RCA

Remember this guy?  Dr. Slapstick?

Well, a couple months ago Dr. Slapstick reverted back to his old habit of doing 3 cases in a day.

He's been explicitly asked told not to do this.  But, since he is the medical director, there is little oversight regarding his practices.  Essentially the top echelon of administration has to get involved if there's any issue with him or his practices.  And we all know how fast administration moves--like I've seen glaciers move faster...especially in this day and age of global warming.

Anyway, Dr. Slapstick's 3rd case of the day comes out on night shift, about 8 pm. 

The patient is a 47 y/o female patient getting a valve repair.  It's her 5th valve surgery.  She had congenital valve problems--two surgeries as a child performed by some other obviously competent surgeon.

The next three surgeries were performed by our very own Dr. Slapstick.  In fact, the reason for the 5th surgery is because Dr. Slapstick damaged a leaflet of her aortic valve during her 4th valve surgery.

Oops.

Now, because of all these previous surgeries, Dr. Slapstick decided that the sternal/mediastinal scar tissue would be so bad he needed to take a different approach--like between the posterolateral ribs, much like a thoracotomy.  The anesthesiologist/perfusionist decide to cannulate the femoral artery and vein.

This is an excellent piece of clinical decision making.  CT surgery is moving towards the minimally invasive route as a whole, and scar tissue on sternotomy reentries can be a real problem.

Except I have never seen Dr. Slapstick do this particular surgery from this particular approach. 

Ever.

And this case ends up with an 8 hour pump time.

Regardless, the patient comes out with rock steady vitals, on very few vasoactive drips, and minimal bleeding (especially for Dr. Slapstick).  Orders are to sleep the patient for 2 hours, then wake her up and extubate.

Well, along comes 2 am, and the patient has been off propofol for 4 hours and is still not responding.  The night nurse is concerned (rightfully so) but the night charge nurse advises against calling the physician.  You see, Dr. Slapstick has three cases scheduled the next day.

Night nurse, (God bless her, she's awesome!) decides she's going to call anyway.

Dr. Slapstick yells at her, "I can't believe you are calling me about this!!  I mean really?!?  I have a 6 am case!!  Just turn the propofol back on and we'll deal with it in the morning."  Which she documents in real time, word for word, with quotation marks.

Next morning this patient is half of my assignment, and the night nurse relays all this to me in report.  I immediately start weaning down the propofol, and perform a thorough shift assessment.  Pupils are a 2 and sluggish, and all the primitive reflexes I test are present.

By 8 am, I'm off propofol completely.  The patient is unresponsive.  Dr. Slapstick comes by shortly after.  He's still miffed about being woken up the night before, assesses the patient, and tells me to continue what I'm doing.

At 10 am, the patient is still unresponsive, and isn't over-breathing the vent.  I'm getting concerned, and my nursing spidey sense is going off like a klaxon horn on the bridge of a WWII warship.  I do another full neuro assessment.

Oh crap.

Right pupil 3 and veeeerry sluggish.  Left pupil 8 and fixed.  No gag, no corneal.  Potential toe flare on babinski.  I can barely hide my concern from the patient family as I dash for the phone to call Dr. Slapstick.

Dr. Slapstick is in the OR.  I relay the message through the circulating nurse, and the reply, incredibly, is to turn the propofol back on, and he'll be out to assess the patient when he's through in about an hour.

I ask for a neurologist consult, but do not receive one.  I ask for a head CT, but do not receive one.

Completely dissatisfied, I call the anesthesiologist who worked the case, trying to get a back door order.  The anesthesiologist is unwilling to countermand Dr. Slapstick.  The charge nurse calls the house supervisor, who calls administration.  Nobody is willing to go out on a limb.

The hours creep by.  Calls to Dr. Slapstick's OR reveal his current case is not going well.  Complications abound.  I've updated the family, because that's what I do.  I don't lie to families, and I keep them informed.  They are besides themselves, and I am too.

Dr. Slapstick finally shows up at the bedside 4, (FOUR!!) hours later.  Does a quick 5 minute exam and has me consult a neurologist.  The neurologist is at the bedside within 10 minutes, does his exam and we are in the CT scanner in another 10 minutes.   The neurologist stays in the control room with us and reads the CT slice by slice as it comes up.

Massive diffuse global anoxic injury.  Oh and she's partially herniated, and it's progressing.

After meeting with the neurologist the patient's husband tells me he's preparing himself for the hardest conversation of his life.  He's headed home to tell his 5 year old daughter that her mother isn't coming home.

---------------------

Two weeks later I get summoned to a Root Cause Analysis (RCA) for this patient's "unexpected negative outcome."  Dr. Slapstick proceeds to attempt to blame the entire debacle on nursing, stating that we "failed to communicate the seriousness of the situation to him."

All I can say is thank goodness for thorough charting and for my less than shy mouth.  And my healthy belief that doctors put their pants on just like everyone else.

One leg at a time.

Two days later, there's a note up in the break room on the unit from Dr. Slapstick.  It seems he's leaving to pursue other opportunities in an outlying community where he has the privilege to develop a CT surgery program.  He trips all over himself thanking us for the excellent care we always gave his patients.

Sometimes administration finally does get it right.

I'm sure the patient's 5 year old daughter really appreciates that.

Nightmare Shift

Just another morning in the ICU (or so I think) as I walk up to the front nurses station to get my assignment.

I see my name next to a pair of patients, but then I notice it's also next to another pair of patients, but on the other side of the unit. 

"Hey Tracy," I call to the night charge nurse, "I think you've got me double assigned here."

"Weeeelll," she hedges, "Not really.  These two will be your assignment, but I need you to take these two also.  But just until their rooms are clean."

She can tell by my face, I'm sure, that I'm much less than thrilled.

"Don't worry, It will just be for a few minutes and you just have to wheel them upstairs, the night nurse already called report."

It occurs to me that the charge nurse, or the night nurse, seem quite capable of "just wheeling them upstairs".  I mean, I've heard of being tripled, but quadrupled?!  In the end though, I grudgingly accept the assignment.

By the time I get report on my two "real" patients, the unit secretary lets me know that the room is ready for one of my "fake" patients.  I glance in on my other patients to make sure they are breathing, load him up in a wheelchair and head for the elevators.

Once I return from settling him, the unit secretary tells me the other room is ready as well.  Maybe this is going to work out just like the charge nurse intended.  But that scares me almost as much as the stupid assignment, because if it does work, they'll be inclined to do it again.

When I go into the other room, the first thing I notice is that the chest tube atrium is almost full.  Knowing full well the floor nurses will bitch and moan about having to change it (and also a high likelihood they'll refuse to accept the patient until it's changed) I head to clean supply for a fresh atrium. 

I fill the atrium with the blue water (same color as the water in porta-johns, think about THAT for moment), clamp off the chest tubes, and make the new connections.  It's only when I slide the old, full one over that I notice the TWO other old, full atriums hiding under the end of the bed. 

Now realize, I haven't gotten any kind of report on this patient.  I really have no clue what's going on with him, even really what surgery he's had.  I assume he's had some sort of CT surgery, given the fact he has chest tubes in.  I pause, contemplating the significance of THREE full atriums.  I mean surely the physician knows, right?  Surely he wouldn't have written floor orders if it wasn't a resolved issue, right? 

Right?

I turn around and happen to look at the fresh new atrium.

The first chamber is already full.

As in 200 mls of fresh, frank blood.  And as I watch, the level is steadily rising. 

Ah crap.

I grab the chart to find out which physician I need to call.

Great.  Dr. Ballantine.  I have NO clue who he is, not one of our regular surgeons.  I fumble around, and find a cell phone number in the progress notes. 

Ring.  Ring.  Ring.

Finally a very tired doc answers the phone,  "....Hullo?"

"Dr. Ballantine?"

"...yeah?"

"Your patient Mr. Soandso is bleeding quite badly into his chest tubes."

"......"

"Um, I have 3 full atriums here, and he's put out 200, no, 400 mls now, in the last 10 minutes."

"......"

"Uh, sir?"

"What do you want me to do about it?" he slurs.

Dumbfounded, I stand there for a moment, only to be shaken from my reverie by the monitor alarming.  Guess whose pressure is now in the 60s.  He's also gone unresponsive.  I set the phone down on the counter to check a pulse.

Of course there is none.

I immediately leap up on the bed and start compressions.

"I need some help in here!!"  I yell.

But nobody seems to be coming.  I yell a second time.

Nobody.

Finally, I lean to the head of bed and while continuing compressions one handed, I mash the code button.  Now, normally we don't use the code button--we run our own codes.  Pushing the code button results in a room crowded too full of overeager, yet usually semi-clueless residents and interns.

Today is no exception.

My knight in shining armor turns out to be a first year resident.  I'm immediately reminded of the 4F's of a gallbladder differential diagnosis--Fat, Female, Forty, Fertile.  With huge boobs.  I wonder abstractly if her stethoscope is long enough to reach past her boobs?

She immediately decides my patient needs to be intubated--which is the most ridiculous thing to be concerned about at this particular moment.  No pulse, no pressure, probably no blood because the damn atrium is full again and the chest tubes look like red garden hoses.  And, since the patient was headed to the floor, no central access.  I tell the resident so.  She is clearly very pissed, but stops the intubation charade.

The room is filling up now, and someone FINALLY brings in the crash cart.

And of course, here comes RT trundling in with a vent.  The vent alarm is continuously going off, "Circuit Disconnect, Not Ventilating!!"

Only then I realize, it's my cell phone alarming.  And I'm home in bed.

Dreaming.

Awfully tiring working a shift in your dreams at night between two day shifts.

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?

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.

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.

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."

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!

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. After hanging 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.

Honor, Truth, Trust

Truth be told, I probably shouldn't be writing this post right now as exhausted as I am.

But today was such an epic day, I feel like I can't let a night's sleep go by without documenting it lest the urgency and intensity of these newly learned lessons fade away like a groggily remembered dream upon waking.

Today I was stretched to my limit in regards to knowledge, ability, precognition, skills... Any and every aspect of being a nurse was tested today. These are the days that make the battle for a position on a badass unit in an amazing hospital totally worth it.

I started the day with one patient. A complicated, but stable patient. I then admitted the first heart case out of the OR. The surgeon doing the surgery is known for his speedy technique, often he's done with CABGs in less than 2 hours.

Today's case took 5.

The patient was a re-do, having had a CABG x4 15 years ago. Today he had a CABG x2 and an AVR. The patient came crashing into the unit a little before noon with a SBP in the 50s. The anesthesiologist dinked him to get me enough BP to get him hooked up and a cardiac index shot. We got him started on epi, dobutamine, and levo. He was still tubed and was on propofol and precedex to boot. His index was crazy. His output was 7.5L, his index was 3.5, but his stroke volume was 40.3 and his SVR was 457... Whacked out numbers.

Once I regained a human BP in the patient, I then set about lowering it. This particular surgeon likes his MAP to be 55-65. Yes I know that the kidneys aren't being perfused at that pressure, and lord knows he's been told that a hundred times, but he doesn't care about the kidneys. He just doesn't want his slapstick grafts to bleed.

But that's a post for another day...

So I started weaning the epi and the levo, and ramped up the propofol and started nitroglycerin to bring his pressure back down. I finally get the patient stable with a SBP in the 70s, but a MAP of 55 just as the surgeon would like.

And then the brown stuff hit the proverbial fan. His rate shot up to the 120s, he dumped 400 ml out of his mediastinals in 45 minutes, his CVP dropped like a rock, and he started having PVC's and small 8-10 beat runs of v-tach. I crammed in 1250 ml of albumin, 3 units PRBCs and 2 units of FFP, and his hematocrit came up two lousy points.

Mercifully, he pseudo-stabilized and I thought all was good again, until I treated a 4.0 K per physician ordered protocol, and suddenly he has a 30 beat run(?) of v-tach and his SBP falls to the 50s again. He earned himself 2 grams of mag, an amp of lidocaine, and a lidocaine drip. He also just about sent me into SVT myself. Sent off a K level out of curiosity, and a 40 meq treat bumped his K from 4.0 to 5.2, all the while his urine output was >100 ml an hour. Tell me how that math works out!

But that wasn't even the hard part of my day.

This man's family was amazing. Sweet, sweet people, and very, very worried. But the complete trust and faith they had in me was staggering. And the sense of responsibility that generated was unexpectedly profound. I've always had a strong sense of duty to the patient--I'm well-versed in advocating for those that aren't able to stand up for themselves. However, the burden of care I experienced today was new to me, and it caught me by surprise a bit.

It struck me that where there was once an empty bed, a quiet, unoccupied space, now it was filled with love, worry, and concern. It was such a transformative experience--it was palpable in the air. My biggest fear was that I was going to let this wonderful family down. I have never worked so hard to stabilize a patient to date in my nursing experience.

Meanwhile, I was also counseling and supporting the wife of my other patient as she made the difficult decision to direct her husband's care from the western curative model to one of palliative care and a dignified end of life. She too was super sweet and so, so vulnerable. Hundreds of miles away from home and completely alone, she needed a great deal of help. The palliative care team was coordinating withdrawal of care as I left for the night.

Any day that I can learn something is a day not wasted. Any day I can be stretched to my limits without breaking is a blessing.

Today was a good day.

On The Other Side Of The Stirrups

I accompanied NurseXX to her first well-woman check-up since my son was born 2 years ago. Since the midwife group who presided over his birth only see OB patients, we were trying out a new OB/GYN.

As a healthcare professional, I tend to sit back and evaluate the experience perhaps with a little more objectivity than the average bear. Here's what I saw.

Our appointment was scheduled for 1330, and being new patients we were asked to arrive 15-20 minutes early to fill out paperwork. We arrived at 1310, and the doors were locked. When we were let inside the first interaction was, "Can I see your insurance card and drivers license?"

We were quite obviously the first appointment of the afternoon, given we were treated to listening to the lunchtime banter of a creepy, sleazy drug rep with the receptionists. Yet somehow we weren't shown back to the exam room until 15 minutes past our appointment time.

When we got to the exam room, the nurse took my wife's blood pressure manually, but did it so quickly there is no possible way she accurately heard any sounds. Oh, and inflated the cuff to 230 mmHG to start with. She then instructed my wife to change into a gown and drape after leaving a urine sample in the bathroom. Throughout the entire interaction, there was no greeting or "How are you doing?"

It was then that my wife realized the first time she'd meet the doctor, she'd be nude in a thin gown...

All in all the visit was actually a good one. The doc turned out to be super cool--she was very matter-of-fact, had an arm tattoo and a nose ring.

It just struck me that a few small changes could have made it a great visit, not just a good one.

RN-BSN

It's official. I am licensed to practice in my state.

I postscripted my name with RN for the first time signing for anti-rejection meds from pharmacy. It was rather anti-climactic and the pharmacy tech didn't care.

A fitting end to one journey, and the beginning of another.

I'm loving my unit, the people I work with are top notch. Everyone is super smart and motivated. We've received our share of the crippling winter weather that grips much of the nation at the moment. When most of the city is flat shutting down, our unit is the only one in the entire 1000 bed hospital that hasn't had a call-in during the bad weather. That's a pretty good indicator of the level of commitment and the sense of duty my coworkers harbor.

I had my first patient family member give me a huge hug for the care I gave. It was a good feeling. The patient was a 46 year old CABG x5 jumps, who had never been sick a day of his life. His near heart attack was an earth shattering event for them. Judging from the way his wife clung to my neck as I was telling her goodbye after transferring them to our step down unit, I may have helped bring them some small measure of stability and hope.

Work has been exhausting due to the sheer volume of information to learn, and I haven't seen my family much because of the lengthy weather commutes. Overall though, it's been good.

Professional Distance

One of my favorite bloggers, New nurse, in the hood (NNITH) has a really touching post, Haunted up over at her blog. I immediately wanted to comment, but as I started composing my thoughts I realized there was so much more to be said than should be left in a comment box.

I'm coming up on a year of work experience in an ICU, and I've made my way through all the clinicals associated with nursing school. All of that, though hard-won experience, isn't terribly impressive, and really I'm still just a baby as far as my nursing career goes. But, I have been around long enough to know that sometimes, certain patients just stick with you long after shift's end.

In school we were counseled on getting too close to our patients. We were told to maintain a professional demeanor, a professional distance, a certain detachment from our patients. This was necessary to protect the patients, and to protect ourselves. You see, we need to remain objective so as not to miss some critical sign or symptom. So as not to be blinded as to what is truly best for the patient. So that we can continue to function in highly stressful situations, and deliver the same standard of care to all whether through good news or bad.

Admirable advice really.

And I think it's a load of crap.

I work in an ICU. People come through our unit on a regular basis, and when you're a patient in the ICU it's generally for a reason. We don't typically see a lot of stubbed toes or sunburns--our patients are sick. Nearly all of them. Some are sicker than others, but everyone has the potential to backslide right down to death's door. Others claw their way back towards health, and I think it's our job to give them a hand up. Or sometimes let them know it's ok to just let go. I see so many gravely ill people that their faces and cases have already started to blend together a bit. The rooms in an ICU are witness to life-altering scenes, and when the patients are gone, the room gets cleaned--a set of fresh linens, and a liberal dose of CHG to wash away the tears and pain. Then, a new patient arrives, and we begin it all again.

I treat every patient with the same standard of care. I am equally conscientious, engaged, and caring, regardless. But the memory of some of them slips away to join my collective experience of the unit. Not individual anymore to me, but part of the background ambiance, or aura, if you will.

But others remain with me, their faces clear as day, dancing just at the edge of my vision in that moment between sleep and wakefulness. Their whispers still echo in my ears in the quiet moments, and I've come to realize their stories are firmly entwined in my heart--a part of my life experience.

I believe that patients like these are put in our path to teach us lessons. Sure, we may be the one to provide the patient care, to serve them, to fight for their well-being on their behalf when they simply cannot. But the true service comes from the lessons we learn about ourselves from them.

The emotions from losing the older gentleman patient that NNITH has written about haunt her in a very real, very painful way. But I guarantee she went home and told the people she cares for that she loves them.

It seems a terrible price to pay for life's lessons; to be haunted in a such a way. But are any of life's lessons worth knowing any less expensive?

We risk being hurt when we care. It's the price of admission of letting yourself be vulnerable. Opening ourselves to experience joy and love leaves us unguarded to pain and suffering as well.

As nurses we routinely intersect people's lives at times when they are in full-on crisis. They are frightened and angry. When we put ourselves in the path of these times and places, it's not unforeseen that they will begin to affect us.

So NNITH, please don't stop caring. I respect you because of the compassion you show for your patients. I respect you for your intolerance to bullshit when people come into your ED to waste everyone's time, and to steal attention and resources away from those that actually need it. I respect you for being affected when life happens in front of you, and you allow yourself to be a part of it, and to ultimately allow your soul to be touched.

I think you're an amazing nurse.

On Quitting

I quit.

No, really, I quit on a regular basis. It's not usually at anything earth-shattering, but it happens. I've noticed it most recently at the gym. The treadmill is a very objective way to measure performance, so when I set a benchmark it's all to easy to see my progress, or lack thereof.

I don't understand what the difference is from day to day. For example, I've run 30 minutes at a 10 minute pace numerous times. In fact I recently ran 40 minutes at that pace. Yet, some days I end up pulling up and walking less than 15 minutes in. I don't sense that I'm hurting any more than the days that I'm more successful--I just seem to have less tolerance. Sometimes something else going on in life is bothering me so badly that I simply can't cope with the discomfort of working out.

It's very frustrating to me. I'm aware that this reveals a great deal about my character, about my mental toughness. Or rather, my mental weakness.

This pattern of quitting carries over into all aspects of my life.

Did I quit too soon when life got uncomfortable after I graduated chiropractic school? Did I give up too easily? Did a little adversity cause me to fold and abandon the profession altogether?

Why was I so quick to post about being done with my marriage? Why did I want to quit after being with my wife since 1999? Is 11 years of commitment so easy to discard?

When one of my better friends from my small group at church tries to challenge me and my faith, why do I simply consider ending the friendship? Sure he isn't particularly good at being diplomatic, and has a certain talent for getting under my skin, but he, his wife, and kids are also among my wife's, my kid's, and my better friends. Why would I simply choose to remove them from our lives?

Because I quit.

It's an embarrassing habit to admit.

This weekend at work I helped take care of a gentleman that wasn't particularly old (middle 50s). He was a relatively newly diagnosed diabetic, and he was having a hard time complying with his regimen of care. He was on our unit for a round of DKA--he came in through the ER with a sugar in the 1200s. His wife was attentive and present. And she was trying her damnedest to get him to change his ways.

We got his sugar down, but he was terribly brittle. His hourly checks were jumping all over the place, sometimes 300-400 points in an hour despite being on an continuous insulin drip. But his level of consciousness was improving and his wife was able to talk with him. Even then she remarked at how depressed he was, and we reassured her that it was just the severe blood sugar extremes his body had been dealing with.

We began having a little trouble keeping his sats up. Every time he'd doze off, he'd start de-satting, and we kept having to rouse him, get him to deep breath and cough, and crank his O2 up to keep him above 95%. We paged the pulmonologist to come take a look at the patient, to possibly discuss a planned intubation, rather than having to emergently tube him in a crisis.

When the doc walked in to assess him, the monitor started alarming. Sats were fine, but his HR was dropping. As we watched he dropped from the 60s to the 50s to the 40s. I dashed across the hall to wheel in the crash cart, and by the time I got back he was dropping from the 30s into the 20s. And he just kept dropping. All the way to asystole. Code doses of epi and atropine didn't produce so much as a wiggle in his ECG. CPR perfused him a little, but as soon as we'd let up, he was still flat-lined. After 34 minutes of coding him, his wife asked us to stop. And the doc declared him.

We were all a little shocked, and completely at a loss to explain what had happened to him to his wife. But she knew.

"He just gave up," she said.

"He quit."

-----------

Saturday evening I went to the gym. There was only 1 other person upstairs in the cardio area when I got on the treadmill. I set a slightly slower pace than usual (5.5 mph instead of 6) just to ensure I'd make it to the end of my 30 minutes--something I'd failed to do in my previous 2 workouts. With Winston Churchill echoing in my ears I then proceeded to run for an hour, covering 5.7 miles and expending 1135 calories.

“Never give in, never give in, never; never; never; never - in nothing, great or small, large or petty - never give in except to convictions of honor and good sense."

--Winston Churchill

T&A

Last night I attended the local district meeting of the Texas Nurses Association. (TNA, *snicker*). It was held at Really Awesome Children's Hospital where I would really like to work--an added bonus. I'm required to attend one professional organization meeting as partial fulfillment of the requirements of my Professional Nursing Trends class.

Surprisingly enough, I thoroughly enjoyed myself. The speakers for the evening included a Really Awesome Children's Hospital employee and the mother of ex-26-weeker triplets. Their combined story was absolutely spellbinding. The over-arching theme was patient-family centered care. Not as a trendy catch-phrase, but in true practice. Things like parents and patients being included in rounds. Things like setting plan-of-care goals together with the patient and parents. Trusting parents to be the expert on their children. And absolutely non-judgmental care. Maybe these are all things you or your hospital does all or in part, but as a unified, intentional concept, I think it could truly change the face of healthcare.

Then the parent got up and spoke about her sons and made it all personal. And completely relevant. One of her sons has just battled so hard over the last 7 years. He's fought through being 14 weeks early, RSV, drug resistant H1N1, a lung transplant, air embolism and the subsequent loss of one of the transplanted lungs, paralysis, legal blindness, and many other hardships. This year he started kindergarten in a public school, and not in a special ed class either. It's an amazing story, and it was told so eloquently and passionately.

After it was over, I spoke with the mom and thanked her. I truly believe we don't get enough of the human element in nursing school, I think it gets lost. I think the profession is only lucky that the vast majority of those that aspire to become nurses harbor a well-developed sense of altruism. As a result, most of us quickly regain that human factor, if we've lost it at all. Probably it's the poop that weeds out most of the posers.

After talking with the speakers I managed to corner the chief nursing recruiter and chat her up. I've come to sense that there's a palpable difference in the atmosphere when you can tell that the people who work for an organization believe they work somewhere special. I so want to work someplace like that.

Do you hear me, Really Awesome Children's Hospital!?!

Epiphany

Last week I helped take care of a patient who had come in through the ED for a drug overdose/suicide attempt. 47 years old, his wife of 17 years had divorced him, and the legal proceedings were final. To celebrate he broke his 8 years of sobriety, got very, very drunk, and started downing pills. He took everything from Lexapro to Ativan. He quite nearly succeeded in killing himself. He had called his ex-wife to tell her his final goodbyes and she could tell he was slurring his words, became concerned and went to check on him. She found him unresponsive and called 911.

He'd been down for bit--his pH was 7.18, his pCO2 was in the 70s. By the time we got him, he was pumped full of charcoal, vented and restrained. I try hard not to be judgmental, but this guy was a character. He had an obvious metro-salon haircut, an elaborate nipple piercing, and his toenails were professionally painted. With daisies on his big toes, and zebra stripes on the others. People are only human, and we humans are some strange birds sometimes. When I inserted a foley on him it was obvious he had some kind of penile discharge--and not the kind you get from a monogamous relationship. So who knows the rest of the story regarding his marriage.

There were other qualities about him too; qualities I'd be envious of. He's a good looking guy--that body type that allows one to wear all the trendy fashions. Think J Crew or A&F. Based on his hygiene and personal effects, he was pretty affluent. He's clearly a guy that people gravitate towards, judging by the crowd that came to visit him. Probably the life of the party.

And in the quiet moments when we kicked his visitors out to suction him or clean the charcoal impregnated shit (one would think that charcoal shit would be odorless since charcoal is used to filter odors, but sadly, it's not) out of his bedding, I had a very harsh epiphany.

**If I'm not careful, I could very well be him in a few short years.**

I've alluded to wanting out of my marriage--that I've felt it's so stagnant that I feel I'll smother if I am required to bear any more hurt and insult. But the sad truth is, if my wife left me, I'd be devastated. And I don't know that I'd have any reason to keep on. I don't want to go so far as to say I'd be suicidal, but I can certainly foresee getting to the place where that might seem a viable option.

And what a horrible, horrible option it would be.

It seems the only truly viable option is to love her now. To love her the way she wants to be loved, not the way I think she wants to be loved. Even if I have to give the whole of myself away, isn't that a better option than splattering myself across the wall or ending up a shit burrito in some LTF somewhere? And maybe somewhere in the process, my love for her will set us free enough to allow that love to be returned.

I think there's a better chance of that in the here and now than if I were laying in a puddle of charcoal impregnated shit with a nasty green penile discharge 10 years from now.

I can change Ebenezer, I can change!

Cashing In Frequent Flier Miles

Today at work the charge pager went off detailing a full arrest that was coming through the doors of the ED. If the paramedics and the ED staff were successful in their efforts, we'd soon have the patient on our unit. As I readied the room, gathering suction, a vent, a Bair-hugger, restraints, SCD's--the whole nine yards--word came that it was a diabetic frequent flier.

This guy was known around our hospital because he visited. A lot. In fact, he'd only been discharged 3 days ago, on the 14th. He was admitted 4 times in April, twice in May, and twice in June. His last hospitalization for DKA lasted over 2 weeks.

He's lost 3 toes, 4 fingers, and most of the muscle mass on both buttocks and thighs. His kidneys are gone, ESRD, and his liver enzymes through the roof.

Did I mention he's 25?

You don't end up an old man at 25 without some compliance issues. Diabetes is quite manageable these days, especially Type I.

As we stood around waiting for news, we chuckled nervously that the RT on shift in the ED is like 1 for 25 in his CPR record. And then the family started arriving en masse. They wanted to wait in his ICU room while the drama played out in ED, and they set up home base there to begin their competitive grieving--wailing and carrying on so much the other patients and families began to ask questions.

As fortune would have it our trusty RT doubled his percentage, (now 2 for 26), and they got the patient back.

They should have left him dead.

He rolled onto our unit with a core temp of 90.7*. His pH was 6.81, his pCO2 was 125. He has no pupillary light reflex, no corneal reflex, no gag reflex, hyperactive c7 and s1 DTR's, a positive Babinski, an absent vestibular ocular reflex. His brain CT was normal (for the moment), but it wasn't long before he started decerebrate posturing, and the twitchy spastic jerks that always seem to accompany an imminent herniation.

Lifegift was consulted, but the way he's treated his body combined with the fact he's VRE and MDR enterobacter positive pretty much precludes placement of any of his tissues or organs.

Such a waste.

A waste of a life. And heaven knows his family tried to save him. Not to mention the staff of our hospital. There was no lack of trying to reach him. In fact he hated coming to our unit, leaving AMA once, simply because we force him to be compliant.

Just makes you wonder why people choose that path?

Now it's just a waiting game until the family chooses to withdraw, or he goes on his own.

Tip From A Lowly Extern

If you are going to brag to the house supervisor about all your previous hardcore ICU nursing experience and that you can easily handle floating to the ICU for the day...

...and then you feel it necessary to brag about all your previous hardcore ICU nursing experience to any ICU staff member who is (un)fortunate enough to be within earshot...

...and you're subsequently assigned a new admit from the ED sent to the ICU for sepsis with suspected peritoneal fistulas...

...and then you insert a foley catheter and get immediate return of 5200 ml of bloody, purulent "urine"...

...you should probably call the physician immediately (0730) rather than waiting until lunch time (1200) to brag about fixing your patient's distended abdomen by simply inserting a foley...

Because then your patient could have been rushed to emergency surgery at 0730 and you would have looked like you saved the patient's life with some timely critical thinking skills...

...rather than looking like a total farking idiot in front of the physician, surgeon, house supervisor, ICU staff, and patient family as the patient gets hustled off to surgery 5 hours later.

Oh yeah, and you probably wouldn't have gotten written up and pretty much banned from the ICU either.

But hey, what do I know, I'm just an extern.

Trauma Moulage

I recently volunteered as a moulage patient for an ATLS course at a local Level I trauma center. The nursing coordinator of the course happened to be a guest lecturer in my critical care class this past semester, so she took the opportunity to solicit volunteers. There were only 4 of us from a class of over 100 that agreed to help. Pretty poor showing in my opinion, but whatever. It turned out later that that we were actually paid $50 for helping out, a detail she purposely neglected to mention.

When I arrived at the hospital, I was immediately whisked off into make-up. They applied white theatrical makeup to my face and hands to simulate pallor, and some blue around my lips and fingertips to simulate cyanosis. Then a stab wound was constructed under my left arm, complete with copious fake blood.

I was then given my scenario to read over so I could effectively play the part of the victim. I was to play a young male whose wife had stabbed him with a large butcher knife. Immediately I recognized a problem--the wound was supposed to have been in the 3rd intercostal space at the mid-clavicular line, but they'd placed it under my arm, so it was more like the 6th or 7th intercostal space at the mid-axillary line. Enter the magic migrating wound, and after they'd already cut a hole in the side of my t-shirt!

As I read through the scenario I worked out in my head what my priorities for treatment would be for the patient--or rather I suppose, what I would anticipate the physician to order for the patient. I was pleasantly surprised to discover I pretty much nailed the scenario when I read through the answers at the end.

Essentially I would arrive at the hospital with a BP of 40/palp and a HR of 170 bpm. Additionally the EMT's were reporting a sucking chest wound and JVD. Given the wound location, my mind immediately leaped to three possible causes of the above symptom set--a tension pneumo, a hemo-thorax, or cardiac tamponade. I was most concerned about tamponade, but the other two aren't pretty either, and based on the basic ABC's they'd get addressed first. It turns out my thoughts were correct, and the patient (me) did indeed have all three issues.

When I got into the room for the testing phase of the seminar, I quickly realized that the docs taking the course were the brand-new, freshly minted first year residents coming on board starting July 1st. And that's when things got interesting, and a little scary.

I died the first 4 times.

Usually it was because an over eager doc stuffed an ET tube down my throat and hooked me up to a vent...with a tension pneumo. Once it was because the doc stood around and said, "Um..." a whole lot.

The residents made the same silly mistake over and over again. When they checked for responsiveness, I was instructed to moan. This was to clue them in that I indeed have an airway, and it was intact. However they didn't pick up on that, rather interpreting my moaning as unresponsive, requiring a GCS assessment that ultimately led them to my needing to be intubated. Granted, I was in bad enough shape that I would eventually end up intubated. Unfortunately, they missed some cardinal danger signs like tracheal deviation, decreased/absent breath sounds on one side, and, oh I don't know, a sucking chest wound.

So the course of care should have included a dart or needle aspiration for the tension pneumo. When my condition didn't improve, and breath sounds didn't normalize, a chest tube was in order. And then when vitals again didn't improve, even though breath sounds were equal, the resident would need to diagnose the tamponade. The scenario was set in a small rural hospital, so the residents didn't have access to an ultrasound machine for a FAST, and would have to rely on performing a pericardiocentesis instead.

I do have more educational background than the average nursing student, especially in "big picture" assessment. But it seemed these docs were missing things that I as a nursing student had been taught to watch for, and to assess. Either I'm getting one hell of an education, or some of these residents were a little slow on the uptake.

In all fairness, the other half of the residents I tested with nailed the scenario. Although the majority of them had trouble re-diagnosing the tamponade when symptoms returned as the pericardial sack refilled with blood. And almost nobody thought to attach an EKG lead to the needle to avoid puncturing the heart itself during the pericardiocentesis. Also, surely these first year residents wouldn't be unleashed on the unsuspecting public without supervision...right?

All in all I enjoyed the experience. It was fun and educational. I look forward to auditing the course myself at some point.

MmmKay? Thanks

Dear Charge Nurse:

Maybe next time we should assign a nurse who actually believes the patient will survive to said patient. I understand he had a massive heart attack, is on a balloon pump, is in renal failure, is maxed on 3 pressors, and needs CRRT, but having a nurse with a positive outlook would be so much more beneficial for the patient. Then the nurse wouldn't say things like, "I'm not in a hurry to start the CRRT, it's not like it's going to matter." And then the overly large family (17 people crammed into one ICU room) won't pick up on her pessimism and become angry because they believe the patient is receiving substandard care--especially if 2 family members are physicians themselves.

MmmKay? Thanks.

And while I'm on the subject, dear family members who happen to be physicians: You, of all people, should know that 17 people don't fit in an ICU room with a balloon pump, a CRRT machine and 2 trees of Alaris pumps maxed on modules. What would happen if we had to, say, code the patient and we couldn't get the crash cart, let alone the required staff, through the door and to the patient? It's an ICU room, not a freaking clown car.

MmmKay? Thanks.

Dear 184kg (404lbs!!!!) woman: Maybe you should seek medical attention for your massive cellulitis in your leg long before you've had it for the 12 months that you claim. Maybe then you won't end up in the ICU for emergency surgery for a wound that started as a blister from a bad pair of shoes. And, PS: When you weigh 404 lbs and it takes 3 of us to hold back the fat rolls so we can place a foley, you don't get to fuss about the procedure being embarrassing.

MmmKay? Thanks.

Dear 144kg (317lbs!!!) man: Maybe you should let your nurse know that you haven't pooped in 12 days (even if it is "normal" for you) BEFORE we give you kayexalate for a potassium of 6.9 (because your kidneys have shut down because you're in cardiogenic shock because your fat ass ejection fraction is a whopping 15%.) They don't make chucks big enough for 12 days of poop, so a little heads up would have been nice. And please don't say things like, "What do you think of my 'organ'?" while we're cleaning your junk up for the 4th time of the day. It's creepy and weird. "Looks about like every other one I've seen today."

MmmKay? Thanks.

Dear 94 y/o little old lady: We typically like to see more than one QRS per monitor screen so, maybe you could bring your heartrate up into at least the 30s for us? And maybe if you'd shut up with the small talk, your heart might actually have the energy to beat more often. I don't really enjoy "little old lady" CPR, you LOLs make too many popping sounds--and that's coming from an ex-chiropractor.

MmmKay? Thanks.

So yeah, kind of a busy 2 days at work.

Several days off now--Mmmkay? Thanks!

As I Lay Dying

I'm a big William Faulkner fan. Have been since we read his novel As I Lay Dying my freshman year. But that's not what this post is about.

Earlier this week at work we had a patient who was actively dying. Being around things like this is just part of working in an ICU. Being around things like this is just a part of nursing in general I guess. Nursing is all about beginnings and endings, and we only hope we make a difference and affect the things that happen in the middle.

The patient was being cared for by a nurse I don't normally associate with when I'm at work. You see, there are extern-friendly nurses, and then there are...well, the others. I'm only lucky to be in complete control over when I work, as well as who I work with when I choose to be at my job.

Sometime in the course of the day, the patient started to brady down. She dropped into the 40s, and since this particular nurse's stunning communication skills meant that she declined to inform the rest of the unit her patient was actively dying and was a DNR, several of us showed up inside the patient room ready to code the patient.

The patient was an old woman with a mane of beautiful white hair. With her face turned toward the window and head half-raised to heaven, the look in her eyes made it easy to tell she wasn't long for this world. At her side she had a brace of sturdy Southern sons who had each clearly gotten something in their eyes judging from the tears that wet their cheeks.

Beat by beat her heart rate climbed back into the 60s and the heavenly escort was waved off for only a touch-and-go for the time being. We all left the room and continued on with our day.

A couple of hours later, her pressures on the monitor started to dip precariously low--80s over 40s. When I got into the room I cycled the cuff again, and she was 70s over 30s. Her sons were not in the room. I hustled across to the nurse's other patient room and informed her that her patient's pressures were bottoming out.

She shrugged and said, "She's a DNR."

After I scooped my jaw up off the floor, I asked, "Where's the family? They aren't in the room?"

"I sent them out because visiting hours were over. Say, can you help me pull this patient up?"

I'm ashamed to say that I *did* help her pull the patient up in bed. I should have given her a death star glare, turned on my heel and marched right back to the dying patient's room.

But as soon as I was free, I did go into the room. I pulled up a chair, and sat down next to the patient.

And then I took her hand and quietly explained, "Ma'am, you can't let go just yet."

"Your sons aren't here just now," I whispered, "I'm so sorry, but they'll be back soon to see you off. Please hold on a little longer."

And she did.

When I came in the next morning, she was gone. Apparently shortly after shift change the night nurse brought the family back in, and the patient was gone within the hour.

I'm not saying that anything I did had anything to do with that. And I'm not saying that the nurse's other patient's care wasn't important. I don't know that in the practical sense that anything else could have happened.

But I do know this: As I Lay Dying, I don't want it to be in an empty room accompanied only by ringing monitor alarms.

I'd want someone to be there.