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?

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.

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

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.

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???

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.

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.