Ebola

This is The Thing right now in the world of nursing, especially the world of MICU nursing, where an Ebola patient seems bound to end up.

I work at a level 1 trauma center, a huge teaching university, a medical center that receives patients from the surrounding region on a daily basis. And in case you're wondering... no, we have not been trained or briefed or in any way notified of what we are to do should someone arrive with Ebola-like symptoms. Just yesterday the ED held an Ebola-preparedness drill. Just yesterday. For several weeks now, our nurses (part of a 4,000 strong nursing union) demanded preparedness information. Just yesterday Ebola was discussed in a general staff meeting on our unit, where we were told that ours is not to be the unit that accommodates an Ebola patient.

Still. The panic is rising among nurses. We are the ones suctioning sputum, wiping up vomit and puke, and breathing in droplet-laced air. We are the ones going in there every 2 minutes to adjust pressors, silence alarms, push meds, etc and so on. If anyone is going to contract Ebola, it's us. And now we're FREAKED. OUT.

I have no intention of caring for an Ebola patient. The rumor now is that only volunteers will be trained and utilized if an Ebola patient should come along. Trust me when I say I won't be among the volunteers.

Also: my dad just called to tell me to quit critical care nursing, and go work in a nursing home. Ebola or no Ebola... that's NEVER gonna happen!

these are not my people

These are not my people...

 

That's the thought I continuously have in my head during my first "graduate" class. My classmates, most of whom are practicing nurses, are not ICU nurses, and for that matter are first or second year nurses to boot. They don't understand my depraved ICU sense of humor. I feel like I'm surrounded by a different species of nurses. The funny thing is, many of them are interested in being nursing faculty.

 

I ask you, how can nursing faculty be effective in a field that is so intensively hands-on, learn-as-you-go, experience-based? Can a nurse with only two years of bedside experience in general med-surg really guide BSN or MSN level students who intend to practice at the bedside? Or are they simply considered theorists, leaving the rest to be learned by preceptors via clinicals?

 

I'm not a huge fan of academia. That being said, I find that I excel in it. Writing comes easy to me. I know what they want from an assignment and I give it to them. But I don't believe in it, necessarily. I don't think the focus is where it should be... the type of learning we should be experiencing, in my opinion, as nurse practitioners should be somewhat akin to med student and resident rounds. But maybe that's to come? This class on health status and trends seems more like the nursing profession indoctrinating its young, and less like preparation for actual advanced practice.

what's the matter with you? and you? and you?

No, seriously, you family members of sweet little old ladies who are floor status... what makes you think that it's ok to freak out and yell at nursing for the fact that your mom ordered white bread for her sandwich. She is totally with it, she totally ordered her own dinner. It is also so not ok to get me at the desk every 5 minutes because there is a spot on a pillow, or there is spit in your mom's mouth, or you dropped an ice chip on the bed. You are being obnoxious. You are not the only patient in the ICU, or the hospital, or the world. I'm not here as your personal servant, or your punching bag.

Call me a mean, bitchy nurse. I've given your moms every ounce of my compassion, care, and attention. I've helped them order food, bathed them, and answered all their questions. You may be scared or sad or nervous about them being in the hospital, but they are getting better and going out. The person in the next bed over may be agonizing over withdrawing life support on the parent of their young children... and you complain about this little shit?? Get it together. No one likes you. The patients yes, you, no. You are wasting our time and making it so that staff runs when they see you coming.

Please send in one of your saner siblings.

And yes, that was me, running across 5 lanes of traffic to get the fuck away from you. I hope tomorrow I do better in the patient family lottery.

when a nurse has to do what a doctor shoulda done

The doctors signed out for the day, a lovely warm Sunday evening with clear blue skies. The attending, who had promised to come back later, decided he wouldn't be returning after all. The cross cover team didn't know the patient, and besides, they were stuck in a room placing a difficult line.

It all fell to me to address the family's concerns and questions regarding the end of their loved one's life, and the removal of his life support. They had made him a full DNR, do-not-escalate care just yesterday. His daughter had panic attacks so bad this morning, when she realized he would not survive the day, that she retched and shook and had to go to the ED herself.

I have often participated in, or even led, these types of discussions. I have never held a family meeting to discuss end-of-life care all by myself. What choice did I have, though? They were ready to let him go, but they didn't know how. They didn't know what to expect or how they would survive it. They didn't know if they could even utter the words that would lead to the push of certain buttons, the end of his life support, the withdrawal of all that kept him alive.

I gave them that permission. I took away that awful choice. I told them that he had lost consciousness days ago, his body had made a decision for all of us. I told them that the doctors had already made the decision that everything that could possibly be done for him had been done. We could keep him going for another day, perhaps, on his current support. Or we could withdraw it and let him slip away peacefully in the next few hours.

I described what would happen to his vital signs. His breathing would quicken, and then slow. His heart rate would go through a variety of rates and rhythms, slow down, and stop. His blood pressure would drop quickly to nothing, as would his oxygen levels. He had already lost consciousness, and he would slip even farther from this world. I described that what we could do to keep him comfortable. They all looked at each other, nodded, and said yes. Let's let him go.

I reported all of this to the cross-cover team. I just needed them to enter the orders. I paged the attending, who still chose not to come in even though he had built a relationship with this family over the last week. I had just met them this morning. Nevertheless, I assured them that their emotions were ok. I said it was ok to cry, or not to cry. It was ok to stay in the room with him, or to leave. There was no right way, and no wrong way.

I was surprised that they chose to say goodbye and to wait outside of the unit. I stayed with him, holding his hand and rubbing his head, representing the Mother that we all call out to in our times of need. I hummed to him and sometimes sang. The family sometimes came in to kiss him and tell him they loved him. Ultimately, they were not there when he passed. I alone was there as his heart beat its final beat. I alone witnessed his exit from this world. And I alone went to the family to express my condolences, and to hug them.

The daughter said to me, through shaky tears, "thank you for being with him when we couldn't be".

This is the greatest work I do, that I've ever done.

back to school

I got admitted to grad school this fall! I applied for Winter, since I missed the fall application deadline. But they called me and told me they were willing to consider me for Fall if I was interested. And there you have it! I got the acceptance letter from the School of Nursing and I'm just waiting on the actual Graduate School to give me my ID and PIN and whatnot so I can register.

 

Every ICU nurse I know wants to go to CRNA school... and while I'd love to sedate people for a living (who wouldn't?!) it's just not feasible for me to devote that much time and energy to school while working full-time and raising a child. Plus, I love the elderly, especially dementia patients, and my school offers an NP program with a concentration in Dementia.

 

Besides the fact that I would love to work exclusively with the elderly, and the pay raise is impressive, I wanted to be an NP so that by the time my daughter is school-age, I'll be working "business" hours as well and can be with her in the evenings and weekends. Even working three 12s a week, I'm going to miss two weekends with her, and be off a lot of days while she's in school all day. It makes no sense to me. I'm always trying to figure out how to be with my little girl MORE. So while she's a baby/toddler it doesn't much matter which days I work, it will later on. I will also be looking for something that's closer to me, as in, not an hour away.

 

My thoughts prior to school are a mix of excitement (who doesn't love a fresh notebook?) and just a general sense of dread. Dread for the stress and additional work that has to be done on any given day. As it is, I can barely keep my house from looking like a disaster zone, the yard from looking like a jungle, or my kid from eating poison or jumping into bodies of water. It's difficult to manage everything just working three days a week and leaving that work behind me when I leave... not to mention that I miss my daughter and desperately want to be with her every second I can when I'm not working.

 

So I know this is going to be hard. It's going to require sacrifice (especially of sleep, god help me) but I'm only doing it because I think it will be worth it in the end. I think I will find my career more satisfying, my home-life more satisfying, and my bank account more satisfying in the end.

them's fightin' words

Don't you always know trouble's a'comin' when a certain nurse takes shift report from you? She's bound to find every possible mistake (and the definition of that word is often debatable) that you made, might've made, or could've made. She will inevitably be riled up if you left anything for her to do. And each and every grievance will be written into a nice little email that is forwarded to you, your supervisor, and your manager.

And then your manager will ask you to come in and address her (real or imagined) concerns, and you address them all in writing and further dig yourself into a hole by making a snide remark about how this nurse obviously can't handle a busy shift.

Because your nursing student fails to give proper oral care, she is dragged into the hospital with her nursing professor to be officially reamed out. I assure her that this is all part of being a nurse (so get out while you still can). The nursing student cries, and shakes, and writes profusely apologetic emails to your manager and you, even though WHO THE FUCK CARES?!

In reality, you kept two very unstable patients alive for 12 hours while simultaneously guiding doctors with a loving but firm hand, keeping butts clean and dry, keeping skin intact with turns q2, ordering pressor refills, and orchestrating a string of procedures that seem to cause more harm than good. Nurse Ratched would prefer that you also restring all new lines for her, keep your tube feed bags full to the brim, iron the sheets and wax the floors, Florence Nightingale style.

Seriously, she said I left my patients in a state of "disarray". Next time I'll wax the floors with your blonde ponytail, you biotch! 

I was much more polite in meetings with the manager.

my purpose statement for NP school

One might say that I was born with nursing in my blood. Raised by grandmother who worked full-time as an ICU and then recovery room nurse, and a mother who worked as a nurse in home health care, I was poised to enter the field of medicine with personal knowledge nurse under my belt of what it takes to be a nurse. I was comfortable from the start with this role in the health care field and felt that I could emulate the positive qualities I had been witness to as a child growing up in a family of nurses. 

Throughout my undergraduate nursing studies, I strengthened my confidence in patient care by working in assisted living and then as an ICU tech in the hospital. I began my nursing career on a step-down telemetry floor and quickly found myself restless and craving a more stimulating environment. I found that ideal workplace in the ***** unit ICU at U of ******, where I have been working full-time for the last four years. In the area of medical intensive care, I have been challenged to think critically and to become an outspoken advocate for my patients. In particular, I am drawn to patients who change their goals from full resuscitation to end-of-life comfort care. My long-time love for the elderly, my passion for providing patient-centered and goal oriented care at the end of life, and the solid background in medicine pathophysiology that develops while working in a top-notch ICU, has led me to pursue an advanced degree in nursing with a concentration in geriatrics.

In addition to working at the bedside of critically ill patients, I have also served as a nurse mentor and preceptor for ***** nursing students over the past five years, including those of your faculty member Kathleen ****. My commitment to the field of nursing is highlighted by my enthusiasm to bring new nurses into the fold in a way that prepares them for real-life nursing and inspires a life-long interest in evidence-based nursing practice. I have been a part of our unit's Patient and Family-Centered Care team, most recently and specifically developing a model of bedside report that will increase family and patient involvement and improve patient safety from shift to shift.

My reasons for applying to ******* School of Nursing's graduate program are many, but the one that is perhaps the most important is that I have a great interest in specializing in geriatric diseases, such as dementia and Alzheimer's disease. The courses offered in the Aging Studies program are of great interest to me, as I have worked with the elderly throughout college, and currently care for a grandfather with Alzheimer's disease. In fact, my desired population of patients as a nurse practitioner will be those suffering from dementia. 

Along with a strong curriculum in Aging Studies, I am further interested in *****'s program because of the nature of its schedule. As a mother of a busy one-year-old, and a full-time staff nurse, I am looking for a program that can offer courses back to back one day a week. With a schedule like this, I will be able to provide financially for my family and spend time with my daughter while pursuing my education and career goals.

As an undergrad in the school of nursing at *****, I met and learned much from the devoted nursing faculty there. Professors I remember fondly include G**** R****, who inspired me to advocate for advancements in the nursing profession, D**** F***, my advisor and final clinical instructor, and M*** T****, whose work in Sub-Saharan Africa continues to motivate me. I look forward to once again working with the diverse and talented group of advanced nurses at ******* University. 

grad school on the horizon

Cross-posted from my foster/adopt blog:

On top of feeling suffocating guilt that I don't spend every waking moment that I'm not working with my daughter, I struggle to balance the other aspects of my life. For some stupid reason, under a hint of pressure from management, I "volunteered" for a committee at work. Then I "volunteered" to help with a certain project. Now, on my day off, I have to go in for four hours to work on this project. No more committees after this year! I'm not interested in being involved in every extra-curricular nursing activity the unit has to offer as if it's college. Do I want to work toward a better work environment for nurses and higher quality care for patients? Absolutely. Am I willing to sacrifice precious time with my toddler for it? Nope.

On the other hand, I have begun the application process for grad school. Before you start thinking that this sounds absolutely crazy, the nurse practitioner program is geared toward working adults with families, and you take two classes per semester, both of which are held on the same night, one night per week. Doable?

I went back and forth about this decision for a long time. The pros are obvious: higher education, the prestige of being an advanced practitioner, and a huge pay raise. Then more pros: being a living example of success to my daughter, providing her with more (material) wealth as she grows up, setting a work/study ethic example for her, and having a schedule that will allow me to be off on evenings and weekends once she is in her later school years.

The cons are financial (for a few years, although my workplace reimburses tuition up to 75%), and yet another time-sucker, what with clinicals and homework and an evening away from home. And also the fact that doing bullshit assignments sounds like hell. The world of academia can be so tedious and stressful. It's been awesome being out of it for 6 years now.

But I think that in the long-run, the short-term sacrifices will be worth it. I want to set an example to my daughter, that aiming high and working toward goals will get you far in life. Self-discipline and temporary sacrifice are tolerable to achieve your dreams.

the maybe-ECMO patient returns...

But not as a patient! He came back to say thank you, along with his wife. He, of course, remembers nothing of his ICU stay here, but his wife remembers it all. He walked in looking fit as a fiddle, and showed us photos of him with his granddaughter at Disney last winter. He told me, "I never would have been able to make those memories if not for you and everyone here," and he gave me a hug. It was really a wonderful moment, and a reminder of why I do what I do.

two codes for the price of one

Yesterday we had two codes happen, at the same time, in beds 8 and 10. Yes, right next to each other.

We were all congregated around bed 10, who was getting a paracardiocentesis for cardiac tamponade. Exciting stuff. He was also on 100% FiO2, PEEP 20, nitric oxide, and two pressors (for non-ICU folks, just think MAX life support). Suddenly, alarms and the nurse in bed 8 yelling, "guys I need help!!!" Her patient bradied down, lost a pulse, and almost everyone (except the cards people who were doing the cardiocentesis) ran into bed 8 to code him. We did a round of epi and atropine, got a pulse back, and no sooner did we get it but we here shouting from bed 10. Everyone stampedes back over there, because he's gone into Vtach and the cards people are doing chest compressions.

We have only one crash cart for the ten beds on our south side and one for the other ten on the north side. Since we had just cracked a cart for bed 8 and he was wearing the defibrillating pads, we had to go running full speed to the other side of the unit for their crash cart. Hope no one over there codes now!

This brought a few nurses from the north side over to help us, as that side was currently coasting on easy and we were drowning. I had finished helping stabilize bed 8, so the code was in full swing in bed 10 and I asked around, "has anyone gotten the family?"

It's important to have at least one family member there to witness the code. We have someone stand with them, a nurse or social worker, to explain what is happening. We want them to see the sequence of events, so that it isn't a surprise, and so they can see how much effort we put into resuscitation.

The code was 15 minutes in, and everyone knew that this young man had a large, very involved and concerned family. I ran down the hall to the waiting rooms, asking anyone if they were here for him. I finally found someone, explained that he had gone into cardiac arrest, and asked her to come with me immediately. She got the wife, and the brothers, and we stood with them as they prayed and cried.

And he did not make it.

He had been diagnosed with AML on Sunday, at the ED, where he had driven himself for "flu-like symptoms". He had been admitted to the ICU with respiratory failure which turned into ARDS. He developed a large cardiac effusion, and then tamponaded. Seven days after his diagnosis of cancer, one week after eating dinner with his family on a normal weekend evening, and on the day of his birthday, he died after a 40 minute code. His family was hysterical. His wife looked bad, in shock, unable to cry or walk.

I carried them all home with me, last night.

(By the way, bed 8 recovered and as far as I know didn't code again that night.)

just give him some ativan, already

As someone who suffers from anxiety disorder (or suffered, I should say, since it's very well controlled now with paxil) I find myself advocating for my anxious, panic attack-laden patients.

You know how nothing is more annoying than a patient who is anxious? Because you can't fix it for them and you can't get the docs to order benzos, because oh-my-god benzos will make the patient STOP BREATHING and become a crazed addict!

Seriously, doctors, 0.5mg of PO ativan will NOT hurt your very anxious patient, the patient with physical signs of having a panic attack, nevermind his subjective reporting. If he's this worked up, a little ativan will only bring him down to normal, the same amount of ativan that had he been normal and just a drug seeker would've brought him down to a RASS of -2.

It's like stairs. A small, appropriate dose of benzos will only bring you to the next step down from whatever step you're already on!

This particular patient is homeless and a known substance abuser with chronic pain. He came in with altered mental status after OD'ing on benzos at an ECF, benzos that were not prescribed. Maybe he wouldn't have felt the need to self-medicate had the staff there been able to give him an appropriate dose that gave him relief from his panic attacks? Maybe not, but still. What's the end goal for this guy? He's old, bed bound, and lives at a facility. He's not going to go through intensive psychotherapy or life style changes. Treat his anxiety and his pain, don't just give him nothing. And if he continues to self-medicate and use, oh well. At least we tried.

Give him nothing and I guarantee that he will self-medicate again, and probably OD again. And we will be right back here where we started, with me paging YOU every time he pushes the call light, which is every 2 minutes, for more pain meds/anxiolytics. No one's having very much fun right now!

a mother says goodbye

As a baby loss mom, it was hard for me to watch. He was only 31, diagnosed with leukemia 9 months ago, an only child. We asked his mother to make the most difficult decision of her life. I turned off the pressors, respiratory decreased his FiO2 to 21%, his rate to 4 bpms.

It only took two hours. His mother was standing with her arms around me when his heartrate hit 0, his EKG rhythm a flat line. She begin to shriek, and writhe, and flail her arms and legs. I jumped back out of the way. She fell to the ground and thrashed with everything she had. It took two large guys, members of their family who were present, to get her to her feet. A few minutes later, she was covered in sweat and hyperventilating. We brought her ice water, told her to breathe in, breathe out, big deep breaths.

I said to her, "this is the worst feeling you will ever have, this is as bad as anyone anything can ever feel."

An intern said to her, "you ended his suffering, you took his pain onto yourself so that he wouldn't feel it." A perfect thing to say to a mother.

We rarely have such physical grief reactions, we are rarely witness to keening or loud displays of emotion. I guess that's just the majority of our culture. We wait until we are alone, in private, to break down and punch and kick and scream.

I'm glad she didn't wait. Her reaction was the purest, rawest form of the worst of the worst kinds of grief and loss. I wish everyone could express their emotions so accurately, and in the moment of their peak poignancy.