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!
Saturday, March 2, 2013
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.
Tuesday, January 1, 2013
life updates
I haven't posted in a long time... mostly because I've been posting at my other blog. It was a blog about fostering and my pregnancy, but unfortunately my pregnancy came to an end after a placental abruption. I went into irreversible labor and was forced to deliver my daughter, who was not old enough to survive. I named her Avalon. My foster son was returned to his parents permanently in Mid-November, and everyone, including myself, was very happy for them.
As far as work goes, I was on my way in to work the morning I abrupted. I called literally 5 minutes before shift change, panicking as blood was gushing out of me. I've been off work since December 8th, and January 8th I go back.
My life is so different now, at least internally, that it will feel strange to go back to work. I almost wish I could start over, work somewhere new. Maybe most people would want familiarity after such a loss, but I'm feeling like I can't bear to remember how happy and pregnant I was working there before everything happened.
I had some moments as a patient I know will stay with me. There were nurses who made my day (the nurse practitioner who told me to come to triage if I was worried AT ALL, the nurse who numbed me up before inserting an 18g in my arm), and there were nurses who were major FAILS (the nurse who told me the baby would be "disposed of" when I asked what would happen to her body). The doctor who delivered me was also not impressive... when I was complete she ASKED me if I wanted to push. No, of course I didn't! She just kept saying, "you can push if you want to". And if I don't? Jeez. I needed so much more. And where was the nurse? Nowhere.
I also related very closely to those family members we always think should "withdraw" on very sick MICU patients. The patient is going to die anyway, no matter what, so we always think the choice should be simple. Just pull the damn plug already, your loved one is just going to suffer! Nothing's going to change! Well, you know what? My placenta was falling apart and my daughter was going to die, but I still didn't want to be the one who pushed her out, who ended her life with premature birth. I was in very active labor, she would come out no matter what, but I still didn't want to be the one to do it. I get that now, and I wish I didn't.
As far as work goes, I was on my way in to work the morning I abrupted. I called literally 5 minutes before shift change, panicking as blood was gushing out of me. I've been off work since December 8th, and January 8th I go back.
My life is so different now, at least internally, that it will feel strange to go back to work. I almost wish I could start over, work somewhere new. Maybe most people would want familiarity after such a loss, but I'm feeling like I can't bear to remember how happy and pregnant I was working there before everything happened.
I had some moments as a patient I know will stay with me. There were nurses who made my day (the nurse practitioner who told me to come to triage if I was worried AT ALL, the nurse who numbed me up before inserting an 18g in my arm), and there were nurses who were major FAILS (the nurse who told me the baby would be "disposed of" when I asked what would happen to her body). The doctor who delivered me was also not impressive... when I was complete she ASKED me if I wanted to push. No, of course I didn't! She just kept saying, "you can push if you want to". And if I don't? Jeez. I needed so much more. And where was the nurse? Nowhere.
I also related very closely to those family members we always think should "withdraw" on very sick MICU patients. The patient is going to die anyway, no matter what, so we always think the choice should be simple. Just pull the damn plug already, your loved one is just going to suffer! Nothing's going to change! Well, you know what? My placenta was falling apart and my daughter was going to die, but I still didn't want to be the one who pushed her out, who ended her life with premature birth. I was in very active labor, she would come out no matter what, but I still didn't want to be the one to do it. I get that now, and I wish I didn't.
Friday, September 7, 2012
anybody out there?
I have no idea if anyone actually reads this... but in any case, I'm still here, and still working full-time with a 4 month old as a single mother. No more 3 in a rows at work. The 2 in a rows about kill me now. I have to get up an hour earlier to leave for the babysitter's, and come back an hour later and put the baby in bed.
And I'm pregnant. Whoo. Not yet 6 weeks, but enough to add just that little extra bit (a lot actually) of exhaustion.
I have also been severely irritable at work. Usually I am happy with my job, grateful to be an amazing ICU at such a good facility, grateful to have a job I love that I went to school for. But I'm unable to keep myself from just wanting to snap at the doctor's, and yell at my patient, and stab some of my co-worker's in the eye with a cue-tip. Then I get so tired, at the end of day 2, tears are coming to my eyes and I'm about to just break down like a big blubbering baby begging someone to just let me sleeeeep.
I haven't told anyone at work yet, either, so right now they all think I'm on lifting restrictions, because I won't lift or turn without a lift or extra help. We do it all day long, and I don't want to break my back when I still have my foster son and a big belly (soon to come) to carry around on top of everything.
I don't think anyone has yet noticed that I'm only dipping into the decaf coffee (and I'm usually a coffee addict) or that I'm sweating and about to pass out whenever we're turning and cleaning a really fat patient, no wait, maybe they did notice that. In fact, two co-workers actually said (not seriously) maybe you're pregnant. My job is physically demanding, but many of our nurses get pregnant and continue to work, but I just never realized how seriously hard it is! And I'm only at the very very beginning!
My boss is going to be so thrilled that I'm going to require another leave for the baby. Oh effin' well. I'm so sick of bosses. And bitchy co-workers. And crazy, uncooperative patients. Have I mentioned I'm cranky as hell??
And I'm pregnant. Whoo. Not yet 6 weeks, but enough to add just that little extra bit (a lot actually) of exhaustion.
I have also been severely irritable at work. Usually I am happy with my job, grateful to be an amazing ICU at such a good facility, grateful to have a job I love that I went to school for. But I'm unable to keep myself from just wanting to snap at the doctor's, and yell at my patient, and stab some of my co-worker's in the eye with a cue-tip. Then I get so tired, at the end of day 2, tears are coming to my eyes and I'm about to just break down like a big blubbering baby begging someone to just let me sleeeeep.
I haven't told anyone at work yet, either, so right now they all think I'm on lifting restrictions, because I won't lift or turn without a lift or extra help. We do it all day long, and I don't want to break my back when I still have my foster son and a big belly (soon to come) to carry around on top of everything.
I don't think anyone has yet noticed that I'm only dipping into the decaf coffee (and I'm usually a coffee addict) or that I'm sweating and about to pass out whenever we're turning and cleaning a really fat patient, no wait, maybe they did notice that. In fact, two co-workers actually said (not seriously) maybe you're pregnant. My job is physically demanding, but many of our nurses get pregnant and continue to work, but I just never realized how seriously hard it is! And I'm only at the very very beginning!
My boss is going to be so thrilled that I'm going to require another leave for the baby. Oh effin' well. I'm so sick of bosses. And bitchy co-workers. And crazy, uncooperative patients. Have I mentioned I'm cranky as hell??
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