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.
Monday, March 4, 2013
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.
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.
Saturday, March 2, 2013
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!
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!
Friday, March 1, 2013
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.
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.
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.
Tuesday, February 19, 2013
ready... get set... overtime!
I'm in need of some hard cash, people. Aren't I lucky to have a career in nursing, where they give out overtime like candy at a parade? It's about to get real, and I'm about to pack my figurative bags and start living most of my waking days on my unit. All so that I might watch that bank account number grow.
I'm creating a memorial garden for my daughter this summer, which all in all will end up costing around $2000. And I want to travel, later in the fall, if I'm not pregnant again. But all of that can be found in every detail at my other blogs: Across the Never Sky (travel) and All My Pretty Ones (baby loss, foster care, and TTC).
I've had some pretty status quo patients lately. Does everyone know what I mean by a "feed/water/turn" patient? Basically, a patient who is out of it (as in, can't press the call light) who is being tube fed and needs turns q2 hours. And that's it. They are just sort of hanging out like that until a) they wean off the vent or get a trach, b) their mental status improves, or c) we decide what the hell else to do with them. So yeah, I had one of those, and a couple of cancer patients. We get our fair share of cancer patients either at end of life, or septic following chemo. We got a lot of BMT patients who are septic, or hypoxic, or what have you. It was actually a pleasant week of nursing, as my awake patients were very nice and not too needy, and my out of it patient was... well, out of it. And both families were quite nice as well. Awesomeness.
It might be time to take a sick single again, though. I try to take my share of doubles, and I do take patients back again even if they are doubled (unless I seriously can't stand them). People get pretty edgy if you ONLY take singles, all the time, and there are a few nurses who are notorious for that. It's considered poor form. On the other hand, sometimes it's necessary to be a bit pushy, speak up, and get a train wreck. Afterall, we live for those train wrecks!
I'm creating a memorial garden for my daughter this summer, which all in all will end up costing around $2000. And I want to travel, later in the fall, if I'm not pregnant again. But all of that can be found in every detail at my other blogs: Across the Never Sky (travel) and All My Pretty Ones (baby loss, foster care, and TTC).
I've had some pretty status quo patients lately. Does everyone know what I mean by a "feed/water/turn" patient? Basically, a patient who is out of it (as in, can't press the call light) who is being tube fed and needs turns q2 hours. And that's it. They are just sort of hanging out like that until a) they wean off the vent or get a trach, b) their mental status improves, or c) we decide what the hell else to do with them. So yeah, I had one of those, and a couple of cancer patients. We get our fair share of cancer patients either at end of life, or septic following chemo. We got a lot of BMT patients who are septic, or hypoxic, or what have you. It was actually a pleasant week of nursing, as my awake patients were very nice and not too needy, and my out of it patient was... well, out of it. And both families were quite nice as well. Awesomeness.
It might be time to take a sick single again, though. I try to take my share of doubles, and I do take patients back again even if they are doubled (unless I seriously can't stand them). People get pretty edgy if you ONLY take singles, all the time, and there are a few nurses who are notorious for that. It's considered poor form. On the other hand, sometimes it's necessary to be a bit pushy, speak up, and get a train wreck. Afterall, we live for those train wrecks!
Wednesday, February 6, 2013
Back in the saddle
I'm back in the saddle at work, after my medical leave. It did feel good to be back. To know how to do something, to be able to it well. The ICU is full of rules. Everything has its place. That was a comfort. You can control so much there, there's a protocol, there's an algorithm.
We had a 2 1/2 hour code... the lady's kept getting a spontaneous pulse after a few rounds of ACLS for PEA arrests. It seemed like it could go on all day, until we finally found a family member to tell us we could stop. THAT was craaaazy.
I had a few patients who were made comfort care, and passed away. I connected so well with the families. I've even shared the story of my loss with a few.
All in all, it's good to be back.
We had a 2 1/2 hour code... the lady's kept getting a spontaneous pulse after a few rounds of ACLS for PEA arrests. It seemed like it could go on all day, until we finally found a family member to tell us we could stop. THAT was craaaazy.
I had a few patients who were made comfort care, and passed away. I connected so well with the families. I've even shared the story of my loss with a few.
All in all, it's good to be back.
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