then your heart melts

When discussing making a patient comfort care, and withdrawing life support... the family said they wanted to do it when I was his nurse.

Awww.

getting an extern

I'm so excited... I'm being assigned a nurse extern this summer! A million years ago, I too was an extern. I love teaching and I'm so excited to get to be a part of such a formative experience for a young nurse.

patient update

Remember that patient I did a live blog on a few weeks ago? The one who was really, really sick?

She came back to visit us from the floor. She walked in, with a walker, as completely normal as could be! When she saw me she burst into tears. She said everything from her time here is a distorted blur, and she wanted to come back to put some normal frame of reference to it.

It was so rewarding to see her do so well, and to hear her thank us.

a girl and her filter: photos

CRRT orientation



The tools I work with

when tattling isn't tattling

I hate tattling in the nursing world. Nurses seem to get a high/boost of self-righteousness by tattling on each other to management. I have had emails from management because other nurses felt I was "using the dictionary" too much in my spare time, or didn't change my ET tube tapes that night, or let my insulin drip expire, etc etc etc. I have learned that every watchful eye is trained upon the smallest detail here. A simple reminder from the nurse would've done the trick (it's ok to be reminded that you've forgotten something), but going to management about it is going too far.

There are times, though, when it's ok to go to management. Like, if you've noticed a problem with another nurse that affects patient care, and you have already reminded that nurse or let them know face-to-face and the problem continues. Or if it's something that really, truly is not good for the patient or dangerous.

I hate tattling. I hate going to management about another nurse. Even when it's totally legit. It just feels so sneaky and underhanded.

This last stretch, a comfort care's family complained to me that their nurse never came in. They announced to me that they were going to "talk to the doctor about it". I said that was ok, but they should also talk to the charge nurse if it's a nursing concern. (The intern doesn't have any authority over nurses, he'll just go talk to charge.) So I went and just told her that the patient's family needed to talk to her. That's it. I don't want to be involved. But... that nurse NEVER went in there. I constantly fixed his pumps and beeps. I know there isn't much to do in a comfort care patient's room, which is why I always make sure to just pop in once an hour to check on the family. I always, always, always fix the beeping drips right away. I try to find a way to make them feel like the impending death of their family member is very important to me. This other nurse didn't do that, and they got mad.

Still. I don't want to be involved.

Unfortunately, my manager found me today and wanted to know what had happened. So I told her the truth. But I felt awful about it. I felt awful for that family, I feel bad for the nurse who is going to be in trouble, and I wish I wasn't involved at all.

oh my

Have you all heard of this hospital-themed restaurant in Taipei (land of the themed restaurant)? It's ri-DONK-ulous. Waitresses dressed as nurses... nurses who wear fishnet stockings with suspenders, and serve cocktails out of syringes, on tables made to look like OR gurneys. CRAZY.

I am the Filter Queen of the World

On this particular 5 day stretch, I scored a sick filter patient. For the most part it's lots of peace and quiet and monitoring, but I've had to do TWO recircs through a fistula site. Yeah, I feel pretty badass, cause I did them by MYSELF. Even a charge nurse said to me, damn, that's a pretty big deal.

Remember, at 3 years I'm still an ICU baby. But this baby is growing up, and I'm turning into the newest CRRT rockstar. Oh baby oh baby.

omg overtime

Today will be day 2 of 5 if I get all of my overtime. I'm on 12 hours of overtime right now. My eyes are bleary and heavy, but my mood is not bad. I'll get through this, and will do a big happy dance on payday.

why my co-workers are like family

1. We didn't choose each other, but we're stuck with each other.

2. We see each other at our worst, at our best, and everywhere in between.

3. We go through really extraordinary circumstances together, and no one else can really "know" what we've gone through. We just look at each other and get it. We get each other's jokes in the same way. Just a few key words are all you need, and it's instant mutual understanding.

4. No matter how much we annoy, dislike, or resent each other in normal circumstances, when something bad happens we are instantly there for each other.

5. We know each other really well. We know when someone is in a good mood or a bad one. We know what type of patient or situation we're good at or prefer. We know how to pick on one another or push each other's buttons, but we also know each other's strengths and draw from them.

Yeah, we're a family. Not all friends, not all buddies, but a family.

what happened to super sick patient?

I really enjoyed the live blog I did the other day. Such a great way to keep track of what my days are actually like, for posterity, I suppose, and my own future entertainment. I had the patient the next day, and she continued to do very well. Actually, she did better than any of the nurses and docs had ever dreamed she would. Despite being intubated, the next day she was following commands and answering yes/no questions! Hooray, mental status still intact after all that coding! Quite remarkable, really. Her kidneys were back to normal. She was off all drips except the epinephrine and the insulin. We were tube feeding her. Her fever was staying down under 38.1. Her vent settings were down to 40%, PEEP of 10. In fact, my day was a bit boring, she was so stable.

Also, the CF patient I mentioned a few days ago passed away the day after I cared for him. Other nurses told me that the next day he seemed much more accepting of the fact that he was dying. Later he pooped, and coded as he was getting cleaned up. Peace to him and his family.

Overtime is out of this world. I'm working nearly every day. I carpool in on Saturdays and Sundays, and will be spending a few nights at the houses of friends in the middle of the week. My paychecks are going to start being out of this world. Blogging here is going to pick up of course, because work is my life right now. As another nurse who does overtime nearly every day told me, it's easy once you get into the rhythm. Break the rhythm and you'll realize that you're extremely exhausted and coming back will be hell.

Live blogging on super sick patient

Background: Middle aged female, arrested during routine dental procedure. Cause unknown. Arrested twice more since admission to hospital. Lactate trending down, now at 10. pH finally normalized to 7.34 overnight. Complete heartblock resolved now to sinus tach. Mediocre urine output, creatinine of 2.3. Troponin of 20.0. Fever of 40.3 (that's 103.5 for farenheit users). Drips: Versed, Fentanyl, Insulin, Bicarb, Epinephrine, Phenylephrine (maxed), cisatracurium, heparin.

0800

Nephrology team: Intern freaks out because of fan blowing on patient under sheet "wind tunnel" for fever. "How can I assess the patient?!" he asks frantically. Step 1. Turn off fan. Step 2. Pull down sheet. Step 3. Assess patient. Wow, this is so difficult.

Nephrology team again: Snarky comment, "ok all powerful ICU nurse, we are going to put a triple lumen on one side and a double on the other". Well gee, don't work too hard on my account. As if it's my fault the patient needs that many lines!

0900

Pulmonary fellow splatters blood on my bed, and almost on me. I love my pulmonary fellow. I shout, "hey hey, you're spraying blood everywhere!" Fellow to me, "Oh shaddup." Intern staring. Fellow to intern: "We've worked together a long time."

Same fellow shouts of the room: "Can we get her a hairnet? I mean, a bonnet?" Do we call them hairnets? Or bonnets? What do we call these surgical caps anyway??? Hairnet and bonnet just sounds weird...

Coming down on Phenyl. All other drips the same. I'm about to send a gas, see what we can do with her vent settings (80%, 40/18 pressure control). Also, thinking about setting up the filter (CRRT) now. Man, I set these damn things up a lot.

Oh, and I had a red bull this morning but... is there coffee around here anywhere???

1000

Made a coffee run. Also got a stellar blood gas... 70% here we come, also weaning nitric oxide down now. Did I mention she was on that?

And to whoever put the donuts in the break room... I HATE YOU!

1100

Where is the time going?? Pulm fellow made a mess in my bed, as in blood. So we got to change her sheets and give her a bath. She didn't like bathtime... BP bottomed out, and she got extra of epi and phenyl. Boy does she need that epi. The second it beeps that it's out, I have to go running and change the bag lickety-split, or she's out of BP commission for the next several minutes.

Making more improvement in vent settings. Yay for that.

1200

Spent a lot of time talking with the family, explaining everything. I actually like that part of my job. Family is super nice. Coming down ever so slightly on phenyl. Vent settings look good. Off nitric soon?

Sidenote: I'm wearing my new glasses today. So spiffy.

1300

Dopplers, and EDMs, still give me a panicky feeling. PTSD from losing the baby.

Ta da! Renal has shown up to finally put in the sorensen. A million hours later.

This renal "fellow" frightens me when he's in the room alone with my patient. He's not the brightest bulb in the box... he totally makes me nervous in there alone.

1400

Wow this guy just had me go get him all his items. The Renal folks are usually so independent, and get their own stuff. I just hope he knows what to do with it.

1800

Just spent the last 4 hours messing with a filter. Setting a new one up, watching it work for 15 minutes, spending an hour (almost) trouble shooting very high pressures, finally giving up, tearing it down. It was a four hour exercise in futility, actually. Luckily, patient's urine output really picked up and her electrolytes are ok without dialysis. Stay the course.

Good news on vent settings: down to 50% and 36/14, nitric at 2. Much less febrile (38.4). Way down on phenyl requirements. So all in all, good work. A lot of extra work, but the patient didn't suffer for it so I guess that's all that matters.

Why can she not have a dialysis cath anywhere but her fem sites? Because NO WIRE can go into her atrium. It puts her into PEA arrest every time, due to her LBB. Interesting.

I'm tired. Haven't peed or eaten since this AM's coffee run. Need to SOAP on this patient and do her care plans. Meet my carpool rider and get my butt home.

Hope you enjoyed this lovely day in the life of an ICU nurse post!

end of life care (and growing some balls)

Lately, we have several end-of-life patients for whom we can no longer treat, that is to say, despite all of our treatments or therapies their prognosis will remain poor and their death is imminent. This particular group is frustrating to all of us working in the ICU, because each of them are being kept alive by our machines (or their dying is being prolonged, you could say), because the family members or even the patient themselves are in denial.

Case #1: This patient has cancer that has spread to many organ systems and is no longer responsive or able to tolerate chemotherapy or any other type of aggressive treatment. Her oncology prognosis is extremely poor... as in, she only has a limited time left to live. Naturally, because we are supporting her on a ventilator, she is living a little longer. But she is very weak, unable to communicate, and she's suffering. Her children insist that she would not want to be kept alive like this, but her husband is unable to let go. He looks for any little positive thing as "progress". He doesn't want to make that decision, the decision to withdraw.

I so get that. When I was in labor and complete, I did not want to be the one that pushed my daughter into the world knowing she would not survive. I knew it was the inevitable outcome, but I did not want to be the direct cause of it! This poor man does not want to make this decision... in this situation, most of our attendings or fellows step in and gently but firmly say, "we've done all we can. We have nothing more to do. It's time to make a decision".

The attending this month is just plain awful. He has let the patient continue to deteriorate while orally intubate for almost a month now. Family meetins are ongoing, but he refuses to draw a firm timeline with the family. In short, he won't let this husband off the hook. He won't make the decision for him, or help lead him to it. This poor husband feels that he is all alone in this choice, and meanwhile his wife, the patient, suffers. It's absolutely terrible to watch.

Case #2: The CFer I mentioned in the last post has been failing for weeks as well. This case is quite different in that it is the patient who is making the decision to prolong his own life. He's still mentally capable of making all of his own decisions, but he is just too afraid of death to withdraw on himself. It's hard to watch, but understandable. The worst thing, though, is how this particular attending comes in in the morning and says things that could almost be perceived (by a very scared patient) as hopeful. It's awful. In this case we are complying with his wishes, but the attending is not helping the situation. The fellow did a much nicer job, later, of explaining to him that we can keep him comfortable, or can continue aggressive vent management that may prolong his life for a short time but may make him uncomfortable. At least with that information he can make an informed decision.

Heavy stuff, always. There are just some doctors who really know how to go about end of life care with the right mix of compassion and firmness, and some who shy away from it.

from my other blog

Copying this in from my blog All My Pretty Ones:

I made a mistake that I never would’ve thought twice about before I lost my baby. I was taking care of a patient who has cancer and no hope of getting better. We are waiting for her family to make her comfort care. Her husband is at her bedside every minute, struggling with that awful choice. Meanwhile, the husband of a different patient I’d taken care of a few days ago walked by the room where I was drawing up meds for the cancer patient. He said hi enthusiastically, and I gushed to him about his wife, “oh she looks great! She’s doing SO well!”

It seems harmless, but a minute later I felt my face burn and my heart drop as I realized I’d said that right in front of the husband of my dying patient. He has NO chance of his wife getting better, or doing well. He faces loss at every turn in the coming weeks. No nurse is going to say those words to him. I realized that I had probably just made him feel very much how I feel as people gush over pregnant co-workers or new moms in front of me, and in his own wife’s room. There was nothing I could do to take it back. It wasn’t like I was “reminding” him of his loss. No one can remind us, right? It’s always there. We don’t forget it. But I was, ignorantly, rubbing his nose in it. Mr. B, I am so sorry. I am more sorry than you’ll ever know.

-----

Working so much overtime, it feels that my life is being mostly lived on the unit. Aren't we nurses truly lucky people though, to have a job that gives you the option of making so much more money, for a time, if you want to?

Anyway, I had a 25-year-old CFer that is in multi-organ failure and for whom we've done absolutely everything we can, but he's dying. His mom knows this. He's her only child... she doesn't leave his side. I told her when she was out of the room, that my heart was really hurting for her, because I lost my daughter in December. Later she brought it up to me again, and I told her that she was stillborn, so it was quite a different situation. I didn't get 25 years to spend with her, but I also never had to watch her suffer. I can't imagine how awful that truly is, but I can imagine a mother's grief. I am living it now. No matter how different the circumstances of grief might be, no matter in what manner your child dies, our grief is much more alike than it is different. I read that on By the Brooke, and it has stuck with me. Our grief is more alike than it is different.