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.

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!

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."

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.

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!

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 demand respectfully request you grow the #@$) up.

And it's only been 3 1/2 months!!!

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.

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!

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.

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 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.

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...

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.

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.

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.

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.

Precepted. But.

Everyone knows what makes or breaks an internship depends a great deal on how well an orientee and preceptor fit together. Some people need that warm fuzzy super supportive hand holder. Some people need the hard ass whip cracker to keep them on the straight and narrow. Some need constant supervision, while others are best left alone until questions arise.

Now admittedly, I'm a difficult case to match with the proper preceptor. I have a great deal of knowledge because of my background, and I've run across preceptor type people that get intimidated--they get hung up on that and fail to see my willingness to learn.

I want to know why we do things, so I tend to ask numerous questions. "Because the doctor wrote an order," and "We just always do it that way," are the bane of my existence. But I also want to learn how you do things, although I may quickly find my own way. I am a very kinesthetic learner, so to really own skills I need to actually do them, although I can reason my way through tasks intellectually. I'm capable of being quite flexible, but that can mean while I appear to be holding my own, I may not be getting what I need to learn or function best.

I'm not sure what the perfect preceptor for me would look like, but I'm pretty sure it's not the one that I've been assigned.

Unfortunately.

The hospital has set criteria for us to meet that count towards our yearly merit raises. The idea is that nurses who contribute back to the workplace take ownership of their workplace, and make it an all-around better place to work. These criteria include teaching projects, community service, leadership roles, and...precepting.

My preceptor has been banned from precepting females, apparently because he has a habit of making them cry. Although I suspect there was some chauvinistic behavior that didn't impress the ladies too much either, particularly since he's married. He's not much of a teacher, or a community service kind of guy. It pretty much leaves precepting for him to get his chance at the full 5% merit raise.

But.

That doesn't seem to take into account whether or not he really should be precepting.

He has all the tools. He's one of the most senior people on the unit, and at 8 years of service that gives you the idea of the turnover we experience. (We have 6 people leaving for CRNA school in August.) He is very knowledgeable. He is in a leadership position on the unit, working as a charge nurse.

But.

He has no people skills. He is sexist, and he constantly makes suggestive comments to and about the female staff members. He takes shortcuts--all the time. He laughs in the face of paperwork, often saying that if an issue can be resolved in the course of the shift, then the paperwork doesn't need to be filled out.

But.

Everyone puts up with it, and nothing gets done or said.

Fine, not my problem, right?

But.

Example #1: Second day on the floor, I'm given a new admit from the OR--a lung decortication secondary to aspergillus infection. Never taken care of a patient with that procedure done before, but she was vented and sedated with propofol, on a few pressors, on an insulin drip, and a fentanyl drip for analgesia--no big deal. My preceptor helped me get her settled, and then I went about managing her care--I was only supposed to have the one patient being my second day and all. About an hour later, he gets a patient from another floor--a trachea erosion secondary to radiation for esophageal cancer waiting for a tracheal stent. Pretty unstable patient actually. We get him settled in the bed next to my patient, and the two have our four bed pod to themselves. Things were clicking along just dandy.

But.

Then he disappeared, leaving me by myself with the two patients for the remaining half of shift.

When the oncoming shift comes in for report, come to find out the way my preceptor had told me to run the fentanyl drips (mcg/hr) is very much NOT acceptable on our unit--unbeknownst to me. It turns out we have a weight-based analgesia protocol in place (1-3/mcg/kg/hr for fentanyl). On the patient I was originally taking, what I was giving was actually less than the weight based formula minimum.

But.

On the tracheal stent dude I was running at 400 mcg/hr to keep him pain free. He weighed 110 kg, and simple math tells you that our weight based max dose of fentanyl is 330 mcg/hr...I was running 70 mcg/hr above our protocol max thanks to my preceptor's cowboy shenanigans.

If the patient had crashed, or become say, hypotensive, (like patients receiving fentanyl are prone to doing,) it would have been my ass hanging in the wind. My hospital has made it very, very clear that as long as we stay within the confines of the policies and procedures, they will back us 100%. Step outside the shadow of those protocols, and we've been told, in no uncertain terms, we're on our own.

I'm sure he'd have been in trouble too, his license in jeopardy, but frankly I don't give a shit what happens to him. He put MY license in jeopardy, and I've had the damn thing for less than a month.

The Gym Weeps For Me

Because I haven't been in over two weeks.

Lucky for me my weight has stayed stable, which is a small miracle considering my diet as of late. I can't believe how much time my job is taking from me. Right now I'm on dayshift for the purposes of orientation and the internship.

And it is absolutely killing me. I'm having to make choices like going to the gym or see my children.

I thought I'd have so much extra time when I started working. I mean, gone were the hours of studying for exams and writing up care plans of my nursing school days. I have a list of things I want to do.

• Reading, other than text books.
• Writing a novel.
• Plant a garden.
• Do some home improvement.
  
• Learn to play guitar.
• Learn to play the bagpipes.
• Learn to paint.
• Actively pursue getting my photography in more galleries.
  
• Build a tent-top camping trailer to pull behind the Jeep.
• Do some upgrades on the Jeep.

My new active lifestyle meant having time for:

• Camping/Backpacking trips.
• At least a 5K every month.
• Starting to ride a road bike and swimming so I can do my first triathlon.
• More travel: Scotland, Vancouver B.C., England, Germany, Austria.

Alas, it's not to be. At least not yet. Maybe it will ease when I come off orientation.

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.