite as exciting, except for one 5am episode when his trach site started gushing blood. Next thing we know we're getting blood in the vent tubing, blood out of his mouth, he's spewing huge clots across the room, everyone is covered in it. The surgeons who did the trach and anasthesia are all at the bedside, while we're bagging him, considering cutting him open right then and there! My co-worker, who was a godsend, was guiding me through it. She was like, oh we're doing surgery right here right now? Here's some propofol. No, just push it. Let's give him a bunch of versed while we're at it. More fentanyl. She gently nudged me in the right direction throughout the crisis and eventually the patient was whisked off to OR where they found.... nothing. But the bleeding stopped with no more events.
In the meantime, my other patient was in respiratory isolation way down at the other end of the hallway, and I couldn't really keep my eye on both of them at the same time. To make matters worse, this patient was very unstable, and I would get stuck in his room for long periods of time and couldn't tend to the grieving family or dying patient the way I wanted to. The unstable patient had a blood pressure that bounced around from 60s systolically up to 220 in a heartbeat. I was chasing my tail all night with pressors on, pressors off. I got very frustrated by the end because I kept thinking, am I doing something wrong?? But another nurse came and looked over everything and assured me I wasn't.
The last three nights I took care of one patient, mainly, who wasn't quite as exciting, except for one 5am episode when his trach site started gushing blood. Next thing we know we're getting blood in the vent tubing, blood out of his mouth, he's spewing huge clots across the room, everyone is covered in it. The surgeons who did the trach and anasthesia are all at the bedside, while we're bagging him, considering cutting him open right then and there! My co-worker, who was a godsend, was guiding me through it. She was like, oh we're doing surgery right here right now? Here's some propofol. No, just push it. Let's give him a bunch of versed while we're at it. More fentanyl. She gently nudged me in the right direction throughout the crisis and eventually the patient was whisked off to OR where they found.... nothing. But the bleeding stopped with no more events.
Sunday, June 27, 2010
calling all angels
Yesterday ended up being not so great. I worked with the family of my patient to help them realize that the future of their loved one included an extended period of time on the ventilator, 24 hour dialysis, and a poor prognosis anyway. They immediately decided he wouldn't have wanted that, and told us to withdraw. I went into the quiet room before they came back, and took away anything extra. The compression devices on his legs, the bair hugger keeping his temperature normal, turned off all the IV pumps except for his fentanyl, versed, and pressors. I arranged the spaghetti of tubes on his bed so they couldn't be easily seen. I turned up the rates of his sedation and pain meds, and I cut the restraints off of his wrists. I dressed him in a clean gown, put a clean blanket on him, and lowered the bed. I pulled the chairs up next to him and put the siderail down so the family could sit beside him if they wanted. I cleaned the rest of the room, put a tray of snacks and juice off to the side. I turned off the bedside monitor so they couldn't see his wave forms on the screen.
They came and told me they were ready. The respiratory therapist and I cut the tape that held his ET tube in place, and removed it. Then, I watched my hand turn off the IV pump running his levophed. They asked me repeatedly how long it would take? I told them we simply couldn't predict, but in our opinion not very long. A couple hours perhaps. I told his son, you can hold his hand if you want. He didn't.
I went out and sat at the nurses station, to watch the monitor. Without the levo, his blood pressure was 48/32 within 5 minutes. His O2 was 80% for a while, before falling to 70%, then 60%. His heart fought valiantly, before becoming brady, then asystole, then the purkinje fibers throwing their last struggling beats in at about 20-30 beats per minute. The daughter and granddaughter put on the light. I went in, and they said "he's gone isn't he?" They were sobbing. I explained that the doctor couldn't call it yet, because there was still a small amount of leftover electrical activity in his heart, but yes, he was gone. The daughter hugged me, and they left. There was no one in there. So I took his hand in mine. No one had touched him while he died, and I hummed "calling all angels" while his heart finally succumbed. And then I left.
Not only did I perform his post-mortem care after that, but a young woman down the way lost her battle with lymphoma earlier that morning. She passed around 8am, and the family didn't leave her side until about 1pm. I helped with her post-mortem care too. The nurse told me that she had suffered immensely, crying, whimpering, never comfortable, always in great pain. Her mother had held her in her arms every day and night. I looked at the face of this deceased woman, 31 years old... in death, her face had relaxed into a smile, yes a SMILE, of relief. I had never seen such a smile before.
The following song always reminds me of nursing, and how we have the honored but very overlooked position in society of helping people through death... either to wellness, or to the great beyond.
a man is placed upon the steps, a baby cries
and high above the church bells start to ring
and as the heaviness the body oh the heaviness settles in
somewhere you can hear a mother sing
then it's one foot then the other as you step out onto the road
how much weight? how much weight?
then it's how long? and how far?
and how many times before it's too late?
calling all angels
calling all angels
walk me through this one
don't leave me alone
calling all angels
calling all angels
we're cryin' and we're hurtin'
and we're not sure why...
and every day you gaze upon the sunset
with such love and intensity
it's almost...it's almost as if
if you could only crack the code
then you'd finally understand what this all means
but if you could...do you think you would
trade in all the pain and suffering?
ah, but then you'd miss
the beauty of the light upon this earth
and the sweetness of the leaving
calling all angels
calling all angels
walk me through this one
don't leave me alone
callin' all angels
callin' all angels
we're tryin'
we're hopin'
we're hurtin'
we're lovin'
we're cryin'
we're callin'
'cause we're not sure how this goes
They came and told me they were ready. The respiratory therapist and I cut the tape that held his ET tube in place, and removed it. Then, I watched my hand turn off the IV pump running his levophed. They asked me repeatedly how long it would take? I told them we simply couldn't predict, but in our opinion not very long. A couple hours perhaps. I told his son, you can hold his hand if you want. He didn't.
I went out and sat at the nurses station, to watch the monitor. Without the levo, his blood pressure was 48/32 within 5 minutes. His O2 was 80% for a while, before falling to 70%, then 60%. His heart fought valiantly, before becoming brady, then asystole, then the purkinje fibers throwing their last struggling beats in at about 20-30 beats per minute. The daughter and granddaughter put on the light. I went in, and they said "he's gone isn't he?" They were sobbing. I explained that the doctor couldn't call it yet, because there was still a small amount of leftover electrical activity in his heart, but yes, he was gone. The daughter hugged me, and they left. There was no one in there. So I took his hand in mine. No one had touched him while he died, and I hummed "calling all angels" while his heart finally succumbed. And then I left.
Not only did I perform his post-mortem care after that, but a young woman down the way lost her battle with lymphoma earlier that morning. She passed around 8am, and the family didn't leave her side until about 1pm. I helped with her post-mortem care too. The nurse told me that she had suffered immensely, crying, whimpering, never comfortable, always in great pain. Her mother had held her in her arms every day and night. I looked at the face of this deceased woman, 31 years old... in death, her face had relaxed into a smile, yes a SMILE, of relief. I had never seen such a smile before.
The following song always reminds me of nursing, and how we have the honored but very overlooked position in society of helping people through death... either to wellness, or to the great beyond.
a man is placed upon the steps, a baby cries
and high above the church bells start to ring
and as the heaviness the body oh the heaviness settles in
somewhere you can hear a mother sing
then it's one foot then the other as you step out onto the road
how much weight? how much weight?
then it's how long? and how far?
and how many times before it's too late?
calling all angels
calling all angels
walk me through this one
don't leave me alone
calling all angels
calling all angels
we're cryin' and we're hurtin'
and we're not sure why...
and every day you gaze upon the sunset
with such love and intensity
it's almost...it's almost as if
if you could only crack the code
then you'd finally understand what this all means
but if you could...do you think you would
trade in all the pain and suffering?
ah, but then you'd miss
the beauty of the light upon this earth
and the sweetness of the leaving
calling all angels
calling all angels
walk me through this one
don't leave me alone
callin' all angels
callin' all angels
we're tryin'
we're hopin'
we're hurtin'
we're lovin'
we're cryin'
we're callin'
'cause we're not sure how this goes
Saturday, June 26, 2010
I love when I love my job
I've been sooo happy at work yesterday and today, because finally, FINALLY, I have a sick patient! I'm not a total weirdo... that's just what I came here to do, take care of patients who are in a life or death situation. Not patients who are ready to go home! This poor gentleman aspirated his own stomach contents during a GI procedure, which got him tubed. Good reason to take that pre-procedure NPO rule seriously folks! But now everything else is going downhill. He's on pressors, unable to tolerate tube feeds, and making no urine. I feel like I'm learning again and enjoying myself immensely. I feel like a real ICU nurse!
Today is my last day shift. I will go to nights on Tuesday. I feel kinda sad, because I feel that I've really built some good working relationships with the day nurses, the interns, and residents.
Today is my last day shift. I will go to nights on Tuesday. I feel kinda sad, because I feel that I've really built some good working relationships with the day nurses, the interns, and residents.
Wednesday, June 23, 2010
can I go back on orientation please?
It's not that I feel I need more orientation. I don't need special help or more time adjusting. What I need is: INTERESTING PATIENTS. Since I've been off orientation, I have been bored stiff. Things that once excited me, like vented patients, art lines, blood gases... they do not excite me on the patients I have been given, easy patients, failure to weans or patients ready to be extubated. These patients are not sedated, they write on paper or mouth words to me (I am terrible at reading lips). Or they bang on their side rails with whatever they can find. Or press the call light 20 million times. Medically they aren't on the verge of coding or needing pressors or anything at all interesting. I've run out of things to google, people to call, appointments to make, things to eat, because I'm so damn bored. On the floor I had patients like this, but I had three of them. Now I have one of them, maybe two, and don't know what to do with myself.
Everyone keeps saying "oh be careful what you wish for" but I'm seriously trying to temp fate. Give me a learning opportunity! A juicy hit! A patient on pressors, paralytics, sedation! Something, anything. I'm in one of the most critical ICUs in the whole country, how can I possibly be this bored???
Everyone keeps saying "oh be careful what you wish for" but I'm seriously trying to temp fate. Give me a learning opportunity! A juicy hit! A patient on pressors, paralytics, sedation! Something, anything. I'm in one of the most critical ICUs in the whole country, how can I possibly be this bored???
Thursday, June 10, 2010
on my own
I started out on Monday without a preceptor for the first time. I had a really easy assignment, a guy that we extubated and a sweet lady who was tubed but totally with it. The next day I had the easiest patient ever, who could've gone home. Finally at 3 I picked up a very sick patient, who immediately started desatting on me. We started turning up the peep and then cranking up the 02. She was too awake so I had to put her down farther, starting with fentanyl boluses and then I was thinking about hanging up the propofol again. When I double checked with another nurse, that's exactly what he would do! Yay, I was so excited! I was thinking the right way!
We'll just have to see what tomorrow brings.
We'll just have to see what tomorrow brings.
Friday, June 4, 2010
the graveyard shift
The last three nights have been midnight shifts for me. Talk about slow, and boring. I have been reading a book, surfing the web, trying to keep myself awake. Nothing happening. Nights are totally different from days, where I was so busy that 12 hours felt like 5 minutes. After a long night of just sitting around, I can barely drive home, my eyes are closing and my car is swerving. I feel like these can't possibly be the same patients that we have during the day! Everyone assures me that usually nights are very busy, but I've yet to see that. At about 6am docs and administration starts to arrive, the lights switch on, suddenly the place is hopping. But until that moment, it's dark and quiet, nurses sitting around with blankets wrapped around their shoulders, reading novels, eating, chatting on facebook. Doobey doobey doo.
Saturday, May 29, 2010
Finishing up orientation
I've been in a lot of classes, some interesting, some not. I've also had some very interesting patients. Like the patient who was brain dead but whom we couldn't 'pronounce' braindead because he was on 'innercool', a hose that brings his body temperature down to 33.0 celcius. I had a patient that we withdrew care on, and I got to watch her cardiac rhythm go from sinus to all sorts of arrhythmias to asystole. I do feel that for the most part I'm independent, and I have learned a million things and gotten SO much smarter in this short time. I'm going to nights for a week and then hopefully I'll be let loose to be on my own.
Saturday, May 15, 2010
4th week ICU
I'm definitely getting more comfortable on my new floor. There is still SO much I don't know, but it will be that way even when I'm off of orientation. I find myself now getting a bit annoyed with having a preceptor. I don't like anyone else adding things to "my" flowsheets, or I sometimes disagree with the way we are titrating the insulin, etc. I guess I'm a bit anal, and fit right in with the rest of the ICU nurses!
Last week I had classes, some interesting, some not. Most of what I got out of it was a sense of comeraderie with other ICU nurses, new and old, and a profound respect for the nurses who have been in it for decades. They are so amazing.
I have been having a lot of difficult discussions with family members about their dying loved ones. It's hard to know what to say to a family that is faced with the most difficult decision of their lives: when to pull the plug, or just stop life support. But as hard as it is, I find myself jumping right in and being willing to have that conversation with the family if they want to. They seem eager to talk to the nurse, to know our opinions, to share their feelings. I don't have the right way of explaining things down pat yet, but my preceptors are good at helping me out with ideas. I didn't realize what a huge part of ICU nursing it would be, dealing with grief and decision making with the family members.
This weekend I tried to relax, sleep in, and work on the yard. I do feel very proud of myself for advancing in my career and being willing to take the plunge into a totally new area in order to learn and grow in my profession. I feel like I am becoming a better nurse, even when it's hard. Add that to the small gardening projects around the house (I'm not a gardening person) and I feel more proud of myself than ever. It's nice to be able to give myself a pat on the back, when I feel so emotionally down.
Last week I had classes, some interesting, some not. Most of what I got out of it was a sense of comeraderie with other ICU nurses, new and old, and a profound respect for the nurses who have been in it for decades. They are so amazing.
I have been having a lot of difficult discussions with family members about their dying loved ones. It's hard to know what to say to a family that is faced with the most difficult decision of their lives: when to pull the plug, or just stop life support. But as hard as it is, I find myself jumping right in and being willing to have that conversation with the family if they want to. They seem eager to talk to the nurse, to know our opinions, to share their feelings. I don't have the right way of explaining things down pat yet, but my preceptors are good at helping me out with ideas. I didn't realize what a huge part of ICU nursing it would be, dealing with grief and decision making with the family members.
This weekend I tried to relax, sleep in, and work on the yard. I do feel very proud of myself for advancing in my career and being willing to take the plunge into a totally new area in order to learn and grow in my profession. I feel like I am becoming a better nurse, even when it's hard. Add that to the small gardening projects around the house (I'm not a gardening person) and I feel more proud of myself than ever. It's nice to be able to give myself a pat on the back, when I feel so emotionally down.
Saturday, May 1, 2010
2nd week ICU
This week I felt pretty independent. Not that there wasn't a lot to learn, but for the most part I felt like I could've done a lot of it without a preceptor. I have to admit- I thought it would be harder than this. The vent and ABGs and pressors and paralytics are really the newest things... for the most part though, it's business as usual. I draw labs myself, and get bladder and central venous pressures, and bag people occasionally. But I had a CF patient that made me feel at home- always on the call light, and in pain. We ambulated her and I bagged her the whole time!
Today my patient had a 1 in 2 million rare lung disease called alveolar proteinosis. It can only be fixed with whole lung lavage. Only trouble is, he can't oxygenate well enough to undergo the procedure- so he is going to placed on ECMO and then they're going to try. This is a ground-breaking surgery, that's never been done on someone this sick, and that could only be performed in a very small handful of hospitals by only a few pulmonologists in the world. I got to listen in on the meeting with the family, and I felt like I was part of a discovery health special.
Of course, this lavage on ECMO crazy revolutionary procedure can't be done tomorrow, because the president is coming, and specialists are prohibited from performing intense procedures that may tie up precious resources... just in case Obama develops a chronic lung condition in a matter of hours!
Today my patient had a 1 in 2 million rare lung disease called alveolar proteinosis. It can only be fixed with whole lung lavage. Only trouble is, he can't oxygenate well enough to undergo the procedure- so he is going to placed on ECMO and then they're going to try. This is a ground-breaking surgery, that's never been done on someone this sick, and that could only be performed in a very small handful of hospitals by only a few pulmonologists in the world. I got to listen in on the meeting with the family, and I felt like I was part of a discovery health special.
Of course, this lavage on ECMO crazy revolutionary procedure can't be done tomorrow, because the president is coming, and specialists are prohibited from performing intense procedures that may tie up precious resources... just in case Obama develops a chronic lung condition in a matter of hours!
Thursday, April 22, 2010
4th day ICU
I feel like I've learned so much more in the last 4 days than I have in a year on cardio-thoracic surgery. Today my patient from yesterday was doing worse than before, in every way. My preceptor left me alone for 5 minutes, and of course the patient's BP went from 105 systolic to 60. I got another nurse to help but told him to NEVER leave me alone again! All we did was bolus him fast but it all leaks out of his vascular system as quick as we could put it in. I mixed up levophed for the first time, just in case, but we didn't need it. I've never mixed up an IV med before.
I also did all of the charting and meds and organization of the day. The family was distraught because basically their dad/husband is going to die, and everything we're doing is just prolonging the fact. A half hour before I left, I checked a residual on the NG tube and got back blood. So we set up and did a gastric lavage. Oh, and nurses also place the dophoff tubes. So take that all you cardio-thoracic PAs who think you're so hot that no one else can drop a tube!
I also did all of the charting and meds and organization of the day. The family was distraught because basically their dad/husband is going to die, and everything we're doing is just prolonging the fact. A half hour before I left, I checked a residual on the NG tube and got back blood. So we set up and did a gastric lavage. Oh, and nurses also place the dophoff tubes. So take that all you cardio-thoracic PAs who think you're so hot that no one else can drop a tube!
Tuesday, April 20, 2010
Toto, we're not in surgery anymore
Cardio-thoracic: The doctor tells a PA what order to write. The PA writes it, and the patient asks the nurse "why?". The nurse asks the PA "why?" and the PA either ignores the question or rolls their eyes and says they're busy.
CCMU: The doctor makes a suggestion for plan of care. The nurse says "I don't that will work because...", the doctor says "oh yeah, that's true", the resident writes orders according to what the nurse dictates.
Cardio-thoracic: You need stat labs. STAT usually means between 1-2 hours, even though you've paged the floor phlebotomist, and the charge phlebotomist twice. You try to find someone on the floor who actually knows how to stick a patient. Respiratory therapy ends up taking pity on you and trying to help you.
CCMU: You need stat labs. You go to the draw, take out the syringe and tubes, and draw the labs from the art line. The respiratory therapist says, hey will you grab some blood gases too? And you do. Then you print the label, walk 8 steps to the lab, and drop the labeled tubes in their bucket. They hand deliver the results to you 10 minutes later.
Cardio-thoracic: The doctor's name is "Dr. P." In two years, he has not made eye contact with you, addressed you in any way, and ignores any comment you might deign to make in his presence. When he walks down the hall, you are expected to move immediately out of his way, or risk the withering glares and cold shoulders of his PAs for the rest of the week.
CCMU: The doctor's name is "Jack". He sits at the desk with the nurses, making chit chat. He shakes the new orientee's hand and introduces himself. He asks the bedside nurse if she agrees with his plan. He is grateful for her input, even though she is directly contradicting him. He remarks on the high acuity of a patient given to the new orientee. He seems, um... human.
CCMU: The doctor makes a suggestion for plan of care. The nurse says "I don't that will work because...", the doctor says "oh yeah, that's true", the resident writes orders according to what the nurse dictates.
Cardio-thoracic: You need stat labs. STAT usually means between 1-2 hours, even though you've paged the floor phlebotomist, and the charge phlebotomist twice. You try to find someone on the floor who actually knows how to stick a patient. Respiratory therapy ends up taking pity on you and trying to help you.
CCMU: You need stat labs. You go to the draw, take out the syringe and tubes, and draw the labs from the art line. The respiratory therapist says, hey will you grab some blood gases too? And you do. Then you print the label, walk 8 steps to the lab, and drop the labeled tubes in their bucket. They hand deliver the results to you 10 minutes later.
Cardio-thoracic: The doctor's name is "Dr. P." In two years, he has not made eye contact with you, addressed you in any way, and ignores any comment you might deign to make in his presence. When he walks down the hall, you are expected to move immediately out of his way, or risk the withering glares and cold shoulders of his PAs for the rest of the week.
CCMU: The doctor's name is "Jack". He sits at the desk with the nurses, making chit chat. He shakes the new orientee's hand and introduces himself. He asks the bedside nurse if she agrees with his plan. He is grateful for her input, even though she is directly contradicting him. He remarks on the high acuity of a patient given to the new orientee. He seems, um... human.
Monday, April 19, 2010
first day in the ICU
I was given a room number and a time. I showed up in scrubs, with my chai tea latte, looked around and thought "why do none of these other people look like orientees?" OMG, they were all the staff nurses and we were doing report! This guy says "hey you're with me today" and then next thing I know I'm signed up for bed 4. There's my name, next to the patient's name, as IF I have one single clue what I'm supposed to do! I thought, well, it's time to just get up and walk out of here because I have made a BIG mistake and I'm not about to kill a patient today!
Luckily, the nurse educator happened to be staffing, so he sort of showed me some stuff, intro'd me to the unit, made me do some competencies online, introduced me to people, and I went to a staff meeting on sentinel events (which included pizza). Basically, all I learned to do was draw blood off an art line, and even that I managed to screw up the second time.
Vents? Totally puzzling to me. 8 pumps with 8 meds that have to be juggled, if one goes up the other goes down, how will I ever remember that??? CVP pressures, why are we doing this again? Oh god, what have I gotten into. I feel like I never went to nursing school for a day. I'm totally lost.
Luckily, the nurse educator happened to be staffing, so he sort of showed me some stuff, intro'd me to the unit, made me do some competencies online, introduced me to people, and I went to a staff meeting on sentinel events (which included pizza). Basically, all I learned to do was draw blood off an art line, and even that I managed to screw up the second time.
Vents? Totally puzzling to me. 8 pumps with 8 meds that have to be juggled, if one goes up the other goes down, how will I ever remember that??? CVP pressures, why are we doing this again? Oh god, what have I gotten into. I feel like I never went to nursing school for a day. I'm totally lost.
Tuesday, April 6, 2010
countdown to ICU continues
My last few weeks on the only floor I've ever known as a nurse have not gone well. I have had one big confrontation with a busy-body co-worker, and 90% of the rest of the nurses pretend I don't exist.
For example, Saturday I took a post-op day 1 esophagectomy patient, whose attending happens to be my very favorite. I started at 3 with a dismal report- very low urine output, even after 1000ccs of bolus and maintenance fluid at 125 cc/hr. BPs super low, pain super high but couldn't do much because of the low BPs. Patient couldn't get out of bed as she was suppose to, and lungs sounds were crappy. I took the patient hoping it would be a challenge that might help prepare me a little for the ICU.
I was managing alright, even got the BPs to stabilize and the PCA and epidural back on, getting her pain down from 10/10 to 6/10. The family liked me and felt confident in me enough to go home for the night. I spent almost every second of my shift at her bedside, only dashing in and out of my two other (stable) patients' rooms, or delegating their meds to the two other nurses who were actually offering me help.
At about 8pm, respiratory showed up to do a breathing treatment. I'd been playing around with the pulse ox for about 45 minutes, warming up her hands, trying her ears, toes, etc. Respiratory tried to help me, and finally got an ok reading, 92% on 3L nasal cannula. BUT- in the process she went from A&O x3 to A&O x1. I was like, oh shit... what is happening??? Urine output for four hours was 25ccs. Resident on call wanted to bolus her AGAIN. I regret not saying NO way. I regret not turning all of her damn fluids off right then.
Suddenly, her sats started dropping. I stat paged respiratory. I told my charge and assistant charge nurse that I would need help with a driveline and meds because I could see this was not going to be good, and I got a great rolling of eyes from them and nothing but reluctance, so I just left. I was stat paging phlebotomy now for labs, and they weren't showing up. Respiratory and pain service were my only help at this point, and they started drawing ABGs and said they'd fill my other tubes for labs.
Now you have to realize, I've never drawn labs in my LIFE! I again went to the charge nurse, asked her for help, she refused, and I said "should I call RRT? (rapid response team" (Resident on call STILL wasn't there, patient now on a rebreather with 100% O2). She says "Call RRT just for labs?" as if it were the stupidest question ever. I went back to respiratory, the supervisor was now there, and said "should I call RRT?" I'd paged the resident on call about a hundred times by now, respiratory said to call RRT, so I paged him one more time and said "If you can't make it now, I'll get RRT".
Guess what? He shows up one hour and 45 minutes after the crisis began, and said "Bed 14, nurse Michelle, call report." I went to the charge nurse and said "She's going to the unit". Her snotty response? "What? I can't even understand you." The other nurses around were listening now. I said, very slowly: My. Patient. Is. Going. To. The. Unit. Did you get that? Because our charge and ass charge didn't step foot in that room the entire time, and I never felt so on my own before.
Grrrr. Now my patient is on a vent with major hypervolemia. Her daughter saw me and hugged me and told me thank you, thank you but I felt like a fraud because I wish I had turned off the fluids. I left the unit with tears in my eyes.
For example, Saturday I took a post-op day 1 esophagectomy patient, whose attending happens to be my very favorite. I started at 3 with a dismal report- very low urine output, even after 1000ccs of bolus and maintenance fluid at 125 cc/hr. BPs super low, pain super high but couldn't do much because of the low BPs. Patient couldn't get out of bed as she was suppose to, and lungs sounds were crappy. I took the patient hoping it would be a challenge that might help prepare me a little for the ICU.
I was managing alright, even got the BPs to stabilize and the PCA and epidural back on, getting her pain down from 10/10 to 6/10. The family liked me and felt confident in me enough to go home for the night. I spent almost every second of my shift at her bedside, only dashing in and out of my two other (stable) patients' rooms, or delegating their meds to the two other nurses who were actually offering me help.
At about 8pm, respiratory showed up to do a breathing treatment. I'd been playing around with the pulse ox for about 45 minutes, warming up her hands, trying her ears, toes, etc. Respiratory tried to help me, and finally got an ok reading, 92% on 3L nasal cannula. BUT- in the process she went from A&O x3 to A&O x1. I was like, oh shit... what is happening??? Urine output for four hours was 25ccs. Resident on call wanted to bolus her AGAIN. I regret not saying NO way. I regret not turning all of her damn fluids off right then.
Suddenly, her sats started dropping. I stat paged respiratory. I told my charge and assistant charge nurse that I would need help with a driveline and meds because I could see this was not going to be good, and I got a great rolling of eyes from them and nothing but reluctance, so I just left. I was stat paging phlebotomy now for labs, and they weren't showing up. Respiratory and pain service were my only help at this point, and they started drawing ABGs and said they'd fill my other tubes for labs.
Now you have to realize, I've never drawn labs in my LIFE! I again went to the charge nurse, asked her for help, she refused, and I said "should I call RRT? (rapid response team" (Resident on call STILL wasn't there, patient now on a rebreather with 100% O2). She says "Call RRT just for labs?" as if it were the stupidest question ever. I went back to respiratory, the supervisor was now there, and said "should I call RRT?" I'd paged the resident on call about a hundred times by now, respiratory said to call RRT, so I paged him one more time and said "If you can't make it now, I'll get RRT".
Guess what? He shows up one hour and 45 minutes after the crisis began, and said "Bed 14, nurse Michelle, call report." I went to the charge nurse and said "She's going to the unit". Her snotty response? "What? I can't even understand you." The other nurses around were listening now. I said, very slowly: My. Patient. Is. Going. To. The. Unit. Did you get that? Because our charge and ass charge didn't step foot in that room the entire time, and I never felt so on my own before.
Grrrr. Now my patient is on a vent with major hypervolemia. Her daughter saw me and hugged me and told me thank you, thank you but I felt like a fraud because I wish I had turned off the fluids. I left the unit with tears in my eyes.
Friday, March 5, 2010
watch out ICU world, here I come!
So, I hatched a plan to get off of my floor at any cost, and Wednesday I interviewed in the CCMU (critical care medical unit). The sickest patients in the hospital, or for that matter, the whole region. Multi-organ failure, highest deathrate in the hospital, vents and bedside dialysis and drips to keep practically every body system functioning... you get the idea. And I have this crazy idea that the nurses there are super smart, smarter than practically anyone else in the whole hospital, and I would like to be one of them.
My interview went great and I met a few nurses on the floor who had great, sarcastic, somewhat morbid senses of humor (fabulous!) They were fascinated by the fact that I was switching from surgical to medical, and did I have any idea what I was getting myself in to? They said nothing would be more important than my critical thinking skills and getting the big picture. Gulp. On the other hand, they absolutely love their jobs and the few times someone has actually left, they usually come back. So I said, sign me up. This sounds like the adventure of a lifetime!
And then came the true test... will my manager let me go or not? I waited two days and just got the email, I start in the CCMU on April 18th! It's going to be a whole new ball of wax and I feel like I need to go back to nursing school first. Or maybe med school. They tell me it's going to change me not just as a nurse, but as a person. I guess that's true. It's not ever what I imagined I'd be doing (I grew up wanting desperately to become a midwife), but it sure sounds like one hell of a challenge, and I feel up to it! (And scared to death...)
More to come!
My interview went great and I met a few nurses on the floor who had great, sarcastic, somewhat morbid senses of humor (fabulous!) They were fascinated by the fact that I was switching from surgical to medical, and did I have any idea what I was getting myself in to? They said nothing would be more important than my critical thinking skills and getting the big picture. Gulp. On the other hand, they absolutely love their jobs and the few times someone has actually left, they usually come back. So I said, sign me up. This sounds like the adventure of a lifetime!
And then came the true test... will my manager let me go or not? I waited two days and just got the email, I start in the CCMU on April 18th! It's going to be a whole new ball of wax and I feel like I need to go back to nursing school first. Or maybe med school. They tell me it's going to change me not just as a nurse, but as a person. I guess that's true. It's not ever what I imagined I'd be doing (I grew up wanting desperately to become a midwife), but it sure sounds like one hell of a challenge, and I feel up to it! (And scared to death...)
More to come!
Thursday, January 7, 2010
caffeine and xanax
This is going to be the new title for my blog. At almost two years, I guess I'm not a "brand new" nurse anymore, just a relatively new one. I started my career on this cardio-thoracic surgical unit very excited and enthusiastic about my co-workers, my profession, and what I did every day. Now- not so much. I have lost faith in my co-workers, my trust in management has been completely smashed, and I find that I do not enjoy my patients either. I feel like a pill-pusher, an ice-fetcher, and a bed-maker. I'm so grateful just to hear a "thank you" once in a while. People say "well it's your job". No, actually, ordering tuna sandwiches and making sure you have not-too-much or not-too-little ice in your cup is NOT my job! But it has become my job, and it is very disasatisfying.
Management has turned into the "mistake" police. They make it extremely hard to relax when you finally get 10 minutes of downtime. Gotta look busy ALL the time, you know! People on other shifts will write you up for every little thing. If you're sucking up to management, life is good. If not, you're on the shit list and watch out!
So I tried to make a graceful exit to L&D, was offered an interview... and guess what? They can technically hold me at this shithole job until September 2010 because our floor downsized! So the whole time the boss has been telling us that if we don't like our job, leave.... but we can't leave. We are stuck. So what does she have on her hands? A bunch of stuck employees who want get the hell out of there and don't have a voice on the floor.
BS and more BS. I could go on, but I think you get the drift.
Management has turned into the "mistake" police. They make it extremely hard to relax when you finally get 10 minutes of downtime. Gotta look busy ALL the time, you know! People on other shifts will write you up for every little thing. If you're sucking up to management, life is good. If not, you're on the shit list and watch out!
So I tried to make a graceful exit to L&D, was offered an interview... and guess what? They can technically hold me at this shithole job until September 2010 because our floor downsized! So the whole time the boss has been telling us that if we don't like our job, leave.... but we can't leave. We are stuck. So what does she have on her hands? A bunch of stuck employees who want get the hell out of there and don't have a voice on the floor.
BS and more BS. I could go on, but I think you get the drift.
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