Alone.
At home in the living room.
Kids in bed. Wife at work.
And I'm searching for the good. The TV is on--an episode of HouseHunters International. A woman is moving to Paris after battling Stage 3 breast cancer and losing her husband over the last year.
She's looking for the good.
When the show is over, she's happy in her new apartment in a beautiful, romantic city.
My eyes scan the shelves of movies we own, and come to rest on "The Sound of Music". It doesn't get much more good than that. My mind examines why this is? It was a time when there was a definite line in the sand. On this side was the bad. On this, the good. One was the enemy, or not.
70 years later it looks pretty black and white.
But what if the enemy is within?
Where has all the goodness gone?
I live in a comfortable home--a dream completely out of reach for many. Yet I want to move. I long to live in another place. Anywhere but here, really.
I have a job--the deepest desire of many. It used to afford me moments of joy. Delight in saving lives. But now I struggle to tiptoe through each shift worried more that I will do something that will get my hand slapped, or worse.
I am married--and so many are so alone. But I struggle to maintain even the simplest lines of communication. The specter of my insecurities and past hurts and grievances shadows over all.
I have kids--while so many are desperate to bear children of their own. One child that no longer wants to live with me. And my bearish tendencies and low patience threshold send the other two to my wife's welcoming arms.
I feel so very grey.
Where, oh where, has all the goodness gone?
Friday, October 28, 2011
Thursday, October 27, 2011
Alone
"We're born alone, we live alone, we die alone. Only through our love and friendship can we create the illusion for the moment that we're not alone."
--Orson Welles
--Orson Welles
Tuesday, October 18, 2011
Perspective
Sunday I worked--another insane shift, and another insane assignment. But that's another post.
I was assigned to our reverse isolation pod where we put our heart and lung transplants. I was assigned two very sick transplants with complications, but across the pod was a fresh lung transplant from Friday. When I came on shift he was doing pressure support trials in preparation for extubation. He was pretty anxious--as most people intubated without sedation are--but even more so because he was a lung patient.
He passed his trials with flying colors and was quickly extubated. His family came in afterwards, thrilled to be able to talk to him. The family was bubbling over with happiness and enthusiasm, which is pretty typical of post transplant patients and families. They are just so thankful that their loved one has been granted a second chance afforded them by their new organs.
The patient was doing his best to match his family's mood, but it was pretty clear to me that he wasn't doing as well as he was making out. His wife kept asking him if he felt better, and he would agree that he did, managing a tentative smile for her.
He was a little more forthcoming with his nurse when the family wasn't present. He admitted to some pain and feeling somewhat short of breath. He also was pretty fatigued. Most of all he was just tired of being in a hospital bed with all the ridiculous lines and tubes we insist on attaching. And rightly so I think--we do tend to take things a little far with what we expect our patients to tolerate. He had come to our hospital from 750 miles away for the transplant consult, and it had taken 10 months to get where he was because of some other complications that needed to be resolved before he was a true candidate. Imagine being away from home temporarily...but for 10 months. Did I mention we don't have TV's in our open pods? In short, he was just cranky.
A couple hours later I overheard him ask his nurse how much of the surgery he would be awake for. I stopped what I was doing to look across the pod and listen in.
The nurse gave him a blank look and asked, "What surgery?"
A little annoyed, he shot back, "The one I've only been waiting 10 months for!?"
"Uh, you had your surgery on Friday, today is Sunday."
His turn to give a blank look.
She repeated, "You got your lungs on Friday, you've had your transplant already."
"No shit??" A slow smile spread across his face.
Thanks to the anesthesia the last thing he remembered was changing into a gown...
It's amazing to see the shift in his perspective and his mood based on that one small piece of information. Suddenly he was pleasant, jovial even. He was happy to see his family, even when they stayed to long, or asked him for the 50th time, "How do you feel? Are you better??"
So let me ask you, when you woke up this morning, did you face the day like it was gift? Like you had been blessed with a new set of lungs?
Or are you still waiting (for 10 months now!) for something good to happen?
If I may draw from the wisdom of Frog on the kids show Little Bear, (a favorite in my house), "A day is just a day. It isn't good or bad." We decide if it's good or bad.
What will you do with your new lungs today?
I was assigned to our reverse isolation pod where we put our heart and lung transplants. I was assigned two very sick transplants with complications, but across the pod was a fresh lung transplant from Friday. When I came on shift he was doing pressure support trials in preparation for extubation. He was pretty anxious--as most people intubated without sedation are--but even more so because he was a lung patient.
He passed his trials with flying colors and was quickly extubated. His family came in afterwards, thrilled to be able to talk to him. The family was bubbling over with happiness and enthusiasm, which is pretty typical of post transplant patients and families. They are just so thankful that their loved one has been granted a second chance afforded them by their new organs.
The patient was doing his best to match his family's mood, but it was pretty clear to me that he wasn't doing as well as he was making out. His wife kept asking him if he felt better, and he would agree that he did, managing a tentative smile for her.
He was a little more forthcoming with his nurse when the family wasn't present. He admitted to some pain and feeling somewhat short of breath. He also was pretty fatigued. Most of all he was just tired of being in a hospital bed with all the ridiculous lines and tubes we insist on attaching. And rightly so I think--we do tend to take things a little far with what we expect our patients to tolerate. He had come to our hospital from 750 miles away for the transplant consult, and it had taken 10 months to get where he was because of some other complications that needed to be resolved before he was a true candidate. Imagine being away from home temporarily...but for 10 months. Did I mention we don't have TV's in our open pods? In short, he was just cranky.
A couple hours later I overheard him ask his nurse how much of the surgery he would be awake for. I stopped what I was doing to look across the pod and listen in.
The nurse gave him a blank look and asked, "What surgery?"
A little annoyed, he shot back, "The one I've only been waiting 10 months for!?"
"Uh, you had your surgery on Friday, today is Sunday."
His turn to give a blank look.
She repeated, "You got your lungs on Friday, you've had your transplant already."
"No shit??" A slow smile spread across his face.
Thanks to the anesthesia the last thing he remembered was changing into a gown...
It's amazing to see the shift in his perspective and his mood based on that one small piece of information. Suddenly he was pleasant, jovial even. He was happy to see his family, even when they stayed to long, or asked him for the 50th time, "How do you feel? Are you better??"
So let me ask you, when you woke up this morning, did you face the day like it was gift? Like you had been blessed with a new set of lungs?
Or are you still waiting (for 10 months now!) for something good to happen?
If I may draw from the wisdom of Frog on the kids show Little Bear, (a favorite in my house), "A day is just a day. It isn't good or bad." We decide if it's good or bad.
What will you do with your new lungs today?
Saturday, October 15, 2011
You Might Be...
You might be a nurse if:
You start a vitals/medication flowsheet at home when a family member is ill...
You start a vitals/medication flowsheet at home when a family member is ill...
Friday, October 14, 2011
Pay Day
My wife and had a financial meeting this morning, as we often do on the morning after our paychecks get direct deposited into the checking account. Usually it's a quick assessment of what little we have to show for our hard work after the dust clears from the bills feeding frenzy.
Today was no different.
However, we did a quick check of our gross income to make sure that we were on track with our tithe amount for church. And that's when it hit me.
My gross pay for the year (with numerous extra shifts and overtime) was just over half of my wife's gross pay to date. Right at 55%. My wife doesn't often work extra shifts (although she has occasionally.)
Let me qualify this observation:
a.) She has been at her job for 9 years, I for less than 1 year.
b.) She works a contracted weekend plan that pays her an extra differential for working every weekend.
Ok, so she's had a significant head start, and she gets compensated for forking over our social life essentially.
But twice as much? Really??
She works for a nationally recognized non-profit children's hospital. It is a large hospital--over 300 beds, and expanding even as we speak. It is a designated trauma center. She works on a critical care unit at the highest level of care provided by the hospital to its patients.
I work for a nationally recognized non-profit hospital. It is a large hospital--over 1000 beds, and expanding even as we speak. We are designated a Level 1 trauma center. I work on a critical care unit at the highest level of care provided by the hospital to its patients.
New grad nurses at her hospital make on average at least $10,000 more per year than new grads at my hospital.
My wife gets paid extra for working in critical care. I get paid the same as any other nurse in the hospital--day surgery to med-surg to L&D. We all get paid the same.
I recently remember working a weekend (extra diff), night (extra diff), holiday (time & a half), overtime (time & a half) shift. After adding up all my diffs and overtime, my hourly pay was only slightly more than my wife's base pay.
I don't mind that my wife makes more than me, at least not consciously. In fact I'm quite thankful as her job is the only way we've survived financially through my job failures and extra degrees. But when I think about how hard I work and the razor edge I routinely walk with my patient's lives and my license, it is a little disheartening to see the disparity. I don't think my wife works any less hard than I do, but I don't think she works any harder either.
Because of my past degrees, I have a crippling amount of student loan debt. Two of my three loan payments were more than this 2 weeks paycheck, and the third loan payment will be another 1/3 of my next paycheck. Lucky for me, the end of those payments is in sight--only 29 1/2 years from now.
I guess like many, I'm lucky to have a spouse willing to lump her paychecks into the joint checking account to provide for her family.
So sweetie, "Thank you," for paying my car payment this month, and my insurance, groceries, and fuel. Oh and "Thanks" for providing me a place to live.
I'll do my best to repay you when I get my earning potential soul back from the student loan companies.
Either that or when my life insurance comes through.
Today was no different.
However, we did a quick check of our gross income to make sure that we were on track with our tithe amount for church. And that's when it hit me.
My gross pay for the year (with numerous extra shifts and overtime) was just over half of my wife's gross pay to date. Right at 55%. My wife doesn't often work extra shifts (although she has occasionally.)
Let me qualify this observation:
a.) She has been at her job for 9 years, I for less than 1 year.
b.) She works a contracted weekend plan that pays her an extra differential for working every weekend.
Ok, so she's had a significant head start, and she gets compensated for forking over our social life essentially.
But twice as much? Really??
She works for a nationally recognized non-profit children's hospital. It is a large hospital--over 300 beds, and expanding even as we speak. It is a designated trauma center. She works on a critical care unit at the highest level of care provided by the hospital to its patients.
I work for a nationally recognized non-profit hospital. It is a large hospital--over 1000 beds, and expanding even as we speak. We are designated a Level 1 trauma center. I work on a critical care unit at the highest level of care provided by the hospital to its patients.
New grad nurses at her hospital make on average at least $10,000 more per year than new grads at my hospital.
My wife gets paid extra for working in critical care. I get paid the same as any other nurse in the hospital--day surgery to med-surg to L&D. We all get paid the same.
I recently remember working a weekend (extra diff), night (extra diff), holiday (time & a half), overtime (time & a half) shift. After adding up all my diffs and overtime, my hourly pay was only slightly more than my wife's base pay.
I don't mind that my wife makes more than me, at least not consciously. In fact I'm quite thankful as her job is the only way we've survived financially through my job failures and extra degrees. But when I think about how hard I work and the razor edge I routinely walk with my patient's lives and my license, it is a little disheartening to see the disparity. I don't think my wife works any less hard than I do, but I don't think she works any harder either.
Because of my past degrees, I have a crippling amount of student loan debt. Two of my three loan payments were more than this 2 weeks paycheck, and the third loan payment will be another 1/3 of my next paycheck. Lucky for me, the end of those payments is in sight--only 29 1/2 years from now.
I guess like many, I'm lucky to have a spouse willing to lump her paychecks into the joint checking account to provide for her family.
So sweetie, "Thank you," for paying my car payment this month, and my insurance, groceries, and fuel. Oh and "Thanks" for providing me a place to live.
I'll do my best to repay you when I get my earning potential soul back from the student loan companies.
Either that or when my life insurance comes through.
Wednesday, October 12, 2011
If It Isn't Charted...It Never...
...happened.
I generally regale you, my faithful readers, with stories of my wild successes. Usually I play the distinguished (if not a little crusty) hero with some great over-arching theme to impart upon the nursing masses.
Not today.
Today I was called into the office for a closed door conference with the unit educator and the unit manager. The door closing behind you is pretty much a fateful sign. You're not escaping without some pound of flesh taken in payment.
All this over a shift that was an ass-kicking from the start. Two very sick patients--one in severe septic shock, and the other most likely in the same situation. One was on hemodialysis, the other on CVVHD. A handful in and of itself, but across the pod lay a 180 kg woman who was to be taken for a CABG. Only the night shift nurse had pulled the PCI sheath, held pressure for 4 minutes flat, determined the patient wasn't bleeding externally from the site, and called it a day. It wasn't much later that the patient developed a football sized hematoma. That grew to be basketball sized while her pressures cratered from the shock of it all. Not hard to do when your ejection fraction is <15%.
Meanwhile that patient's nurse was chasing herself silly trying to get her other patient transferred to the floor because the first case of the day needed to go into that bed for staffing reasons. As in, we didn't have staff to take that case. When she left to transfer her patient, I was tasked with watching her other patient's hematoma grow.
I was left to doppler distal pulses and set up a C-clamp to hold pressure on the femoral artery to prevent the hematoma from growing any bigger. All the while maintaining some semblance of hemodynamic stability. I had just turned the patient's levophed up to our unit's max dose to maintain a pressure in the 60s (nothing like squeezing a dry tank, right!?!) when my patient on hemodialysis bottomed her pressures in response to the fluid draw. So away I went to titrate some pressors to maintain a MAP above the renal injury threshold. Just as I was about to get her settled, my CVVHD patient clotted her filter. And it was while I was attempting to rinse back the 200+ mls of blood in the machine that the anesthesiologist and anesthesia tech appeared to take hematoma lady to the OR.
It was a dangerous situation. Did I mention my charge nurse was off the floor kissing Joint Commission ass with the manager--we were being recertified for LVADs you see.
I had no help.
I spent the rest of the shift trying to catch up on my charting while taking care of two still very sick patients. Towards the end of the shift one of my patients began breathing at a rate greater than 50. She was intubated, but not sedated, and pressure support CPAP-ing. (Recipe for disaster really since we were not about to extubate her...)
My calls to physician essentially fell on deaf ears. I received orders to increase the pressure support, but nothing else. I complied, and at shift change the patient wasn't doing much better.
In my rush to get home to take over care of my children from the babysitter, I neglected to chart my communications with the physician. (And somehow went an entire shift without charting vent settings!? Facepalm! WTF??)
And the night shift nurse took exception to the hot mess I handed her and promptly tossed me under the bus.
Fade to employee conference. I sat in my seat while my manager and educator talked down to me, asked me loaded questions in the most condescending tone they could muster, and basically held my nuts to fire...
Because I screwed up and didn't document.
So in the meantime, I've been banished to "the garden" to take care of chronic patients.
There are so many things wrong with the way I was treated that even now I get tears of frustration thinking about it.
BUT.
Kids, remember this.
If it isn't charted.
It. Never. Happened.
I generally regale you, my faithful readers, with stories of my wild successes. Usually I play the distinguished (if not a little crusty) hero with some great over-arching theme to impart upon the nursing masses.
Not today.
Today I was called into the office for a closed door conference with the unit educator and the unit manager. The door closing behind you is pretty much a fateful sign. You're not escaping without some pound of flesh taken in payment.
All this over a shift that was an ass-kicking from the start. Two very sick patients--one in severe septic shock, and the other most likely in the same situation. One was on hemodialysis, the other on CVVHD. A handful in and of itself, but across the pod lay a 180 kg woman who was to be taken for a CABG. Only the night shift nurse had pulled the PCI sheath, held pressure for 4 minutes flat, determined the patient wasn't bleeding externally from the site, and called it a day. It wasn't much later that the patient developed a football sized hematoma. That grew to be basketball sized while her pressures cratered from the shock of it all. Not hard to do when your ejection fraction is <15%.
Meanwhile that patient's nurse was chasing herself silly trying to get her other patient transferred to the floor because the first case of the day needed to go into that bed for staffing reasons. As in, we didn't have staff to take that case. When she left to transfer her patient, I was tasked with watching her other patient's hematoma grow.
I was left to doppler distal pulses and set up a C-clamp to hold pressure on the femoral artery to prevent the hematoma from growing any bigger. All the while maintaining some semblance of hemodynamic stability. I had just turned the patient's levophed up to our unit's max dose to maintain a pressure in the 60s (nothing like squeezing a dry tank, right!?!) when my patient on hemodialysis bottomed her pressures in response to the fluid draw. So away I went to titrate some pressors to maintain a MAP above the renal injury threshold. Just as I was about to get her settled, my CVVHD patient clotted her filter. And it was while I was attempting to rinse back the 200+ mls of blood in the machine that the anesthesiologist and anesthesia tech appeared to take hematoma lady to the OR.
It was a dangerous situation. Did I mention my charge nurse was off the floor kissing Joint Commission ass with the manager--we were being recertified for LVADs you see.
I had no help.
I spent the rest of the shift trying to catch up on my charting while taking care of two still very sick patients. Towards the end of the shift one of my patients began breathing at a rate greater than 50. She was intubated, but not sedated, and pressure support CPAP-ing. (Recipe for disaster really since we were not about to extubate her...)
My calls to physician essentially fell on deaf ears. I received orders to increase the pressure support, but nothing else. I complied, and at shift change the patient wasn't doing much better.
In my rush to get home to take over care of my children from the babysitter, I neglected to chart my communications with the physician. (And somehow went an entire shift without charting vent settings!? Facepalm! WTF??)
And the night shift nurse took exception to the hot mess I handed her and promptly tossed me under the bus.
Fade to employee conference. I sat in my seat while my manager and educator talked down to me, asked me loaded questions in the most condescending tone they could muster, and basically held my nuts to fire...
Because I screwed up and didn't document.
So in the meantime, I've been banished to "the garden" to take care of chronic patients.
There are so many things wrong with the way I was treated that even now I get tears of frustration thinking about it.
BUT.
Kids, remember this.
If it isn't charted.
It. Never. Happened.
Wednesday, August 3, 2011
Friday, July 29, 2011
You Might Be...
You might be an ICU nurse if:
Your measurement of time is "minutes until it's time to write vitals."
Your measurement of time is "minutes until it's time to write vitals."
Tuesday, July 26, 2011
I Just Don't Know
Lately I've been contemplating the direction I'd like to take this blog.
The longer this space exists, the chances of my true identity being unmasked grows, possibly exponentially. When I started this iteration of my blog, I had no idea that it would grow to be even as mildly popular as it has. I wasn't clear sighted enough to plan for that from the start. As a result this "anonymous" blog is hopelessly entangled with my "real" life.
For instance, the master email Blogger associates with this account happens to be my gmail account that I use for *everything*. Not a big deal because that email address isn't used anywhere except for me to sign in. Nicely compartmentalized I thought. Only when somebody sends me a Google+ invite, suddenly my Picasa account (with all my blog pictures) will be linked to my uber-Facebook experience. And suddenly my real name will be substituted where my nicely anonymous username had reigned. Blast it.
I can't say that it isn't tempting to exit the proverbial blogging closet, and just become a real person in both senses. But that would pretty much preclude any patient stories no matter how fabricated. And frankly, do I have enough important things to say regarding nursing that people will continue to visit without the sensationalism of my patient encounters?
Am I ready to give up the sanctity of my virtual repository to unload and get things off my chest?
I just don't know.
At some point I'd like to transition my writing to more mainstream outlets. Does an anonymous body of work allow for that?
"I'd send you examples of my writing...except I can't...you know patient privacy and all. I write real good though. I swear."
I just don't know.
The longer this space exists, the chances of my true identity being unmasked grows, possibly exponentially. When I started this iteration of my blog, I had no idea that it would grow to be even as mildly popular as it has. I wasn't clear sighted enough to plan for that from the start. As a result this "anonymous" blog is hopelessly entangled with my "real" life.
For instance, the master email Blogger associates with this account happens to be my gmail account that I use for *everything*. Not a big deal because that email address isn't used anywhere except for me to sign in. Nicely compartmentalized I thought. Only when somebody sends me a Google+ invite, suddenly my Picasa account (with all my blog pictures) will be linked to my uber-Facebook experience. And suddenly my real name will be substituted where my nicely anonymous username had reigned. Blast it.
I can't say that it isn't tempting to exit the proverbial blogging closet, and just become a real person in both senses. But that would pretty much preclude any patient stories no matter how fabricated. And frankly, do I have enough important things to say regarding nursing that people will continue to visit without the sensationalism of my patient encounters?
Am I ready to give up the sanctity of my virtual repository to unload and get things off my chest?
I just don't know.
At some point I'd like to transition my writing to more mainstream outlets. Does an anonymous body of work allow for that?
"I'd send you examples of my writing...except I can't...you know patient privacy and all. I write real good though. I swear."
I just don't know.
Sunday, July 24, 2011
A Different Kind Of Crazy
Amongst my least favorite patients to care for are those that have lost their noodle. Be it dementia, ICU psychosis, mental illness, it just wears me out having to deal with them.
I like logic. I like things to be orderly. I like it when people have been educated, and the information leads them to draw the conclusions I intend.
Crazy people don't do that. And that cuts across the grain of everything that makes my purplish haze of a world tolerable.
But I ran across a new kind of crazy this week at work.
This lady, (let's call her Eleanor), was 100% with it. She was completely lucid, she truly was that ever elusive A&Ox4. This is quite an achievement considering she'd come in for a valve replacement over a month ago and ended up with a CABGx5 and a balloon pump. Following her surgery, she rode our carepath upstairs only to come crashing back down as an RRT in respiratory stress.
It seems that the yahoo techs on our stepdown floor *still* cannot get it through their thick skulls that if a patient drinks too much water, with all the fluid shifts from being on pump, the patients drink themselves straight into pulmonary edema. Not to mention the atropine given pre-anesthesia makes *everyone* wickedly thirsty, for *days*. So when the techs get tired of answering call bells about drinks of water, they sure as heck will bring the patient a big huge pitcher of water and let them drink themselves into a gurglely, pink frothy mess.
So it was with Eleanor.
And she ended up re-intubated. Then extubated. Then re-intubated, and extubated yet again. If you've played this game before, you know that each subsequent re-intubation significantly reduces the chances of a favorable outcome. Counting her surgery, Eleanor is working on post-extubation #3. Even now after spending 8 hours each night on BiPAP, her PCO2 is routinely greater than 65 each morning.
She's also failed her swallow study 3 times now.
All this to say that Eleanor is *strictly* NPO.
She knows this.
And she knows why.
And she knows the consequences of noncompliance.
But this does not stop her from asking, begging, pleading, groveling for a drink of water as many times an hour as you are willing to entertain. She actively tries to deceive anyone who comes near her bed and trick them into giving her water. She tries to split staff and family members and play them off one another to manipulate them into giving her water.
Honestly I've been around better behaved toddlers. (Two of which happen to live with me.)
Really I'm at a loss to adequately convey the sheer, colossal, unbelievable stupidity of it all.
I performed impeccable oral care hourly to maintain her oral mucosa. But my reward for this above and beyond (unit policy and procedure is Q4)? Each swab is met with a greedy demand, "MORE!!" Upon refusal, she throws anything within reach on the floor in protest. Pillows. Blankets. Her Bairhugger nozzle. You wouldn't believe how low my bullshit tolerance for this kind of shenanigans is.
Maybe a better, more saintly nurse would have had the patience to deal with these outbursts. Me, with my curmudgeonly tendencies, simply didn't give the items back to her the second time they ended up on the floor. When she started immediately sucking the water out of each swab (nearly aspirating on that small amount of water each time) rather than letting me wet her mucosa, I promptly switched to using chlorhexidine gluconate instead. Funny, she was much less enthusiastic about her oral care after that.
On my second night taking care of her my frustration came to a head. My other patient, a fresh pericardial window was starting to act pretty sick. He was bradying down into the low 40s, and I had no pacing access other than transcutaneous pads on the crash cart. His pressure was dropping from 160's systolic on 5 mcg/kg/min of nipride, to a systolic of 90-100 with the nipride on standby.
In the middle of this, Eleanor started demanding water. Yelling, cussing, cajoling. Saying idiotic things like, "Just pour it on top of me, I don't even have to drink it. Just pour it all over me." When nobody was paying attention to her, and there were several of us in the room because of my other patient, she ripped her BiPAP mask off and threw it across the room.
I'd had enough, and as I was putting her mask back on, I kind of lost it on her.
"You need to *stop* this. You are a *grown woman*, you need to start acting like it. You are embarrassing yourself and your family by the way you are acting. My other patient is extremely sick right now, and instead of being able to help him like I should, I'm here, dealing with this foolishness."
In a poetic cinematic world, she would have realized how silly she was being, become remarkably compliant, if not apologetic. Then she would have written letter to the administration about the incredible life-saving care she received, highlighting each of the nurses she had.
In the real world, she pulled off the biggest 2-year-old pouty-lip I've ever seen.
But at least she was quiet.
I like logic. I like things to be orderly. I like it when people have been educated, and the information leads them to draw the conclusions I intend.
Crazy people don't do that. And that cuts across the grain of everything that makes my purplish haze of a world tolerable.
But I ran across a new kind of crazy this week at work.
This lady, (let's call her Eleanor), was 100% with it. She was completely lucid, she truly was that ever elusive A&Ox4. This is quite an achievement considering she'd come in for a valve replacement over a month ago and ended up with a CABGx5 and a balloon pump. Following her surgery, she rode our carepath upstairs only to come crashing back down as an RRT in respiratory stress.
It seems that the yahoo techs on our stepdown floor *still* cannot get it through their thick skulls that if a patient drinks too much water, with all the fluid shifts from being on pump, the patients drink themselves straight into pulmonary edema. Not to mention the atropine given pre-anesthesia makes *everyone* wickedly thirsty, for *days*. So when the techs get tired of answering call bells about drinks of water, they sure as heck will bring the patient a big huge pitcher of water and let them drink themselves into a gurglely, pink frothy mess.
So it was with Eleanor.
And she ended up re-intubated. Then extubated. Then re-intubated, and extubated yet again. If you've played this game before, you know that each subsequent re-intubation significantly reduces the chances of a favorable outcome. Counting her surgery, Eleanor is working on post-extubation #3. Even now after spending 8 hours each night on BiPAP, her PCO2 is routinely greater than 65 each morning.
She's also failed her swallow study 3 times now.
All this to say that Eleanor is *strictly* NPO.
She knows this.
And she knows why.
And she knows the consequences of noncompliance.
But this does not stop her from asking, begging, pleading, groveling for a drink of water as many times an hour as you are willing to entertain. She actively tries to deceive anyone who comes near her bed and trick them into giving her water. She tries to split staff and family members and play them off one another to manipulate them into giving her water.
Honestly I've been around better behaved toddlers. (Two of which happen to live with me.)
Really I'm at a loss to adequately convey the sheer, colossal, unbelievable stupidity of it all.
I performed impeccable oral care hourly to maintain her oral mucosa. But my reward for this above and beyond (unit policy and procedure is Q4)? Each swab is met with a greedy demand, "MORE!!" Upon refusal, she throws anything within reach on the floor in protest. Pillows. Blankets. Her Bairhugger nozzle. You wouldn't believe how low my bullshit tolerance for this kind of shenanigans is.
Maybe a better, more saintly nurse would have had the patience to deal with these outbursts. Me, with my curmudgeonly tendencies, simply didn't give the items back to her the second time they ended up on the floor. When she started immediately sucking the water out of each swab (nearly aspirating on that small amount of water each time) rather than letting me wet her mucosa, I promptly switched to using chlorhexidine gluconate instead. Funny, she was much less enthusiastic about her oral care after that.
On my second night taking care of her my frustration came to a head. My other patient, a fresh pericardial window was starting to act pretty sick. He was bradying down into the low 40s, and I had no pacing access other than transcutaneous pads on the crash cart. His pressure was dropping from 160's systolic on 5 mcg/kg/min of nipride, to a systolic of 90-100 with the nipride on standby.
In the middle of this, Eleanor started demanding water. Yelling, cussing, cajoling. Saying idiotic things like, "Just pour it on top of me, I don't even have to drink it. Just pour it all over me." When nobody was paying attention to her, and there were several of us in the room because of my other patient, she ripped her BiPAP mask off and threw it across the room.
I'd had enough, and as I was putting her mask back on, I kind of lost it on her.
"You need to *stop* this. You are a *grown woman*, you need to start acting like it. You are embarrassing yourself and your family by the way you are acting. My other patient is extremely sick right now, and instead of being able to help him like I should, I'm here, dealing with this foolishness."
In a poetic cinematic world, she would have realized how silly she was being, become remarkably compliant, if not apologetic. Then she would have written letter to the administration about the incredible life-saving care she received, highlighting each of the nurses she had.
In the real world, she pulled off the biggest 2-year-old pouty-lip I've ever seen.
But at least she was quiet.
Friday, July 22, 2011
You Might Be...
You might be a nurse if:
Before taking ibuprofen for body aches or headache, you automatically try to code the barcode for documentation...
Before taking ibuprofen for body aches or headache, you automatically try to code the barcode for documentation...
Thursday, July 21, 2011
25 Best
It seems nurseXY has been selected as among the 25 best nursing blogs by David Gurevich over at QI Exam Prep.
Pretty heady company he's put me in with, I'm not sure I quite belong. However, I appreciate the recognition.
Thanks David!
Wednesday, July 20, 2011
P. R. N-competence.
So I started working PRN at the ICU where I did my externship. I'll be working 4 shifts a month, which works out to one a week, but it's nice in that I don't have to work them that way, I can clump them if I like.
It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.
One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.
This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.
The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.
Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.
So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!
It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.
One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.
This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.
The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.
Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.
So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!
Monday, July 18, 2011
You Might Be...
You might be a nurse if:
When using the restroom you automatically reach for gloves before wiping...
When using the restroom you automatically reach for gloves before wiping...
Thursday, July 7, 2011
Up In The Air
Life is up in the air right now.
I have no real focus, and I'm really unsure what direction to proceed.
My original plan was painfully simple. Go to nursing school. (Check.) Graduate and get a job on the biggest, baddest ICU around. (Check.) In two or three years apply for CRNA school and get on with life. (.....)
Muddying circumstance #1:
This lovely president of ours, Obama, enacted legislation that dictates those that make 10 years of payments on their federal student loans while working in a public service capacity, will have the remaining balance of their federal student loans forgiven. RN's definitely qualify as long as they work for a not-for-profit organization, which I currently do. Interesting tidbit: Nurse Practitioner's qualify, CRNA's do not. After doing the math, this loan forgiveness could total as much as $200,000 in my case... Market analysis of compensation for NPs shows that the gap between CRNAs and NPs is starting to narrow. In short NPs may soon be making the kind of salary reserved previously for CRNAs.
Now consider that the cost of the CRNA schools in my metro area both top $75,000, while NP school falls under the category of regular graduate school. CRNA students are prohibited from working during school (in fact both schools here will kick you out of the program, no questions asked, if they catch you working.) NP students at local schools do not have any such restrictions. And here's the kicker--the tuition reimbursement program at my current hospital *almost* covers the tuition for graduate school. They also have a TDA (Two Day Alternative) program where employees work Saturday-Sunday every week--two shifts, but keep full time status and benefits, and earn an extra differential that approximates working three shifts instead of two--that would allow me to go to school full time during the week.
The nursing school I graduated from has an Acute Care Nurse Practitioner program...
Thinks that make you go hmmm.
Muddying circumstance #2:
My wife and I have been fortunate enough to have her younger sister living with us to watch our kids while both of us work night shift. This allows us to work as many shifts together as possible, allowing us to have days off together. However, that situation will be changing. I'll spare you all the drama and gnashing of teeth, but rest assured it hasn't been a pleasant situation with frustrations ranging from not being available when we were counting on her, to wondering about our kids safety while in her care.
The nice thing about working as nurses is that we only work 3 days a week, so it *can* be done not needing childcare at all. But that means that we will only have one day a week off together, and really because of the logistics of night shift, it means that we'll have two half days off rather than a full day.
We are exploring options that include me moving to day shift to cut down on the daycare needs, but that also requires me transferring to another hospital within the system since my wife and I work on opposite ends of the city currently. And that means leaving my beloved CVICU...
Muddying circumstance #3:
I have been dying to get out of this town since I got here (state, really). The summer heat/humidity kills me. I crave seasons. I crave snow. I crave being able to spend time outdoors without melting into a puddle on the blistering concrete or triple digit asphalt.
I began researching grad schools in other parts of the country, and have been very, very attracted to Duke. I love the idea of a big name school. I love that the hospital is next door to the school. I love that the hospital has a program for employees that pays up to 90% of your schooling in exchange for contract on graduation... I love the idea of North Carolina, where the average high temperature in the summer tops out in the low 90s... I love that North Carolina is a Nurse Licensure Compact state... I love that Duke has one of the few Pediatric Acute Care Nurse Practitioner programs in the country...
Aauugggh! My brain hurts!
I have no real focus, and I'm really unsure what direction to proceed.
My original plan was painfully simple. Go to nursing school. (Check.) Graduate and get a job on the biggest, baddest ICU around. (Check.) In two or three years apply for CRNA school and get on with life. (.....)
Muddying circumstance #1:
This lovely president of ours, Obama, enacted legislation that dictates those that make 10 years of payments on their federal student loans while working in a public service capacity, will have the remaining balance of their federal student loans forgiven. RN's definitely qualify as long as they work for a not-for-profit organization, which I currently do. Interesting tidbit: Nurse Practitioner's qualify, CRNA's do not. After doing the math, this loan forgiveness could total as much as $200,000 in my case... Market analysis of compensation for NPs shows that the gap between CRNAs and NPs is starting to narrow. In short NPs may soon be making the kind of salary reserved previously for CRNAs.
Now consider that the cost of the CRNA schools in my metro area both top $75,000, while NP school falls under the category of regular graduate school. CRNA students are prohibited from working during school (in fact both schools here will kick you out of the program, no questions asked, if they catch you working.) NP students at local schools do not have any such restrictions. And here's the kicker--the tuition reimbursement program at my current hospital *almost* covers the tuition for graduate school. They also have a TDA (Two Day Alternative) program where employees work Saturday-Sunday every week--two shifts, but keep full time status and benefits, and earn an extra differential that approximates working three shifts instead of two--that would allow me to go to school full time during the week.
The nursing school I graduated from has an Acute Care Nurse Practitioner program...
Thinks that make you go hmmm.
Muddying circumstance #2:
My wife and I have been fortunate enough to have her younger sister living with us to watch our kids while both of us work night shift. This allows us to work as many shifts together as possible, allowing us to have days off together. However, that situation will be changing. I'll spare you all the drama and gnashing of teeth, but rest assured it hasn't been a pleasant situation with frustrations ranging from not being available when we were counting on her, to wondering about our kids safety while in her care.
The nice thing about working as nurses is that we only work 3 days a week, so it *can* be done not needing childcare at all. But that means that we will only have one day a week off together, and really because of the logistics of night shift, it means that we'll have two half days off rather than a full day.
We are exploring options that include me moving to day shift to cut down on the daycare needs, but that also requires me transferring to another hospital within the system since my wife and I work on opposite ends of the city currently. And that means leaving my beloved CVICU...
Muddying circumstance #3:
I have been dying to get out of this town since I got here (state, really). The summer heat/humidity kills me. I crave seasons. I crave snow. I crave being able to spend time outdoors without melting into a puddle on the blistering concrete or triple digit asphalt.
I began researching grad schools in other parts of the country, and have been very, very attracted to Duke. I love the idea of a big name school. I love that the hospital is next door to the school. I love that the hospital has a program for employees that pays up to 90% of your schooling in exchange for contract on graduation... I love the idea of North Carolina, where the average high temperature in the summer tops out in the low 90s... I love that North Carolina is a Nurse Licensure Compact state... I love that Duke has one of the few Pediatric Acute Care Nurse Practitioner programs in the country...
Aauugggh! My brain hurts!
Tuesday, June 28, 2011
By Faith, Not By Sight
A large man by anyone's standard, he was much more than overweight. He was tall and heavily framed, with a broad face and meaty hands. Still though, he carried probably close to 75 lbs extra with him wherever he wandered. By all accounts this mountain of a man was immovable, unconquerable, invincible.
That is, until he went to the dentist.
It was a simple extraction, nothing so involved as a root canal or other oral surgery. And it took no more than 15 minutes from needlestick to lollipop unwrapped from the cheery mug on the counter, meant to soften the blow of paying for often painful services at the payment window.
Even as he lumbered out the door, pausing to hold it open for a harried mother with three small children in tow, he had no idea.
He had no idea he was already dead.
A few weeks later, he had been ill for more than a week. He passed it off as being fatigued from the busy season at work, but his wife knew better. That was his way though, shrugging off illness like a bull swatting a horde of biting flies with his tail. But when he began talking out of his head, making incomprehensible requests and becoming severely agitated when she couldn't make heads or tails of it at all, she ran for her cell phone to call 911. Likely that saved her from injury as well, for as soon as she left he had gathered himself unsteadily to his feet and promptly collapsed onto the oak and stained glass coffee table, flattening it and sending shattered leaded glass whistling through the air like so many pieces of brightly colored shrapnel.
Arrival at the ED found him in dire straights indeed. The 12 lead EKG in the ambulance on the way in showed massive ST elevation, but his clear stroke-like symptoms described by his wife were also particularly troubling. The monitors barely registered a blood pressure. The impressive array of superficial cuts from the coffee table that seeped and oozed blood were by far and away the most visible sign of trouble, but were the least concerning. At least until the removal of the particularly large fragment in the middle of his chest began bubbling black purulent blood like black gold oil flowing out of the ground in West Texas.
The final tally of CT's and other tests read like a cheap Saturday night horror flick. An abscess in the sternum had carved out its own living quarters, eroding into the aortic arch and front face of the heart. This did little more than expose the massive biological vegetation growing throughout both ventricles and atria.
Clearly a large fragment of this vegetation is what caused the massive stroke that strangled the life from half of the cerebellum, and most of the occipital, temporal, and frontal lobes on the left side of the brain. Unmercifully the mid brain and brainstem were spared, allowing bodily function to continue. And just to make life interesting, he was in massive septic shock, which had taken out most of his gut and kidneys.
A semi truck would have caused less damage.
And that's how I met him--recovering him from the 16 hour surgery to replace his aortic arch and bypass the 5 coronary artery blockages, and to reconstruct as much of his mediastinum as possible. He was on the ventilator, IABP, CVVHD. He was maxed on 4 different pressors, barely maintaining a MAP greater than 50. Chest tubes sprouted from every possible sector of his chest, draining foul black sludge from his tortured body. His urine, less than 20 mls of it per 12 hour shift, was black as well.
No other hospital in our area would have done this operation.
And through it all his beautiful family persevered. Stealing 5 minutes at a time during lulls of activity to pray over him, and gracefully stepping back to allow us to continue our care. Remaining sweet and grateful, thanking each nurse, each physician for caring for him as they left his bedside. Speaking words of encouragement to the other three patients and their families in the pod (none of which nearly as ill as their own loved one). Undeniable, unbridled, impossible faith.
I found myself in a moral dilemma. Every ounce of my medical knowledge told me that this man would not, could not survive. This knowledge demands of my ethical standards to keep my patient's family informed, albeit with caring and sensitivity, but a *realistic* picture. I simply could not live with myself if I created a false sense of hope for someone.
But this family's faith is contagious. Do I dare hope against glimmer of hope that a miracle happens? Is it my duty to battle this unrealistic shred of sanguineness?
I carefully, lovingly even, kept the family up to date regarding his condition. I could tell they were firmly grounded. They knew and understood the severity of his condition.
After one such update to his wife, I found myself apologizing to her for not being able to fix him for her.
Resting her hand momentarily on my arm, her tired eyes sought mine and smiled a quiet, knowing smile.
"Right now," she said, "We're walking by faith, not by sight."
That is, until he went to the dentist.
It was a simple extraction, nothing so involved as a root canal or other oral surgery. And it took no more than 15 minutes from needlestick to lollipop unwrapped from the cheery mug on the counter, meant to soften the blow of paying for often painful services at the payment window.
Even as he lumbered out the door, pausing to hold it open for a harried mother with three small children in tow, he had no idea.
He had no idea he was already dead.
A few weeks later, he had been ill for more than a week. He passed it off as being fatigued from the busy season at work, but his wife knew better. That was his way though, shrugging off illness like a bull swatting a horde of biting flies with his tail. But when he began talking out of his head, making incomprehensible requests and becoming severely agitated when she couldn't make heads or tails of it at all, she ran for her cell phone to call 911. Likely that saved her from injury as well, for as soon as she left he had gathered himself unsteadily to his feet and promptly collapsed onto the oak and stained glass coffee table, flattening it and sending shattered leaded glass whistling through the air like so many pieces of brightly colored shrapnel.
Arrival at the ED found him in dire straights indeed. The 12 lead EKG in the ambulance on the way in showed massive ST elevation, but his clear stroke-like symptoms described by his wife were also particularly troubling. The monitors barely registered a blood pressure. The impressive array of superficial cuts from the coffee table that seeped and oozed blood were by far and away the most visible sign of trouble, but were the least concerning. At least until the removal of the particularly large fragment in the middle of his chest began bubbling black purulent blood like black gold oil flowing out of the ground in West Texas.
The final tally of CT's and other tests read like a cheap Saturday night horror flick. An abscess in the sternum had carved out its own living quarters, eroding into the aortic arch and front face of the heart. This did little more than expose the massive biological vegetation growing throughout both ventricles and atria.
Clearly a large fragment of this vegetation is what caused the massive stroke that strangled the life from half of the cerebellum, and most of the occipital, temporal, and frontal lobes on the left side of the brain. Unmercifully the mid brain and brainstem were spared, allowing bodily function to continue. And just to make life interesting, he was in massive septic shock, which had taken out most of his gut and kidneys.
A semi truck would have caused less damage.
And that's how I met him--recovering him from the 16 hour surgery to replace his aortic arch and bypass the 5 coronary artery blockages, and to reconstruct as much of his mediastinum as possible. He was on the ventilator, IABP, CVVHD. He was maxed on 4 different pressors, barely maintaining a MAP greater than 50. Chest tubes sprouted from every possible sector of his chest, draining foul black sludge from his tortured body. His urine, less than 20 mls of it per 12 hour shift, was black as well.
No other hospital in our area would have done this operation.
And through it all his beautiful family persevered. Stealing 5 minutes at a time during lulls of activity to pray over him, and gracefully stepping back to allow us to continue our care. Remaining sweet and grateful, thanking each nurse, each physician for caring for him as they left his bedside. Speaking words of encouragement to the other three patients and their families in the pod (none of which nearly as ill as their own loved one). Undeniable, unbridled, impossible faith.
I found myself in a moral dilemma. Every ounce of my medical knowledge told me that this man would not, could not survive. This knowledge demands of my ethical standards to keep my patient's family informed, albeit with caring and sensitivity, but a *realistic* picture. I simply could not live with myself if I created a false sense of hope for someone.
But this family's faith is contagious. Do I dare hope against glimmer of hope that a miracle happens? Is it my duty to battle this unrealistic shred of sanguineness?
I carefully, lovingly even, kept the family up to date regarding his condition. I could tell they were firmly grounded. They knew and understood the severity of his condition.
After one such update to his wife, I found myself apologizing to her for not being able to fix him for her.
Resting her hand momentarily on my arm, her tired eyes sought mine and smiled a quiet, knowing smile.
"Right now," she said, "We're walking by faith, not by sight."
Wednesday, June 22, 2011
Re-Emergence
Perhaps it's just been a break to catch my breath. Perhaps memorializing everything in black & white electrons here on this blog meant I had to sort through and deal with everything that's been going on--which I just didn't want to do. Perhaps I've just been lazy.
I don't know.
But here I am, first post in nearly a month. I'm not sure where to begin, but I'll try.
In short, my depression came raging back, despite the SSRI I've been taking. I'm fairly certain it's probably because I just quit running cold turkey. My trip to the Grand Canyon (although a life altering experience) injured my knee making it very difficult to run without pain. Add the insane schedule of my internship, and the thought of a painful gym session was much less than appetizing. Or maybe depression just does that--returns without invitation to steal away joy for no reason at all, to just laugh its evil giggle while I foundered and gasped and struggled.
Regardless the reason, I slipped again into the deep, dark pit of loathing. My wife disengaged because it's easier to get wrapped up in kids and work than deal with an embittered bastard of a husband cloaked in the throes of desolation. My kids were driving me up the wall. Church ceased to salve my soul. My friends disappeared because I was always working or sleeping. Work sucked, but amazingly it just sucked the same amount and actually became relatively tolerable.
The breaking point came the night that I had an extremely vivid dream where I awakened in an unknown place. By the time I pieced things together I realized I had been committed to a mental health facility. As I lay there trying in vain to orient myself, mind befuddled in a medication hangover, my wife appeared in the doorway.
Cheerily she said, "Oh great! Look who's awake!"
My relief in seeing a friendly face was quickly replaced with abject horror over the realization she was there as an employee, not as a wife. She actually worked on the unit.
I was then accused of sleeping with my "hands under the blanket, again", with a knowing shake of the head. She left the room as I lay there trying to understand what that could possibly mean, why it was bad, and how I could prevent myself from putting my hands under the blanket while I slept...
I followed her from my room into the large common area to discover her sitting at a table with the other nurses, chattering away and laughing at some unheard story of levity.
The dream was wrong in so many ways, and couldn't happen in real life, but I cannot even begin to express the vividness of the dream or the feeling of betrayal...
Regardless it galvanized me to action, and I began taking double the dose of my SSRI, and now a couple weeks later, things seem to be smoothing out a bit. I'm not sure what I'm going to do when my 3 month supply is gone in a few weeks rather than a few months.
I need to return to exercising, but I'm finding it difficult to force myself.
Anyway, I'm back. Thanks for all the concern. I hope the next post won't be quite so long in the making.
I don't know.
But here I am, first post in nearly a month. I'm not sure where to begin, but I'll try.
In short, my depression came raging back, despite the SSRI I've been taking. I'm fairly certain it's probably because I just quit running cold turkey. My trip to the Grand Canyon (although a life altering experience) injured my knee making it very difficult to run without pain. Add the insane schedule of my internship, and the thought of a painful gym session was much less than appetizing. Or maybe depression just does that--returns without invitation to steal away joy for no reason at all, to just laugh its evil giggle while I foundered and gasped and struggled.
Regardless the reason, I slipped again into the deep, dark pit of loathing. My wife disengaged because it's easier to get wrapped up in kids and work than deal with an embittered bastard of a husband cloaked in the throes of desolation. My kids were driving me up the wall. Church ceased to salve my soul. My friends disappeared because I was always working or sleeping. Work sucked, but amazingly it just sucked the same amount and actually became relatively tolerable.
The breaking point came the night that I had an extremely vivid dream where I awakened in an unknown place. By the time I pieced things together I realized I had been committed to a mental health facility. As I lay there trying in vain to orient myself, mind befuddled in a medication hangover, my wife appeared in the doorway.
Cheerily she said, "Oh great! Look who's awake!"
My relief in seeing a friendly face was quickly replaced with abject horror over the realization she was there as an employee, not as a wife. She actually worked on the unit.
I was then accused of sleeping with my "hands under the blanket, again", with a knowing shake of the head. She left the room as I lay there trying to understand what that could possibly mean, why it was bad, and how I could prevent myself from putting my hands under the blanket while I slept...
I followed her from my room into the large common area to discover her sitting at a table with the other nurses, chattering away and laughing at some unheard story of levity.
The dream was wrong in so many ways, and couldn't happen in real life, but I cannot even begin to express the vividness of the dream or the feeling of betrayal...
Regardless it galvanized me to action, and I began taking double the dose of my SSRI, and now a couple weeks later, things seem to be smoothing out a bit. I'm not sure what I'm going to do when my 3 month supply is gone in a few weeks rather than a few months.
I need to return to exercising, but I'm finding it difficult to force myself.
Anyway, I'm back. Thanks for all the concern. I hope the next post won't be quite so long in the making.
Saturday, May 28, 2011
Missing In Action
I'm still here. I think.
Work has been mostly ok.
Everything else has been a little rough.
Work has been mostly ok.
Everything else has been a little rough.
Wednesday, May 4, 2011
Bathos
[bey-thos, -thaws, -thohs]–noun, 1.) a ludicrous descent from the exalted or lofty to the commonplace; anticlimax.
Throughout my internship I was often given the most difficult patients on the unit. And as I blossomed from a fragile seedling root-bound in a plastic sprouting tray to a plant hardy enough for transplant, my preceptors stepped further and further back, allowing me to manage my patients, my way, developing my practice. At the end I was virtually on my own as my preceptors often were called to fulfill other functions on the unit.
And I did well. I managed some truly tough assignments, and my patients were the better for my care. I admitted countless CABG's. And those turned into redo CABG's, or extremely sick CABG's. And then it was IABPs, and LVADs, and impellas, culminating with admitting heart transplants and double lung transplants. On my own.
My unit and my internship experience turned out to be everything it was advertised to be. I was excited when I came off orientation to be on my own, ready to save the world. Or at least whatever train-wreck heart surgery came out of the OR suite that day.
Our unit is very busy right now, and higher acuity patients than usual. Right now we have 2 double lungs, 2 heart transplants, 2 LVADs, and an impella. One of the heart transplants went on ECMO yesterday, and there is another heart transplant, and lung transplant scheduled for today. This is on top of the run of the mill CABGs. 21 beds, 21 patients.
With all this glorious acuity, for the past 3 nights I've been assigned...
**drumroll please**
A blind VAT with cancer, on the unit for 33 days because he has a creatinine of 7.5 while making copious urine, pneumonia that won't heal, and he can't hold his sats above 85% without a venti and nasal cannula.
And a recent stroke victim who had an AVR and came down with a serious case of pump-head. He's so unpleasantly confused he's pulled nearly every tube and line possible, while restrained. He's been on the unit for almost 3 weeks now.
And for the 3 weeks I've been off orientation? Exactly the same kind of patients, night after night.
Grind your soul into the asphalt slightly-too-sick-for-the-floor confused med-surg patients. EXACTLY the kind of patients I busted my ass to get hired into a high acuity unit to AVOID.
I get that I'm new. I do. I really, really do.
But come ON.
Throughout my internship I was often given the most difficult patients on the unit. And as I blossomed from a fragile seedling root-bound in a plastic sprouting tray to a plant hardy enough for transplant, my preceptors stepped further and further back, allowing me to manage my patients, my way, developing my practice. At the end I was virtually on my own as my preceptors often were called to fulfill other functions on the unit.
And I did well. I managed some truly tough assignments, and my patients were the better for my care. I admitted countless CABG's. And those turned into redo CABG's, or extremely sick CABG's. And then it was IABPs, and LVADs, and impellas, culminating with admitting heart transplants and double lung transplants. On my own.
My unit and my internship experience turned out to be everything it was advertised to be. I was excited when I came off orientation to be on my own, ready to save the world. Or at least whatever train-wreck heart surgery came out of the OR suite that day.
Our unit is very busy right now, and higher acuity patients than usual. Right now we have 2 double lungs, 2 heart transplants, 2 LVADs, and an impella. One of the heart transplants went on ECMO yesterday, and there is another heart transplant, and lung transplant scheduled for today. This is on top of the run of the mill CABGs. 21 beds, 21 patients.
With all this glorious acuity, for the past 3 nights I've been assigned...
**drumroll please**
A blind VAT with cancer, on the unit for 33 days because he has a creatinine of 7.5 while making copious urine, pneumonia that won't heal, and he can't hold his sats above 85% without a venti and nasal cannula.
And a recent stroke victim who had an AVR and came down with a serious case of pump-head. He's so unpleasantly confused he's pulled nearly every tube and line possible, while restrained. He's been on the unit for almost 3 weeks now.
And for the 3 weeks I've been off orientation? Exactly the same kind of patients, night after night.
Grind your soul into the asphalt slightly-too-sick-for-the-floor confused med-surg patients. EXACTLY the kind of patients I busted my ass to get hired into a high acuity unit to AVOID.
I get that I'm new. I do. I really, really do.
But come ON.
Friday, April 29, 2011
Ok, Ok, I Want To Be Popular...
...so please vote for me.
I got sucked in. Fibers.com is hosting a T-shirt design contest for Nurses Week. There are prizes, and of course in exchange, you fork over your intellectual property allowing them to market your T-shirt idea and profit from your creativity. But, it's kind of fun designing them and I highly doubt I'd get rich from the T-shirt business anyway.
Anyway, here's my designs, please go vote for me:
Vote for Nursing Poop Poseurs Here.
Vote for Nurses Saving Butts Here.
And one for the guys here:
Vote for RN-BSN-XY Here.
While you're there, design your own. It really is kind of fun.
I got sucked in. Fibers.com is hosting a T-shirt design contest for Nurses Week. There are prizes, and of course in exchange, you fork over your intellectual property allowing them to market your T-shirt idea and profit from your creativity. But, it's kind of fun designing them and I highly doubt I'd get rich from the T-shirt business anyway.
Anyway, here's my designs, please go vote for me:
Vote for Nursing Poop Poseurs Here.
Vote for Nurses Saving Butts Here.
And one for the guys here:
Vote for RN-BSN-XY Here.
While you're there, design your own. It really is kind of fun.
Brought To You By The Letter, "Oh $#1T!"
I learned something new last night.
You know what sounds like rain gently thrumming on the soft top of a Jeep?
Well, it turns out that blood spurting and spattering onto acoustic ceiling tiles makes almost exactly the same sound. Eerie really.
And that folks, is what happens when a patient pulls his IABP out of his femoral artery.
I learned something else last night too.
You know what sounds like a dropping a watermelon on concrete?
Well, it turns out that a fainting coworker's head smacking the floor sounds remarkably similar.
And that folks, is what happens when your pod partner faints when she sees blood spurting from her patients femoral artery after he pulls out his IABP.
Lucky for me I was already gloved up about to draw labs on one of my patients when I heard the aforementioned, very liquid sound followed closely by the monitor and IABP machine alarming. The other aforementioned sound rounded out the trio.
On a dead sprint to the other side of the room I managed to scatter the bucket of bed bath supplies for the sake of grabbing a towel, all the while yelling my head off for help.
The patient, all 6'5", 148kg of straight-up-pissed-off was thrashing around in the bed. He was intubated, and supposedly sedated on 60 mcg/kg/min of propofol (which is a 100 ml bottle every 90 minutes!). He apparently took exception to, well, hemostasis I guess.
I clamped the towel down on his fem site, then got control of his right wrist and pinned it to the bed. Next I stuck the elbow of my arm holding pressure deep into his quad and got him to straighten his leg. Lucky for me his other arm got tangled up in his vent circuit and I was able to should block his other knee or there's a good possibility I'd be wearing a black eye today, or worse.
By this time help was arriving, the crash cart got yanked open, the patient is in v-tach (as best we could tell), and was being restrained forcibly by 3 other people. The CRNA on call rolls in (their sleeping rooms are right outside our unit). He takes one look, calls for a vial of vecuronium and paralyzes the patient on the spot. The secretary is running for blood and a rapid infuser from the trauma ICU, there's a saline bolus running in wide open. Somebody shoots an index, it's like 0.9, but the dude somehow still has a pulse. His pressure is in the toilet, and although he converts out of v-tach with some epi, he still has ectopy all over the place. Someone was nice enough to set up a c-clamp because my arms are burning from holding that much pressure on the site (I may or may not have been trying to single handedly push his hip through the bed.)
Meanwhile a code purple has been called for my coworker and she gets C-collared and whisked off to CT on the way to the ED.
There was eleventy-billion people in the room, including family from the other 3 patients in the pod. They couldn't get out because there were so many people attending to the patient and my coworker. It was more chaotic than any code I've been to yet.
Surgeon arrives on unit, and he's pissed. He wants somebody's head on a platter, and since my co-worker cracked hers on the floor, I'm next in line. He literally wants someone fired. My night charge nurse steps up to the plate, and sets the surgeon straight--for which I'm truly, truly grateful.
"That nurse and his quick thinking is the very reason your patient is still alive!"
We did, in fact, get the patient stabilized. He's only slightly more sick than he was before the incident, and that is a very lucky thing. It could have easily been much worse.
I'm sure there will be all kinds of legal shenanigans and ass-covering in the days to come, but it was enough for one night.
In fact, I hope I never see that again!
You know what sounds like rain gently thrumming on the soft top of a Jeep?
Well, it turns out that blood spurting and spattering onto acoustic ceiling tiles makes almost exactly the same sound. Eerie really.
And that folks, is what happens when a patient pulls his IABP out of his femoral artery.
I learned something else last night too.
You know what sounds like a dropping a watermelon on concrete?
Well, it turns out that a fainting coworker's head smacking the floor sounds remarkably similar.
And that folks, is what happens when your pod partner faints when she sees blood spurting from her patients femoral artery after he pulls out his IABP.
Lucky for me I was already gloved up about to draw labs on one of my patients when I heard the aforementioned, very liquid sound followed closely by the monitor and IABP machine alarming. The other aforementioned sound rounded out the trio.
On a dead sprint to the other side of the room I managed to scatter the bucket of bed bath supplies for the sake of grabbing a towel, all the while yelling my head off for help.
The patient, all 6'5", 148kg of straight-up-pissed-off was thrashing around in the bed. He was intubated, and supposedly sedated on 60 mcg/kg/min of propofol (which is a 100 ml bottle every 90 minutes!). He apparently took exception to, well, hemostasis I guess.
I clamped the towel down on his fem site, then got control of his right wrist and pinned it to the bed. Next I stuck the elbow of my arm holding pressure deep into his quad and got him to straighten his leg. Lucky for me his other arm got tangled up in his vent circuit and I was able to should block his other knee or there's a good possibility I'd be wearing a black eye today, or worse.
By this time help was arriving, the crash cart got yanked open, the patient is in v-tach (as best we could tell), and was being restrained forcibly by 3 other people. The CRNA on call rolls in (their sleeping rooms are right outside our unit). He takes one look, calls for a vial of vecuronium and paralyzes the patient on the spot. The secretary is running for blood and a rapid infuser from the trauma ICU, there's a saline bolus running in wide open. Somebody shoots an index, it's like 0.9, but the dude somehow still has a pulse. His pressure is in the toilet, and although he converts out of v-tach with some epi, he still has ectopy all over the place. Someone was nice enough to set up a c-clamp because my arms are burning from holding that much pressure on the site (I may or may not have been trying to single handedly push his hip through the bed.)
Meanwhile a code purple has been called for my coworker and she gets C-collared and whisked off to CT on the way to the ED.
There was eleventy-billion people in the room, including family from the other 3 patients in the pod. They couldn't get out because there were so many people attending to the patient and my coworker. It was more chaotic than any code I've been to yet.
Surgeon arrives on unit, and he's pissed. He wants somebody's head on a platter, and since my co-worker cracked hers on the floor, I'm next in line. He literally wants someone fired. My night charge nurse steps up to the plate, and sets the surgeon straight--for which I'm truly, truly grateful.
"That nurse and his quick thinking is the very reason your patient is still alive!"
We did, in fact, get the patient stabilized. He's only slightly more sick than he was before the incident, and that is a very lucky thing. It could have easily been much worse.
I'm sure there will be all kinds of legal shenanigans and ass-covering in the days to come, but it was enough for one night.
In fact, I hope I never see that again!
Friday, April 22, 2011
The Honeymoon is Over
It was nice while it lasted, but the honeymoon is over. The true colors of my coworkers are starting to show through.Now that I'm no longer new enough for everyone to still be playing nice, all the personalities are starting to emerge. And on a unit like mine, you better believe there's some strong personalities.
To the nurse that found it necessary to inform the night supervisor I didn't get the SCDs on a patient until nearly shift change a few shifts ago, two things:
A.) I was at my other patient's bedside the vast majority of the night taking care of small things like, oh, keeping them alive.
B.) If you had time to keep track of when exactly I got the SCDs on the patient, couldn't you have helped me out and put them on yourself? You know, teamwork? Just sayin.
To my pod partner from last night:
I get that you're the top poodle on the nightshift now having reached the ripe old age of 3 years experience. I am also aware that our collective 4 patients were relatively stable, especially for our unit. However, you spending the entire night out of the pod at the nurses station yammering with your friends and cohorts meant that I was stuck in our pod all night caring for your patients and mine both. Not really that big of a deal, except that if I wanted to wear the soles of my shoes out running from bed to bed, I'd have gotten a med-surg job. And then having to help you get your patients primped and fluffed at 0600 in a frantic rush, while mine have been settled for hours? It should have been my turn to sit down.
To the dayshift nurse who told the night supervisor I didn't bathe my patient because I missed changing 1 of 6 dressings:
You suck. And you lie.
To the RT who didn't believe me when I told her a patient's ETT needed retaping:
I wasn't just playing about, and our patient really, really didn't need the exposure--or the jostling--of a stat portable chest X-ray to reconfirm ETT placement.
Oh, and to the unit in general:
I'm so very tired of hearing, "You have to be careful how you approach so and so about that."
Why can't I openly and clearly communicate my patient's needs to those responsible for assisting me in caring for them? I am so tired of having to slink up to various people from docs to support staff like a helpless, hapless junior high damsel in distress to get what my patient needs. Too many egos to stroke. I
And it's only been 3 1/2 months!!!
Friday, April 15, 2011
ICU Psycho
When I came in for my much heralded first solo shift it turned out I was assigned two patients that'd had floor orders since that morning, but no rooms available upstairs. So much for saving the world all on my own.
Pt #1 is a post-op day 1 CABG patient who, aside from being overtly particular, seems pretty chill. He's sitting up in the bedside chair, reading a book and just hanging out. I introduce myself, get report, grab vitals, and head off to meet patient #2.
Pt #2 is a post-op perf'd bowel resection. Brand new colostomy and ileostomy. The only reason he's on our unit at all is he's an old double lung transplant from 2007. He's the picture perfect double lung--10/10 anxiety, twitchy, constant guppy breathing--basically crawling the walls. He has a Dilaudid PCA and knows exactly when he got his last nurse bolus, and when the next one is due. And the last and next Ativan.
From the above brief description, can you pick which patient is going to be the troublemaker?
If you picked like I did, you'd be wrong.
I get Pt #1 assessed and charted, just in time for Pt. #2 to have an anxiety attack, (right on the scheduled Ativan dose time coincidentally), and head to his bedside. I get him settled down, drugs admin'd, assessed and charted. He slowly starts dragging his sats--was at 95% most of the day now consistently at 93-94% on 5L NC. (Cue ominous music.)
By 2100, I've assessed and charted both patients, given 2100 meds, hung about 4 different antibiotic IVPB's on Lung Boy (Hmmm immuno-suppressed and septic much?), and I've gotten Pt #1 into bed (in his Dean & Deluca bathrobe, no less). Lights out; Pt #1 drifts off to sleep and Pt #2...doesn't.
About 2230 Pt #1 awakes suddenly and starts yelling my name, completely freaked out. I dash to his bedside, only to discover...the bedside computer monitor has him freaked out. It's not on, it's just sitting there.
Pt #1 doesn't like this.
Now you're starting to see how this is going to go...
At this point he sits up on the side of the bed and tries to leave the unit. (Post op day 1, mind you.) Through some fancy wordwork I talk him down and avoid having to physically intervene. After 90 minutes of constant reorientation and reassurance, I manage to get him settled back in the chair and reading his book. Where he stays. The. Entire. Night. Hypervigilant. Refuses to sleep. Won't take his antibiotic because he's convinced it's spiked with something to put him to sleep (hmmm...not a bad idea thinking back...).
As the night rolls on, Pt #2 is getting weaker and weaker, it's clear that his physiological reserve is just spent. But he's hanging in.
Meanwhile about 0430 Pt #1 starts nodding off in the chair. He starts complaining how uncomfortable he is so I suggest getting back into bed and surprisingly he agrees. For the briefest of moments he appears to be going to sleep. But alas, the light comes back on and he continues reading.
By 0600, Pt #2 drops his sats to 88-89% and I start him on a non-rebreather, which perks him up to 98% or so. I figure I better notify the pulmonologist since that's a pretty big status change, not to mention it's after 0600 anyway--pager fair game.
It's while I'm on the phone with the pulmonologist getting a lecture about not trying a simple mask first before the non-rebreather (WTF?) that Pt #1's monitor starts alarming. Afterhanging up on politely excusing myself from the doc on the phone, I dash to Pt #1's bedside to discover he's in V-tach or SVT, and all hell breaks loose. My pod partner runs for some lidocaine, my charge nurse starts paging the on call CT surgeon, and I try and get Pt #1 to valsalva just to see if he's possible in SVT that we can convert.
And he flips out.
Gone.
Bonkers.
Looney.
ICU Psycho.
He's screaming obscenities, misogynistic slurs, anything he can think of. I'm physically holding him in bed after he assaults the RT trying to get an ABG. He tries to attack me, but he's 72, just had major surgery, and I'm probably 6" taller and 100 lbs heavier. He ends up in 4 point restraints struggling with all his might, which although puts him at danger of dehiscing his sternal incision, it's actually bringing his heart rate down because he's in one constant valsalva. Amio bolus on board, Haldol x10 mg, and that's where he was when I left after giving report.
Oh, and Pt #2? During report I coax him into coughing, and he coughs up a nasty black mucus plug and immediately starts satting better. (Guess who's a closet smoker with a double lung transplant.)
When I called in after I got up to check on the two of them, Pt #1 was in 4 point restraints, a posey vest, and mittens after scratching a nurse. Pt #2 had transferred upstairs.
It makes me wonder if Pt #1 would have been alright if he'd made it upstairs to a private room. Kind of sad really.
Pt #1 is a post-op day 1 CABG patient who, aside from being overtly particular, seems pretty chill. He's sitting up in the bedside chair, reading a book and just hanging out. I introduce myself, get report, grab vitals, and head off to meet patient #2.
Pt #2 is a post-op perf'd bowel resection. Brand new colostomy and ileostomy. The only reason he's on our unit at all is he's an old double lung transplant from 2007. He's the picture perfect double lung--10/10 anxiety, twitchy, constant guppy breathing--basically crawling the walls. He has a Dilaudid PCA and knows exactly when he got his last nurse bolus, and when the next one is due. And the last and next Ativan.
From the above brief description, can you pick which patient is going to be the troublemaker?
If you picked like I did, you'd be wrong.
I get Pt #1 assessed and charted, just in time for Pt. #2 to have an anxiety attack, (right on the scheduled Ativan dose time coincidentally), and head to his bedside. I get him settled down, drugs admin'd, assessed and charted. He slowly starts dragging his sats--was at 95% most of the day now consistently at 93-94% on 5L NC. (Cue ominous music.)
By 2100, I've assessed and charted both patients, given 2100 meds, hung about 4 different antibiotic IVPB's on Lung Boy (Hmmm immuno-suppressed and septic much?), and I've gotten Pt #1 into bed (in his Dean & Deluca bathrobe, no less). Lights out; Pt #1 drifts off to sleep and Pt #2...doesn't.
About 2230 Pt #1 awakes suddenly and starts yelling my name, completely freaked out. I dash to his bedside, only to discover...the bedside computer monitor has him freaked out. It's not on, it's just sitting there.
Pt #1 doesn't like this.
Now you're starting to see how this is going to go...
At this point he sits up on the side of the bed and tries to leave the unit. (Post op day 1, mind you.) Through some fancy wordwork I talk him down and avoid having to physically intervene. After 90 minutes of constant reorientation and reassurance, I manage to get him settled back in the chair and reading his book. Where he stays. The. Entire. Night. Hypervigilant. Refuses to sleep. Won't take his antibiotic because he's convinced it's spiked with something to put him to sleep (hmmm...not a bad idea thinking back...).
As the night rolls on, Pt #2 is getting weaker and weaker, it's clear that his physiological reserve is just spent. But he's hanging in.
Meanwhile about 0430 Pt #1 starts nodding off in the chair. He starts complaining how uncomfortable he is so I suggest getting back into bed and surprisingly he agrees. For the briefest of moments he appears to be going to sleep. But alas, the light comes back on and he continues reading.
By 0600, Pt #2 drops his sats to 88-89% and I start him on a non-rebreather, which perks him up to 98% or so. I figure I better notify the pulmonologist since that's a pretty big status change, not to mention it's after 0600 anyway--pager fair game.
It's while I'm on the phone with the pulmonologist getting a lecture about not trying a simple mask first before the non-rebreather (WTF?) that Pt #1's monitor starts alarming. After
And he flips out.
Gone.
Bonkers.
Looney.
ICU Psycho.
He's screaming obscenities, misogynistic slurs, anything he can think of. I'm physically holding him in bed after he assaults the RT trying to get an ABG. He tries to attack me, but he's 72, just had major surgery, and I'm probably 6" taller and 100 lbs heavier. He ends up in 4 point restraints struggling with all his might, which although puts him at danger of dehiscing his sternal incision, it's actually bringing his heart rate down because he's in one constant valsalva. Amio bolus on board, Haldol x10 mg, and that's where he was when I left after giving report.
Oh, and Pt #2? During report I coax him into coughing, and he coughs up a nasty black mucus plug and immediately starts satting better. (Guess who's a closet smoker with a double lung transplant.)
When I called in after I got up to check on the two of them, Pt #1 was in 4 point restraints, a posey vest, and mittens after scratching a nurse. Pt #2 had transferred upstairs.
It makes me wonder if Pt #1 would have been alright if he'd made it upstairs to a private room. Kind of sad really.
Thursday, April 14, 2011
From the Beginning: Interview
Since my posts here have become a little sparse, I thought this might be a good time to consolidate my nursing school posts from an older blog. Here's a post about my nursing school interview, originally posted September 25, 2008:
My interview went well today. I only managed to tongue tie myself once. My interviewer's office phone went off 3 or 4 times, her personal cell phone went off once, and someone knocked at the door and intruded. Interesting.
The questions were pretty basic:
Why do you want to be a nurse?
What are some qualities of a good nurse?
What are your strengths that you would bring to nursing school?
What are your weaknesses that you would bring to nursing school?
How do you study?
How do you plan to deal with the rigors of the program?
Do you plan to work?
Think of a time when you had a great deal of stress. How did you deal with that stress?
The one that made me think was:
Think of a time that a problem couldn't be solved with your current way of thinking. What did you do to solve the problem?
All in all it was a relatively painless experience. She seemed genuinely attentive, and took notes on my answers. When we were through she all but told me I'd gotten in. Acceptance letters go out towards the end of October, so I'll be glad when it's in my grimy little hand. Orientation is Jan 7 and 8, but classes don't start until after the 20th. Nice little break there to get myself properly immunized.
Oh boy.
My interview went well today. I only managed to tongue tie myself once. My interviewer's office phone went off 3 or 4 times, her personal cell phone went off once, and someone knocked at the door and intruded. Interesting.
The questions were pretty basic:
Why do you want to be a nurse?
What are some qualities of a good nurse?
What are your strengths that you would bring to nursing school?
What are your weaknesses that you would bring to nursing school?
How do you study?
How do you plan to deal with the rigors of the program?
Do you plan to work?
Think of a time when you had a great deal of stress. How did you deal with that stress?
The one that made me think was:
Think of a time that a problem couldn't be solved with your current way of thinking. What did you do to solve the problem?
All in all it was a relatively painless experience. She seemed genuinely attentive, and took notes on my answers. When we were through she all but told me I'd gotten in. Acceptance letters go out towards the end of October, so I'll be glad when it's in my grimy little hand. Orientation is Jan 7 and 8, but classes don't start until after the 20th. Nice little break there to get myself properly immunized.
Oh boy.
Wednesday, April 13, 2011
Solo, and not the big red plastic cups.
Tonight is my first solo shift.
NurseXY RN-BSN.
No more "Let me ask your nurse...", "Let me ask my preceptor...", "What do I do now..."
Just me and my paper brain. I'm probably making a bigger deal out of this than it really is. My coworkers are really great about helping, and I haven't met any of them that I feel I couldn't ask to help me. I have been essentially on my own for a few weeks now, even with a preceptor. Multiple times my preceptor got called away to take patients of their own, so it's not like it's my first time solo.
Still, it's different.
There is an excellent chance I will get floated tonight, or even left at home on call because coming off orientation puts me right at the top of the "bad list". Both of my fellow ex-interns floated their first night off orientation. They both said that it was simply boring being off our unit. At least I don't have to worry about a step up in acuity, haha. And the nice thing is we can only be floated to other ICUs, no floors.
My first shaky day of clinical (during which I participated in a code, got to put in a flexiseal, put in a foley, and started an IV--we were only supposed to observe, haha!) seems like a long time ago, mostly because it was way back in 2009. Not to mention the hurdles I've crawled over, ducked under, or simply lowered my head and obliterated since then.
I'd wax nostalgic, but I really need to get some lunch and then take a nap before my night shift.
Thanks for reading about my journey and offering bits of advice and encouragement along the way. It means a great deal to me.
Special shout out to Kirsten, Tiffany, and Running Wildly for being with me from the bitter beginning--probably couldn't have made it without you!
NurseXY RN-BSN.
No more "Let me ask your nurse...", "Let me ask my preceptor...", "What do I do now..."
Just me and my paper brain. I'm probably making a bigger deal out of this than it really is. My coworkers are really great about helping, and I haven't met any of them that I feel I couldn't ask to help me. I have been essentially on my own for a few weeks now, even with a preceptor. Multiple times my preceptor got called away to take patients of their own, so it's not like it's my first time solo.
Still, it's different.
There is an excellent chance I will get floated tonight, or even left at home on call because coming off orientation puts me right at the top of the "bad list". Both of my fellow ex-interns floated their first night off orientation. They both said that it was simply boring being off our unit. At least I don't have to worry about a step up in acuity, haha. And the nice thing is we can only be floated to other ICUs, no floors.
My first shaky day of clinical (during which I participated in a code, got to put in a flexiseal, put in a foley, and started an IV--we were only supposed to observe, haha!) seems like a long time ago, mostly because it was way back in 2009. Not to mention the hurdles I've crawled over, ducked under, or simply lowered my head and obliterated since then.
I'd wax nostalgic, but I really need to get some lunch and then take a nap before my night shift.
Thanks for reading about my journey and offering bits of advice and encouragement along the way. It means a great deal to me.
Special shout out to Kirsten, Tiffany, and Running Wildly for being with me from the bitter beginning--probably couldn't have made it without you!
Sunday, April 10, 2011
From the Beginning: Busy Day Tomorrow
Since my posts here have become a little sparse, I thought this might be a good time to consolidate my nursing school posts from an older blog. Here's a post about prerequisite classes, originally posted September 24, 2008:
I have a busy day tomorrow... Start things off with an Anatomy & Physiology exam at 9:30, but I'll be up at school long before then, studying. I think having a Bachelor's in Human Anatomy is actually spurring me to study harder. I'm deathly afraid that I'm going to slack off, thinking I can coast on my prior knowledge, and I'm going to get smacked. How embarrassing would that be? Failing an undergraduate anatomy exam would just top off my whole chiropractic school experience. I should be fine, there isn't much material covered, and I am comfortable with the material. Still though, when one gets complacent...
Then I have class until 1400. At that point I head home in time for my girls to get home from school.
Then out the door again at 1630, all spiffed up--suit and tie. My nursing school interview is at 1730. It's an exciting step in my journey, and I hope I'll sleep tonight. I am scheduled to interview with the Assistant Dean, the one in charge of admissions--no pressure, haha! The interview is scheduled for 30 minutes, and my classmates that have already interviewed said to expect to be there for every minute of it. As long as I don't fark up my interview, my advisor has all but said I'm a shoo in. I hope that holds true, and I really hope I don't fark up my interview! We'll find out officially by the end of October. Hopefully the mail moves a little more quickly than it did with my interview letter--it took a full week to travel less than 10 miles, within the same city.
I've been thinking about what I'd like to do once I'm through with nursing school. I'm almost certain that I could be just fine working as an RN in a critical care unit somewhere, hopefully a pediatric critical care unit. I've considered the thought of working on a transport team. How fun would that be? Travel, and nursing. Not to mention all the autonomy being in transit affords.
I have also thought about continuing on a bit. I could see myself as a Nurse Practitioner working on a critical care unit. The salary increase isn't very substantial over working as an RN though. Another thought is becoming a CRNA. Big time salary potential there and that's not something to blow off...
I'm sure the path I'm supposed to take will be revealed at some point. Let's hope sooner than later!
I have a busy day tomorrow... Start things off with an Anatomy & Physiology exam at 9:30, but I'll be up at school long before then, studying. I think having a Bachelor's in Human Anatomy is actually spurring me to study harder. I'm deathly afraid that I'm going to slack off, thinking I can coast on my prior knowledge, and I'm going to get smacked. How embarrassing would that be? Failing an undergraduate anatomy exam would just top off my whole chiropractic school experience. I should be fine, there isn't much material covered, and I am comfortable with the material. Still though, when one gets complacent...
Then I have class until 1400. At that point I head home in time for my girls to get home from school.
Then out the door again at 1630, all spiffed up--suit and tie. My nursing school interview is at 1730. It's an exciting step in my journey, and I hope I'll sleep tonight. I am scheduled to interview with the Assistant Dean, the one in charge of admissions--no pressure, haha! The interview is scheduled for 30 minutes, and my classmates that have already interviewed said to expect to be there for every minute of it. As long as I don't fark up my interview, my advisor has all but said I'm a shoo in. I hope that holds true, and I really hope I don't fark up my interview! We'll find out officially by the end of October. Hopefully the mail moves a little more quickly than it did with my interview letter--it took a full week to travel less than 10 miles, within the same city.
I've been thinking about what I'd like to do once I'm through with nursing school. I'm almost certain that I could be just fine working as an RN in a critical care unit somewhere, hopefully a pediatric critical care unit. I've considered the thought of working on a transport team. How fun would that be? Travel, and nursing. Not to mention all the autonomy being in transit affords.
I have also thought about continuing on a bit. I could see myself as a Nurse Practitioner working on a critical care unit. The salary increase isn't very substantial over working as an RN though. Another thought is becoming a CRNA. Big time salary potential there and that's not something to blow off...
I'm sure the path I'm supposed to take will be revealed at some point. Let's hope sooner than later!
Friday, April 8, 2011
From the Beginning: Chest Pains
Since my posts here have become a little sparse, I thought this might be a good time to consolidate my nursing school posts from an older blog. Here's a post about interview letters, originally posted September 13, 2008:
This is the start of a new blog, and I'll update with back story as we get further along. But for now, I'd just like to get a post on the books.
Wednesday in my nursing concepts course, the Dean of the nursing school dropped by. She was there to relay information that the nursing school has changed their application process, and instead of submitting a writing sample, the HESI A2 exam would be used to assess verbal and written communication skills. This wasn't news to me as I'd already taken the HESI as a part of my application process for Spring 2009. The exam did not prove strenuous and thankfully I scored very well. Apparently however, there were 4 applicants for the Spring 2009 class that did not take the exam during the appointed times, and thus their application was incomplete. Since ours is the first applying class to use the HESI, the nursing school has made arrangements to allow those 4 students to take the exam anyway, though the deadlines are past. I'm not sure I agree with that--the nursing school did send two letters and numerous emails about the HESI, but I suppose compassion is the best policy. Especially if I were one of the 4.
Anyway, during her 5 minute spiel, the Dean mentioned that interview letters for the Spring 2009 applying class had been mailed two days earlier, on Monday. Sitting in my seat, I got goosebumps. I knew that this could very well mean that if I were selected for an interview, my letter was probably sitting in our mailbox at that very moment. I had to strongly resist the urge to gather my things and slip out.
Alas, when I arrived home, there was no letter in my mailbox.
Now, for perspective, I live about 10 miles from school, in the same town. Mail usually travels within the city in one day. Mailed on Monday would have a strong possibility of being delivered on Tuesday, and almost positively by Wednesday. Stretching to Thursday was unusual, but not beyond the scope of imagination.
Thursday afternoon the mail arrived. No letter.
At this point I was getting concerned. My conversations with my advisor, and even the Dean, had led me to believe that I had a very strong chance of being accepted to the program, but I was beginning to have doubts.
On Friday, I made a special stop at the house to check the mail between a business lunch and my anatomy lab.
No letter.
Now I was relatively certain that a letter was not mailed to me on Monday, and the panic began to set in. My hands were shaking, my mind was reeling, and I honestly had chest pains. I'm not sure if that's how anxiety attacks feel, but I do know that I was not in a happy place as visions of our carefully laid plans came crashing down around me.
I knew that if I let things ride, I would be a wreck all weekend long. I needed action. I needed answers. As I drove my way to campus, I dialed 411 for the number to the nursing school and called to make an appointment with my advisor. Luckily she had an availability, even late on a Friday afternoon. Meanwhile, I numbly sat through anatomy lab, making small talk to my lab partners, and making all the incisions in our fetal pig for our group. (It's amazing what two trimesters spent dissecting a human cadaver for gross anatomy will give you tolerance for...or callousness to?)
As my advisor walked me back to her office, she asked how she could help. I tried very hard to remain completely calm and affable, and I think I did a pretty good job. I told her I was curious about my application, as I knew that the interview letters had been sent out, and I hadn't yet received one. In fact I was wondering how I might strengthen my application so that next semester I might be selected to move on in the application process.
She frowned at me and said, "But we mailed your letter just yesterday."
It turns out that since I have a professional degree already, I'm in a different applicant group than normal undergraduate applicants. My group's letters hadn't gone out until Thursday.
I'm certain my spontaneous relief was transparently obvious to her, because she apologized for having stressed me out so badly. She then made a copy of the letter from the duplicate in my file so I could bring it home with me.
All's well that ends well, right?
Well, one would hope, but now the system won't accept my login name to schedule my interview...
This is the start of a new blog, and I'll update with back story as we get further along. But for now, I'd just like to get a post on the books.
Wednesday in my nursing concepts course, the Dean of the nursing school dropped by. She was there to relay information that the nursing school has changed their application process, and instead of submitting a writing sample, the HESI A2 exam would be used to assess verbal and written communication skills. This wasn't news to me as I'd already taken the HESI as a part of my application process for Spring 2009. The exam did not prove strenuous and thankfully I scored very well. Apparently however, there were 4 applicants for the Spring 2009 class that did not take the exam during the appointed times, and thus their application was incomplete. Since ours is the first applying class to use the HESI, the nursing school has made arrangements to allow those 4 students to take the exam anyway, though the deadlines are past. I'm not sure I agree with that--the nursing school did send two letters and numerous emails about the HESI, but I suppose compassion is the best policy. Especially if I were one of the 4.
Anyway, during her 5 minute spiel, the Dean mentioned that interview letters for the Spring 2009 applying class had been mailed two days earlier, on Monday. Sitting in my seat, I got goosebumps. I knew that this could very well mean that if I were selected for an interview, my letter was probably sitting in our mailbox at that very moment. I had to strongly resist the urge to gather my things and slip out.
Alas, when I arrived home, there was no letter in my mailbox.
Now, for perspective, I live about 10 miles from school, in the same town. Mail usually travels within the city in one day. Mailed on Monday would have a strong possibility of being delivered on Tuesday, and almost positively by Wednesday. Stretching to Thursday was unusual, but not beyond the scope of imagination.
Thursday afternoon the mail arrived. No letter.
At this point I was getting concerned. My conversations with my advisor, and even the Dean, had led me to believe that I had a very strong chance of being accepted to the program, but I was beginning to have doubts.
On Friday, I made a special stop at the house to check the mail between a business lunch and my anatomy lab.
No letter.
Now I was relatively certain that a letter was not mailed to me on Monday, and the panic began to set in. My hands were shaking, my mind was reeling, and I honestly had chest pains. I'm not sure if that's how anxiety attacks feel, but I do know that I was not in a happy place as visions of our carefully laid plans came crashing down around me.
I knew that if I let things ride, I would be a wreck all weekend long. I needed action. I needed answers. As I drove my way to campus, I dialed 411 for the number to the nursing school and called to make an appointment with my advisor. Luckily she had an availability, even late on a Friday afternoon. Meanwhile, I numbly sat through anatomy lab, making small talk to my lab partners, and making all the incisions in our fetal pig for our group. (It's amazing what two trimesters spent dissecting a human cadaver for gross anatomy will give you tolerance for...or callousness to?)
As my advisor walked me back to her office, she asked how she could help. I tried very hard to remain completely calm and affable, and I think I did a pretty good job. I told her I was curious about my application, as I knew that the interview letters had been sent out, and I hadn't yet received one. In fact I was wondering how I might strengthen my application so that next semester I might be selected to move on in the application process.
She frowned at me and said, "But we mailed your letter just yesterday."
It turns out that since I have a professional degree already, I'm in a different applicant group than normal undergraduate applicants. My group's letters hadn't gone out until Thursday.
I'm certain my spontaneous relief was transparently obvious to her, because she apologized for having stressed me out so badly. She then made a copy of the letter from the duplicate in my file so I could bring it home with me.
All's well that ends well, right?
Well, one would hope, but now the system won't accept my login name to schedule my interview...
Wednesday, April 6, 2011
To Hell & Back
Tonight I accompanied my wife to a yoga class at our gym. You have no idea how huge this is.
I suck at yoga. When we first got our Wii Fit, the yoga game frustrated me beyond belief. I had very little balance. It had a great deal to do with my being overweight--it's hard to control your body when you're carrying around the equivalent of an extra human being on your back.
Tonight the class was supposed to be hot yoga, but apparently the heat in the room was broken so it was more like luke-warm yoga. Regardless, I was pleasantly surprised at how many of the poses that used to elude me I was able to accomplish in some shape or fashion. I was even able to do the higher level variations a few times. Overall it was a really positive experience.
But this post isn't about yoga.
During the quiet reflection time at the end of the class, I was almost overwhelmed by a rush of emotion. I was nearly brought to tears as I became acutely aware of the grinding, oppressive intensity of my job.
Critical care nursing is a violent, violent beast.
The inhumanity of so many of the "interventions" we implement is staggering. We often do things to our patients where the success or failure of the therapy depends solely on our determination to see the procedure through to the end. Our patients are broken, hacked into pieces and put back together, sometimes not in the right order or composition. We administer vehemently severe drugs that force the body to battle against itself to raise a blood pressure, or increase perfusion, or to be stone still when the entire body aches to thrash about in protest.
This realization caught me by surprise. Actually, the discordant nature of what I do to heal people caught me by surprise.
My compassion for my patients abounds--this isn't the issue. I feel for them; I practice from an empathetic heart.
But this is different.
This is about me. And the horrors I witness on a daily basis in the due course of my job. My career. My livelihood.
Like I'm a computer programmer, or a grocer, or an account customer service representative.
Except that I'm not.
When people ask me what it is that I do, they have no idea the profundity of question they are asking. And I reply like I change oil for a living. Or buy bonds on the stock market.
The reality is my unit is a battlefield. A desolate, bleak, derelict, forsaken, smoking wasteland. Where Death prowls like the inky darkness at the edge of your vision. Where I'll make deals with the Devil to save a soul so they can gasp a few more breaths. Or if we're all lucky, and have muttered the right incantation in the right timbre, to the right lord of medication, the patient pulls back from the brink and returns from the land of nowhere. Where I will attack, wage war, and blatantly injure a patient in the name of healing them. And so I go, petting the hellhounds, whispering in their ears so that I might escape with one more patient's soul.
No rest for the weary.
But there must be balance.
Namaste.
Wednesday, March 30, 2011
As the Internship Wanes
It was a lifetime of 12 short weeks ago that I embarked on this critical care internship. I thought I knew what it would be like, and I was mostly right.
The fact that even in the interview they asked me if I was sure I "wanted to do this", again when they offered the position to me, and a third time when we were at the beginning illustrates the degree of difficulty. The neck snapping uptake onto this learning curve was akin to being rear-ended by an academic semi-truck on a towering bridge--not only do you have to survive the impact, you have to make sure you get propelled down the lane of traffic and not over the side of the bridge into the water. I've always prided myself in some small way on the amount of stuff in my brain; it's what I do, it's my thing. This, however, was the first time where my knowledge, or potential lack thereof, had actual life or death consequences. And I don't mean that in a hyberbolic, grandiose way. I mean that quite, quite literally. Often, if I were to screw up, there simply isn't time or physiologic reserve for the patient to recover.
This is singularly the most difficult thing I've ever done. So far beyond nursing school it's laughable. Easily more intense than the worst day in chiropractic school. The level of performance required on a minute to minute basis leaves me mentally and physically exhausted at the end of each and every shift.
I have assimilated so much knowledge my head hurts and I dream about titrations, QTc's, filling pressures, and cardiac indexes. Yet I'm surrounded by people that possess the same knowledge, at times seemingly disguising the fact that I've learned all that much.
I can tell that I've grown though. It used to be when a preceptor stepped in and made an adjustment to a pump or initiated a therapy, I was simply thankful that there was someone there to make sure the patient got what they needed. Now, it annoys me, because a.) they don't tell me what they've done, potentially making me look like a fool when I get questioned by a physician, b.) because it disrupts my train of thought or plan of care, or c.) because, "It's my patient damnit, and keep your grubby hands to yourself!!", that's why!
To get out of the internship I have to take a drug test tomorrow, and not the pee-in-a-cup kind either. These are the notecards for the drugs I have to know by heart. The test? Not multiple choice, not fill-in-the-blank, but short answer. Many of them I know well because I've used them daily for the past 12 weeks. Some of them I still haven't seen in practice. I have to know class, mechanism of action, preparations--including all concentrations we use, dosing--including initial, titration, max and wean dosing, side effects, nursing actions, as well as surgeon preferences for each drug. But no problem, I got this. *sigh*
Beyond that, I have two more shifts on days, tomorrow and Friday. Then Monday, I head to night shift for 3 shifts with a preceptor to get a feel for how things run on nights.
And then, fin. All done. Completed.
On my own.
And the next new adventures begin...
I love my job.
The fact that even in the interview they asked me if I was sure I "wanted to do this", again when they offered the position to me, and a third time when we were at the beginning illustrates the degree of difficulty. The neck snapping uptake onto this learning curve was akin to being rear-ended by an academic semi-truck on a towering bridge--not only do you have to survive the impact, you have to make sure you get propelled down the lane of traffic and not over the side of the bridge into the water. I've always prided myself in some small way on the amount of stuff in my brain; it's what I do, it's my thing. This, however, was the first time where my knowledge, or potential lack thereof, had actual life or death consequences. And I don't mean that in a hyberbolic, grandiose way. I mean that quite, quite literally. Often, if I were to screw up, there simply isn't time or physiologic reserve for the patient to recover.
This is singularly the most difficult thing I've ever done. So far beyond nursing school it's laughable. Easily more intense than the worst day in chiropractic school. The level of performance required on a minute to minute basis leaves me mentally and physically exhausted at the end of each and every shift.
I have assimilated so much knowledge my head hurts and I dream about titrations, QTc's, filling pressures, and cardiac indexes. Yet I'm surrounded by people that possess the same knowledge, at times seemingly disguising the fact that I've learned all that much.
I can tell that I've grown though. It used to be when a preceptor stepped in and made an adjustment to a pump or initiated a therapy, I was simply thankful that there was someone there to make sure the patient got what they needed. Now, it annoys me, because a.) they don't tell me what they've done, potentially making me look like a fool when I get questioned by a physician, b.) because it disrupts my train of thought or plan of care, or c.) because, "It's my patient damnit, and keep your grubby hands to yourself!!", that's why!
To get out of the internship I have to take a drug test tomorrow, and not the pee-in-a-cup kind either. These are the notecards for the drugs I have to know by heart. The test? Not multiple choice, not fill-in-the-blank, but short answer. Many of them I know well because I've used them daily for the past 12 weeks. Some of them I still haven't seen in practice. I have to know class, mechanism of action, preparations--including all concentrations we use, dosing--including initial, titration, max and wean dosing, side effects, nursing actions, as well as surgeon preferences for each drug. But no problem, I got this. *sigh*Beyond that, I have two more shifts on days, tomorrow and Friday. Then Monday, I head to night shift for 3 shifts with a preceptor to get a feel for how things run on nights.
And then, fin. All done. Completed.
On my own.
And the next new adventures begin...
I love my job.
Sunday, March 27, 2011
The C-Word
Collaborative.
It's one of those magic buzzwords that we in health care like to liberally sprinkle around in our conversations when we're feeling particularly self-righteous and saintly.
Please don't mistake my flippant comment as total disregard for the concept. I do, in fact, believe it is absolutely the best possible framework for patient care. I just wish people used it for more than a feel-good talking point.
I think nursing as a whole accomplishes collaborative care the most consistently, at least at my hospital. We actually coordinate much of the inter-disciplinary care; we often facilitate the communications between disciplines. We're like home base--everyone checks in with us. The way we choose to phrase patient condition or answer questions can significantly alter the course of patient care.
It's a power not all nurses realize we wield. Maybe it's most seen in the ICU setting where patient condition can drastically change by the time a doc walks from one end of the unit to the other. They truly depend on our eyes and ears. Still, even we nurses don't always play nice either. How many times have you heard nurses complain when case management steals the chart? Or grumble when X-ray shows up just as we got the patient settled (regardless of the fact that we called them)?
The docs though, they can be real stinkers. (Not all docs, but enough to stereotype.) I often wonder if they think we don't have ears, or that we only hang out at the patient bedside when they're there. Do they not realize that we get the whole picture? From shift beginning to end, we entertain every discipline, and that we actually see what really takes place regarding the things they complain about?
I've heard several docs make snide remarks when pharmacy leaves notes to them in the chart. Often it's regarding vancomycin dosing, or GI prophylaxis--not entirely unimportant issues. In fact, I had a doc tell me to tell the pharmacy to "shove it up their ass" when they had me contact him about ordering Bactrim and Zinacef on a patient with documented sulfa and penicillin allergies. I hadn't caught it yet, but I hadn't given a dose of either yet. The patient did however receive doses of each in the OR--I guess that's what that red truncal rash was, aye doc? Funny how it disappeared after a dose of Benadryl.
Or how about the docs that brush aside the palliative care team? Or disparage the lab for taking so long with their stat super-specific free level neutrogenic assay panel level?
But docs aren't just hard on other disciplines, they have it out for each other too. For example, take the double lung transplant we had last week. The surgeon, Dr. Particular, put the patient on an epi drip to keep cardiac output up, and blood shunted centrally. Not a lot of epi, 0.03 mcg/kg/min, but it was enough to keep the patient in sinus tach and SBP in the 150s. The pulmonologist, Dr. Low-Key, came in and and D/C'd the epi because he didn't like the pressures that high on the new anastamosis and the lung capillary beds.
Having worked with the Dr. Particular before, I was pretty certain he wasn't going to take someone monkeying around with his drips too well. So I discontinued the epi while Dr. Low-Key was there, and as soon as he left, I paged Dr. Particular.
"What!?! That is MY drip. All the vasoactive meds are MY meds! Why would Dr. Low-Key D/C drips that are mine! We don't just D/C drips like that!" Etc, etc, ad nauseum.
So the epi went back on (actually, as far as Dr. Particular knows it was never turned off). And when Dr. Low-Key came back through for afternoon rounds, I had to play the other side of the fence. "You know how Dr. Particular is, he likes his drips." And we had a round of teasing and snide remarks at the expense of Dr. Particular. In the end, Dr. Low-Key left placated. But the drip was still running.
When Dr. Particular came through to write his progress notes, I was able to bring up Dr. Low-Key's concerns carefully disguised as nursing recommendations, and got the epi weaned to 0.015 mcg/kg/min, which kept her CO/CI at 4.8/2.7, but allowed her pressures to settle into the 130s. All the while bantering about Dr. Low-Key's "slip-shod practices", just turning off a drip without weaning, and generally talking up the other side of the fence again. Gleefully, Dr. Particular left vindicated.
And the patient maintained perfusion, with tolerable systolic blood pressures.
Yeesh, I think foreign relations in the Middle East aren't this complicated.
But that's collaborative care.
The C-word.
It's one of those magic buzzwords that we in health care like to liberally sprinkle around in our conversations when we're feeling particularly self-righteous and saintly.
Please don't mistake my flippant comment as total disregard for the concept. I do, in fact, believe it is absolutely the best possible framework for patient care. I just wish people used it for more than a feel-good talking point.
I think nursing as a whole accomplishes collaborative care the most consistently, at least at my hospital. We actually coordinate much of the inter-disciplinary care; we often facilitate the communications between disciplines. We're like home base--everyone checks in with us. The way we choose to phrase patient condition or answer questions can significantly alter the course of patient care.
It's a power not all nurses realize we wield. Maybe it's most seen in the ICU setting where patient condition can drastically change by the time a doc walks from one end of the unit to the other. They truly depend on our eyes and ears. Still, even we nurses don't always play nice either. How many times have you heard nurses complain when case management steals the chart? Or grumble when X-ray shows up just as we got the patient settled (regardless of the fact that we called them)?
The docs though, they can be real stinkers. (Not all docs, but enough to stereotype.) I often wonder if they think we don't have ears, or that we only hang out at the patient bedside when they're there. Do they not realize that we get the whole picture? From shift beginning to end, we entertain every discipline, and that we actually see what really takes place regarding the things they complain about?
I've heard several docs make snide remarks when pharmacy leaves notes to them in the chart. Often it's regarding vancomycin dosing, or GI prophylaxis--not entirely unimportant issues. In fact, I had a doc tell me to tell the pharmacy to "shove it up their ass" when they had me contact him about ordering Bactrim and Zinacef on a patient with documented sulfa and penicillin allergies. I hadn't caught it yet, but I hadn't given a dose of either yet. The patient did however receive doses of each in the OR--I guess that's what that red truncal rash was, aye doc? Funny how it disappeared after a dose of Benadryl.
Or how about the docs that brush aside the palliative care team? Or disparage the lab for taking so long with their stat super-specific free level neutrogenic assay panel level?
But docs aren't just hard on other disciplines, they have it out for each other too. For example, take the double lung transplant we had last week. The surgeon, Dr. Particular, put the patient on an epi drip to keep cardiac output up, and blood shunted centrally. Not a lot of epi, 0.03 mcg/kg/min, but it was enough to keep the patient in sinus tach and SBP in the 150s. The pulmonologist, Dr. Low-Key, came in and and D/C'd the epi because he didn't like the pressures that high on the new anastamosis and the lung capillary beds.
Having worked with the Dr. Particular before, I was pretty certain he wasn't going to take someone monkeying around with his drips too well. So I discontinued the epi while Dr. Low-Key was there, and as soon as he left, I paged Dr. Particular.
"What!?! That is MY drip. All the vasoactive meds are MY meds! Why would Dr. Low-Key D/C drips that are mine! We don't just D/C drips like that!" Etc, etc, ad nauseum.
So the epi went back on (actually, as far as Dr. Particular knows it was never turned off). And when Dr. Low-Key came back through for afternoon rounds, I had to play the other side of the fence. "You know how Dr. Particular is, he likes his drips." And we had a round of teasing and snide remarks at the expense of Dr. Particular. In the end, Dr. Low-Key left placated. But the drip was still running.
When Dr. Particular came through to write his progress notes, I was able to bring up Dr. Low-Key's concerns carefully disguised as nursing recommendations, and got the epi weaned to 0.015 mcg/kg/min, which kept her CO/CI at 4.8/2.7, but allowed her pressures to settle into the 130s. All the while bantering about Dr. Low-Key's "slip-shod practices", just turning off a drip without weaning, and generally talking up the other side of the fence again. Gleefully, Dr. Particular left vindicated.
And the patient maintained perfusion, with tolerable systolic blood pressures.
Yeesh, I think foreign relations in the Middle East aren't this complicated.
But that's collaborative care.
The C-word.
Sunday, March 20, 2011
Dr. Slapstick
I mentioned one of the CT surgeons at my hospital in past posts. I thought I would elaborate. Now, CT surgeons by breed tend to be a little "off" in my experience. Whether they suffer from grandiose delusions or are just odd little men, the sheer amount of schooling/residency/fellowship required to become a competent CT surgeon tends to emphasize a certain margin of the population.
Dr. Slapstick is no exception. He truly is a strange little man.
He creeps out some of the female nurses because of his over-friendly manner. Among the chosen few is my fellow friend intern, Ash. She's managed to attract his attention, and he's so slimy about it he makes both of our skin crawl when he's around her. It's not hard to decipher his intentions.
He's on his 3rd wife, and she truly is a trophy wife this time around by all intents and purposes. She is much younger than him, is legendary for her "good" looks, and apparently previously made her living at various fine gentlemen's establishments.
Not that there's anything wrong with that...
Did I mention he's the medical director for our unit?
But that's not the real issue, however scandalous it may be.
I call him Dr. Slapstick because of his technique. And I don't mean the way he woos the ladies. His surgical technique. CT surgery is a sport to him. Each case is a race to him--I've seen him finish a CABG in under an hour. While that does wonders for productivity, it leaves much to be desired in patient outcomes.
Dr. Slapstick's post op orders regularly include keeping the patient's MAP between 50 and 60 mmHg. He claims this is to protect the new grafts, but it is common knowledge that it's actually to prevent his slapstick grafts from bleeding. He is adamant about the pressure, and will often watch his previous case in the ICU on the monitor while he's working on his second or third case in the OR. If your pressure begins to even think about straying north of 60, we'll get a phone call from him, from the OR suite. For the uninitiated, a MAP of at least 65 mmHg is required to adequately perfume the kidneys, in a healthy patient.
Remember the patient that tamponaded and coded that I mentioned in my last post?
A Dr. Slapstick patient.
Ash (her patient) and I couldn't figure out why nobody would call a spade a spade and actually label it tamponade. It was textbook as it comes--agitation, brief spike in BP, then falling BP, narrowing pulse pressures in the art line, dampened art line wave form, PAD and CVP equalized. Not to mention when Ash manipulated the mediastinal chest tubes, they were clotted and then dumped 300 mls. But nobody was willing to chart that the patient had tamponaded, let alone was bleeding. After asking our educator what we were missing, she let us know that Dr. Slapstick was being looked into by the board. Apparently he has one of the highest return-to-OR rates in the country...
Not sure how I feel about my coworkers trying to cover for him...
Wednesday, March 16, 2011
Today
5 am has come way too soon. On nights before I work a shift on the unit, I worry so much about oversleeping that I wake up nearly every hour through the night to make sure I haven't slept through my alarm. Usually my jaw muscles are aching and quivering by morning because I've been clenching my teeth--a sign of the tension I'm carrying about my upcoming shift.As I pull out of the driveway, the brisk 50* March morning breeze tousles my hair. It's one of the things I love about owning a Jeep--the removable top. My morning NPR thrums in time to the tires rhythmically bumping over the expansion joints in the concrete roadway. I sip on the Dunkin Donuts french vanilla coffee that my wife brought home for me to try. Its toasty roasted warmth permeates my sinuses, coaxing my brain awake.
I get to the remote parking lot just in time to catch the early shuttle, saving me a 1 mile walk from lot to unit. I sit near a former classmate of mine from nursing school that got hired into the OR internship at my hospital, happy to see a familiar face. Early morning small talk splatters across the aisle, like dew dripping from hesitant grass.
Once on the unit, I'm 30 minutes early as usual, and check out the assignment board. I discover I've been assigned to a tough pair of patients--neither one entirely lucid, swimming instead in the murky waters of ICU psychosis. I notice my hard-ass preceptor is back from his 2 week paternity leave.
*Sigh*
It's going to be a long day.
I head into my pod and get report 20 minutes early, just to get a jump start on my day. As expected, both patients are super busy, and heavy on meds and tasks. They've both been on the unit a full week or more. That's about a week longer than most of our heart patients--we transfer out on post-op day 1 when things go right. One patient has had seizures and other neuro complications. The other has been in 4 point restraints for most of the week to prevent him from pulling out his balloon pump and flopping onto the floor to writhe around like an out of water guppy.
As I'm doing my morning assessment, my seizure lady kicks into full-on anxiety mode. Taking her hand in mine, I get her to focus on my face and gently talk her down from her ledge. She tearfully thanks me for helping her, and profusely apologizes for being troublesome. I assure her that everything will be ok, and it's my pleasure to help her. "We're going to get through this day together," I promise.
It's a scene that will repeat several times during day.
Meanwhile my 4 point restraint man is satting 100% on bipap, but shaking his head like an angry mule trying to dislodge the mask. I DC the bipap to a simple mask at 30%, just to see what he's going to do. Eventually I get him down to 3L NC, still satting 100%. He begs me to get him up to the chair, and I oblige--releasing 2 soft point restraints per limb. Once he's in the chair, he is completely lucid and cutting up, causing trouble.
The good kind of trouble.
As his family comes in to revel in his new found lucidity and good fortune, he gets very emotional. His fear that he'd never see his wife of 65 years again is a heart-rending confession when she comes in to visit with him. They're only 87 years old. Halfway through the shift he starts weeping, and as I try to console him he thanks me for saving his life. What words are adequate to respond?
I kick seizure lady's family out of the pod so she can sleep. I'm convinced her psychosis and seizures have more to do with sleep deprivation than a neuro issue. Towards the end of the shift I convince the CT surgeon to transfer my seizure lady to the floor where she'll have a private room, and blessed sleep. I lecture her family about talking her into asking for pain meds. Maybe if she's not on Dilaudid every 4 hours her GI tract will break free from its paralysis. They fuss at my iron-handedness. They thank me profusely as I transfer them to floor, regardless of me taking them to task. In the waiting room I overhear them bragging on me to the other families.
When I get back from transferring my patient, I assist with a new admit surgery--a fresh CABG. That's when the woman across their pod chooses to tamponade and code. I'm next in line to do compressions when we get her back. Her 16 year old grand daughter was bedside when it happened. I shepherd her into the waiting arms of the chaplain as I dash down the hall to pull another 750ml of 5% albumin from the Omnicell. It's a delicate ballet--a well orchestrated exercise in futility. Her RCA perf'ed in the cath lab, and her entire right ventricle and most of her septum has infarcted. She's not long for this world, but we did buy her another afternoon conversation with her grand daughter. Worth it I think.
4 point restraint man gets visibly upset when I let him know I won't be back the following day. He worries that his new nurse will let him down and that he'll sink back into the confusion. I settle him as best I can, and reiterate his goals to get to floor, and then home. I think he halfway believes me when I tell him that he's going to be fine.
Surprise. I admit a patient with Marfan's. She's been in the ED all day with hemoptysis and a deep tearing pain in her chest. Hmm, dissection anyone? I have just enough time to get her settled and an assessment documented before I have to total out my I&O's.
Night shift has moseyed in. I'm lucky--the nurse taking over my patients is as punctual as they come. I give report, astounded that the 12 hours I've experienced can actually be condensed down into a 10 minute synopsis. We check orders, and I autograph the chart with a flourish.
My crusty preceptor tells me, "You did a good job today," as we clock out. I'm dumbfounded.
My nursing school classmate that works on my unit was the primary nurse on the patient that coded earlier, and I let her decompress on me as we walk the mile back to the remote lot. Her husband is supportive, but doesn't understand all the pressures we go through. He doesn't understand the subtlety and gravity of the events of our day. She destresses and I just listen as we walk. By the time we reach the parking lot, she's calm enough to drive. I know she'll do the same for me, and likely soon.
As I climb into the Jeep for the drive home, I realize I've parked under a flowering pear tree. There's a layer of fragrant petals sprinkled across the interior. As I pull onto the highway, the freeway evening breeze turns them into a petal snowstorm. They swirl around me and lightly flutter across my face, reminding me of the gentle way we as nurses can affect the recovery of our patients. It goes way beyond the obvious, lifting gently into the air in a menagerie of healing.
And for what must be the hundredth time in a week, a month, a year, I thank my lucky stars that someone, somewhere saw it fit to place me in this time; this moment; this space.
Thursday, March 10, 2011
On Mountains, Valleys, & Beasts
One of the foremost lessons I've learned in my internship is that our unit is like a live, wild animal.
It breathes. It eats. It's reactive.
And if you're not careful, it will bite you.
Just when I think I've gotten a handle on it, something comes along and takes my legs back out from under me, leaving me on my knees.
And so it goes--I have huge mountaintop experiences where I've safely admitted extremely unstable and complicated patients. It is such a rush when you're literally managing a hemodynamically unstable patient's life on a minute by minute basis through the titration of 4 or 5 different vasoactive drips. It's cathartic. And it's easy to see how god-complexes develop in physicians because it's addicting. It feels oh-so-good when you're doing it the right way and your patient lives. The rush whispers in your ears, seducing you with it's siren words of success. I've had 3 such admits so far, and I only look forward to more.
But there are the valleys too. Like when a simple case comes back, and suddenly I'm paralyzed because nothing is as it should be. There's no index to shoot, there's no cordis, but I've got two art-lines, and I don't know why. The patient is a 31 year old mother of 3 that discovered she had a ASD when she had a TIA at home taking care of her kids. A simple septal defect repair done through the femoral artery--it completely blew my mind and I imploded. I simply couldn't think of what I needed to do next. So humiliating, and unbelievably frustrating.
I just have to keep getting up and going back to work. It may not get any easier, but I know I'll be better for it in the end. And I can tell I'm becoming a stronger nurse each passing shift.
And that my friends, is even more cathartic, and more addicting.
The thirst for knowledge and experience is almost unbearable at times. My skin prickles from the sheer volume of electrical activity required to lay down the new neuronal pathways. It's like a drug. And it's not always a therapeutic dose. Often it's a back-alley, Bic-lighter-and-rusty-metal-spoon black-tar of a rush.
The knowledge also lives and is animate, I swear. I can feel its hot breath on my neck while I work and move among my patients. It lays in wait for the right moment to pounce on its unsuspecting prey, to remind me that I am not in control of it. Untameable. But when harnessed, lurches us forward at synergistic ability and speed...
And so I exist, abiding in the mist of the gray, no black or white in sight. Between scope of practice and patient need. Trying to bridle the knowledge just enough to battle the specter of the horrible beast that is the life-or-death illness that stalks the patients on my unit. All the while I'm holding on for dear life, only hoping to come out the other end of the shift having honored the needs of the patient and served their families in a way that I can be proud of.
And I love it.
Every.
Vicious.
Second.
It breathes. It eats. It's reactive.
And if you're not careful, it will bite you.
Just when I think I've gotten a handle on it, something comes along and takes my legs back out from under me, leaving me on my knees.
And so it goes--I have huge mountaintop experiences where I've safely admitted extremely unstable and complicated patients. It is such a rush when you're literally managing a hemodynamically unstable patient's life on a minute by minute basis through the titration of 4 or 5 different vasoactive drips. It's cathartic. And it's easy to see how god-complexes develop in physicians because it's addicting. It feels oh-so-good when you're doing it the right way and your patient lives. The rush whispers in your ears, seducing you with it's siren words of success. I've had 3 such admits so far, and I only look forward to more.
But there are the valleys too. Like when a simple case comes back, and suddenly I'm paralyzed because nothing is as it should be. There's no index to shoot, there's no cordis, but I've got two art-lines, and I don't know why. The patient is a 31 year old mother of 3 that discovered she had a ASD when she had a TIA at home taking care of her kids. A simple septal defect repair done through the femoral artery--it completely blew my mind and I imploded. I simply couldn't think of what I needed to do next. So humiliating, and unbelievably frustrating.
I just have to keep getting up and going back to work. It may not get any easier, but I know I'll be better for it in the end. And I can tell I'm becoming a stronger nurse each passing shift.
And that my friends, is even more cathartic, and more addicting.
The thirst for knowledge and experience is almost unbearable at times. My skin prickles from the sheer volume of electrical activity required to lay down the new neuronal pathways. It's like a drug. And it's not always a therapeutic dose. Often it's a back-alley, Bic-lighter-and-rusty-metal-spoon black-tar of a rush.
The knowledge also lives and is animate, I swear. I can feel its hot breath on my neck while I work and move among my patients. It lays in wait for the right moment to pounce on its unsuspecting prey, to remind me that I am not in control of it. Untameable. But when harnessed, lurches us forward at synergistic ability and speed...
And so I exist, abiding in the mist of the gray, no black or white in sight. Between scope of practice and patient need. Trying to bridle the knowledge just enough to battle the specter of the horrible beast that is the life-or-death illness that stalks the patients on my unit. All the while I'm holding on for dear life, only hoping to come out the other end of the shift having honored the needs of the patient and served their families in a way that I can be proud of.
And I love it.
Every.
Vicious.
Second.
Tuesday, March 8, 2011
ACLS Drama
Because of our patient population, unit policy states that to travel with a patient (to radiology, dialysis, or even transferring to the step down unit), the nurse accompanying the patient must be ACLS certified. Hospital policy states that new-hires must become ACLS certified within 12 months of hire.
Obviously, waiting 12 months to take ACLS isn't really an option on our unit, since a good deal of our patients travel, and not being able to accompany them becomes a logistical staffing nightmare. And that's not even considering the sheer number of codes we see... Therefore, our educator and manager both "strongly encouraged" us to take ACLS before the end of our internship so that we'd be certified when we come off orientation.
My fellow interns and I sit on the front row during the classroom portion of the internship. The classes are combined with all med-surg, tele, and ICU interns, and that's what our unit does--"we're the best of the best, and we act that way." Or so we were "strongly encouraged" to portray by our manager and educator. One day as the internship class broke for lunch, my fellow interns and I discussed heading over to the unit to pick up the books for our Saturday ACLS class so we could take the pretest.
And thus started the ACLS Drama.
The class instructor overheard us, (a conversation she was not part of,) and flipped out.
"You haven't had the entire EKG interpretation internship course yet. We haven't talked about any of the ventricular arrhythmias. We haven't introduced the blocks yet. You won't even understand what they're talking about in the ACLS course, so it's pointless for you to even go right now!"
As insulting as this was ("You're too stupid to take the course!"), I have turned over a new leaf, and I let it roll off my back, shrugged my shoulders, and said, "We're just doing what our manager and educator told us to do."
So the class instructor called our manager to gripe. And she called our educator to gripe. And then she called the ACLS instructor and told her that we'd signed up and couldn't possibly be ready for such an advanced course.
All around us the political (and hormonal I suspect) firestorm raged, but our manager directed us to take the course regardless.
Meanwhile, I had an entire semester of critical care in nursing school that incorporated EKG interpretation throughout. I also had a year's ICU experience where rhythm identification was a daily part of my job. I know what a heart block looks like first degree, third degree, even both types of second degree. I know enough to say, "Oh S#&%!" when the monitor screen fills up with v-fib squigglys or v-tach scribbles. Hell, I even know that a nice pretty rhythm is useless without an accompanying pulse.
But I digress.
When I showed up on Saturday morning for ACLS (with pretest with passing score in hand), we quickly sailed through the BLS portion of the course and then split into renewals and first time certifications. There were only 5 of us first timers--the 3 of us from our unit, and then a nurse with 4 months experience and a nurse with >20 years of experience that had let her certification lapse. As soon as we were separated out, the instructor starts in on a tirade of how those of us in the internship, "with so little experience," weren't going to reap the full benefit of the class, etc, etc, ad nauseam.
I'd had enough.
And so I went all nurseXY on her.
"I guess I'm confused. Do we need to sign up for another class? Are we not allowed to take this class?"
"Well, no, I can't keep you from taking the class."
"Then why are we still discussing this? And when will we move on to the course content?"
Not particularly diplomatic, I know. Rude? Quite possibly.
But SHEESH!!
And so we began. As we moved into the content it was immediately clear she was singling us out with questions, trying to trip us up and make us feel inadequate or unprepared. What she didn't realize was how hard we had been pushed to learn drugs used daily on our unit, most of which are code drugs. She didn't realize the amount of physiologic and pathological knowledge required to get through a single shift on our unit. She didn't realize that we had to truly understand our patients disease processes to even begin managing them.
Everything she threw at us, we had a ready answer for. It was downright inspiring--you could hear the triumphantly rowdy underdog music swelling in the background. And then we caught her in a mistake.
In the end, after all the fuss, in our "but this is the way we do things" face-off, she was the one who blinked first.
As the day moved on into the megacode and we took turns at each position, it was quickly apparent that the other two nurses were actually the weak links.
For example, the one with 4 months of tele experience couldn't wrap her head around the concept of PEA--interestingly enough exactly how much experience our class instructor told us we needed to have to fully understand the intricate subtleties of ACLS. The other, the one with >20 years of experience kept mixing up atropine and amiodarone, and forgetting to defib the patient when appropriate.
One of my fellow interns summed up the day perfectly: "And it was us she was worried about?!?"
Today in class, more than 3 weeks later, we finally went over the heart blocks and ventricular arrhythmias. And wouldn't you know it the whole inappropriately early ACLS class came up again! And then we were politely asked to stop answering questions during the lecture and let others have a chance as we learned about hospital SDMOs on cardiac resuscitation, which oddly enough mirror ACLS.
Ugh. I hate drama.
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