P. R. N-competence.

So I started working PRN at the ICU where I did my externship. I'll be working 4 shifts a month, which works out to one a week, but it's nice in that I don't have to work them that way, I can clump them if I like.

It works well since the hospital is about 10 minutes from my house, as opposed to 45 minutes minimum to my other job. It also works well considering I have only 6 months experience, 3 1/2 months really if you look at my experience since coming off orientation. Most hospitals around here won't even glance at you until you have one year plus at least. My manager had to go to the CNO to get me approved. It's nice to have people willing to go to bat for you though.

One thing I've learned quickly though in my short career thus far is that experience doesn't necessarily equal competence. This has been vividly illustrated to me a couple of times recently.

This past week I sat through hospital and nursing orientation, (again) at my new job. Part of that orientation process involved a pair of EKG exams. The first of these exams was 15 questions long, but only the 4 lethal rhythms held any point value--25 points each. The other 11 questions weren't worth any points--information not announced to us, but readily available because the computer displayed point values for each question during the exam. The lethals were not difficult. Predictably there were strips showing asystole, v-fib, and a couple v-tach (one even a torsades, but that wasn't even an option to be picked.) Not rocket science, not tricky.

The nurse next to me there in orientation had been quite vocal about her 1 1/2 years of big-time experience at an ED in a medium-size town about an hour away from our metro area. She unfortunately failed the lethal EKG exam. Studied for 30 minutes, and promptly failed it again. Now she has to complete an EKG/Dysrhythmia course, just to keep her job.

Secondly, my wife is currently precepting at work. Her intern is a nurse with 18 months experience up on the floor and transferred into the PICU. But this nurse lacks basic skills like passing meds on time. She's been sent to a couple codes, only to stand around and watch. Even tasks such as recording vitals appears to be beyond her skill-set. In fact, it seems what she's demonstrated she's best at is letting the PICU nurses know, "That's not how we do it on the floor..." The scariest part of this situation is that she's already started her acute-care nurse practitioner program--online of course.

So on behalf of all us with less than that magic bullet of one year's experience... I rattle convention's cage!

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

A Quiet Shift

I worked yesterday for what felt like the first time in a long time, although in reality it had only been a week. It was however, the first time I'd worked with my regular crew in quite some time, so there was a bit of catching up to do.

Lucky for me, there was only one patient on the unit, leaving lots of time for chit chat.

The patient we did have was a mess though. She was originally brought in for shortness of breath which was a bit of an understatement. She was traveling to our area to visit her family, and in the middle of the night her portable oxygen ran out. She was discovered unresponsive the next morning when she failed to show up for breakfast. When EMS arrived on scene she was satting at 60%, and had been for who knows how long. She was surprisingly alert and oriented when she arrived in our ED, and begged not to be intubated. The physicians reluctantly agreed, even though her gas looked like crap. She then bottomed her pressures, and ended up on a couple pressors.

She has a pretty impressive history. Two valve replacements, and both were leaking so badly that her ejection fraction couldn't be determined by echo. She'd had an abdominal aortic aneurysm repaired, currently had a carotid aneurysm, and the our radiologist diagnosed a thoracic aortic aneurysm from the CT we took. Her chest X-ray was impressive too, what with the sternotomy wires, mechanical valves, and the massive infiltrates around her massively enlarged heart.

And best of all was the fact that she was as sweet as could be. She was a real pleasure to be around. I got to put in another IV and draw lots of labs since she was on serial heart enzymes as well as everything else.

About halfway through the shift, we got a second patient--a 17 year old girl who attempted suicide by downing about a months worth of her psych meds--clonidine and citalopram. We didn't get her until about 15 hours after the fact and she was so stable it was a joke. When questioned as to why she was being admitted to the ICU, we were told that the ED doc was concerned about her pressure after taking the clonidine. She was 80s over 60s, which might have been concerning if she'd been a 57 year old male with a beer gut. But a 17 year old girl?

Her mom showed up at the ED for about 10 minutes, and then left for the airport to go on the family vacation they had planned, leaving the stepdad behind to deal with her daughter--both of who were supposed to be going on the trip as well. Her concern for her daughter was overwhelming. Not hard to see why the poor girl felt she needed to pull stupid stunts like taking a bunch of pills to get attention.

I took blood cultures, labs, and started an 18 gauge in her hand since her ED-special AC stick was super positional.

It was a good day. Lots of chit-chat and I went 4/4 on sticks/IV starts.

Clarity

As previously stated, I've been trying to decide how energetically to pursue jobs at other hospitals since I've been all but guaranteed a position on the ICU where I'm externing. Like I've said before, it's the safe and familiar versus the new, exciting, and prestigious. It's an admittedly prodigious conundrum, especially granted the current job market that many graduate nurses are currently facing. Like any major decision though, I've been obsessing and over-thinking it nonstop since, well, last October when I secured my externship.

Over the past month though, we've had a series of patients that have helped show me the way. I wish I could say it's been a positive process, but it hasn't.

Patient #1: A late 30s male with a long psych history decided to take himself off his meds. The resulting psychotic break landed him in our hospital, (which was frustrating in itself since we're not a psych facility,) for what may, or may not have been a suicide attempt by alcohol. At first we were keeping him sedated because he ended up intubated. But when he was extubated, the beast was awakened. He became violent, combative, and generally uncooperative. At one point he assaulted a new grad nurse, and if I hadn't been there to physically intervene (as in bodily lifting him off the ground and body-slamming him back into the bed,) he might have actually hurt her. Needless to say, and rightfully so, he end up in 4 point restraints in the bed. But then we did nothing else for him for the next 72 hours while we went through the court system to get an OPC. Nothing. No psych meds, no sedation, no Ativan, no diet, no PT. Nothing. NOTHING.

Patient #2: This mid-50s woman was brought into the ED by EMS because her husband thought she had a mental status change. The only thing longer than the list of organs she'd had removed because of cancer, was the number of pain medications she was on. The ED gave her Narcan, and holy smokes did she wake up. She was 82 lbs on a bloated day, but she had the super-human strength of a junkie whose buzz had just been killed. It took 4 of us to hold her down long enough to get her in 4 point restraints. And there she stayed for the next 2 days. Completely in pain, and withdrawing from her pain meds. She was given no pain meds, no diet, no IV. No physician would help her.

Patient #3: This poor woman ended up on our unit for a suspected stomach mass, so the docs ordered her PEG tube clamped while they figured it out. Never mind that's how she was getting her meds for her Huntington's disease. We all watched as she slowly descended into Huntington's hell. She ended up restrained as her EPS symptoms accelerated. And. Nobody. Would. Advocate. For. Her.

I don't think I can last long on a unit where the culture allows for patients to just languish with no clear treatment goals, and tied to the bed. Maybe I don't have a clear idea as to what the realities of nursing truly are, but it disturbs me that this still happens.

I know for a fact this would never, ever, ever happen on my wife's unit at her hospital. Maybe it's because she works with kids. Or maybe it's because they have specialists on the unit 24-7. Maybe it's just that good of a hospital.

Regardless, these patients have pushed me to actively look elsewhere, and at hospitals with stellar reputations. My hope is that that translates into physicians and staff that actually care.

A little clarity is a good thing.

Any experienced nurses care to comment?

War of Attrition

When I first started my externship this past January, there were two GNs starting their internships on our unit. They were both externs during nursing school-- one on our unit, the other on a generic med-surg unit.

The GN that had externed on our unit made it out of her internship, but only a few weeks past that. It was quickly evident she wasn't ICU material, although she claimed it was because nobody would help her, and we all let her drown. Of course when you stand around flapping your jaws, people tend to assume you're caught up, and don't need help. But whatever. Whatever it takes to soothe that keen edge of personal responsibility.

The other GN did much, much better. She is turning into a solid nurse, especially for having as little experience as she does. She's 8 months in--always comes to work when she's on the schedule, and shows up swinging with both arms. She's doing really well.

Or so we thought.

Yesterday I found out she changed her status to PRN. When I asked where her new job was, she just gave me a blank look. Confused, I asked why she was going PRN if not for a new job. She just about broke down when she told me.

Since she started working she's been having major anxiety attacks at home. She's gaining weight, her hair is falling out. She's been having crazy dreams about patients and about work. One night she dreamed she'd left a patient in her car, and even though she knew better, she went downstairs to check her car, just to settle her mind. She'd been able to hold it together at work, but her personal life was a wreck, and she was a shell of a human at home.

I'd had no idea. None of us did. Didn't ask for help, didn't confide in anyone. She was trying to soldier on, on her own.

Now have no doubt, our ICU is relatively small. We're only 16 beds, and we get bypassed for most major traumas. But we are pretty busy and we do see our fair share of critically ill patients, and the pace can be pretty heavy.

I feel bad for her, I really do. I think she's selling herself short thinking she's not ICU material. This hits home for another reason too.

These days I sit and contemplate: Do I stay where I am or move to a major hospital in the area?

I like the unit I'm on. It's a brand new hospital built only 4 years ago. I know the people both on the unit and around the hospital. I know how things are done. I will get some solid experience, especially DKA's, post-cath, post CABG, STEMIs, strokes, renal failure, COPD. Pretty well rounded actually. It's only 7 minutes from my house by car. The down side, it's not a hugely impressive name on my resume. I won't see major traumas, and I may not see as *much* cool stuff.

The big-name hospitals are all at least 30 minute commutes, but they are all awesome organizations. I will no doubt get an amazing amount of experience. But with current job markets, I may not even get onto a dream unit.

And now, given my co-worker's plight, the self doubt starts to creep in. Could I really hack it on a truly busy unit? Am I up to the truly critical nature of the patients at a teaching hospital?

My current unit is safe. The big hospitals are the great unknown.

I'm scared to death regardless. Maybe like a patient extubated too soon, I just won't fly...

I don't know if I can take another graduation and then colossal failure.

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.

Hodge Podge

Sorry for the lack of posts, but my wife called in to work last weekend, so evenings I normally would have spent writing blog posts, I spent in family time instead.

Work has been super busy, and I've been working a lot. I'd been assigned a preceptor as an extern, but in the short term she's precepting an actual intern. Normally I hang out with her for the majority of the time I'm at work, with a few exceptions. These days though, since I'm an orphan, I spend more time with more people. I can tell they're beginning to trust me more by the simple fact I'm being sent into rooms to take care of increasingly complex nursing tasks by myself. It's gratifying, really.

"NurseXY, can you go change the chest tube dressings on bed 12?"

"NurseXY, bed 7 needs their central line redressed, do you mind?"

"NurseXY, can you go pull the femoral sheath on bed 4?"

It's nice to be used for more than blood sugars and turns. I seem to be pulling copious amounts of femoral sheaths lately. Most likely it's because the sheer enormity of my hay hooks is enough to scare even the most persistent hematoma into submission. That and when the doc specifies a particular time to pull (instead of relying on a bedside ACT), I have the strength to actually will the femoral artery to clot, simply by applying enough constant pressure to physically push the patient through the bed. It turns out it may actually be possible to return the blood from two trays of 4x4s and a washcloth soaked through back to the patient if you push hard enough...

Running is going pretty well. We're nearing the end of the second week of Week 4. The first workout of Week 5 seems almost like a step back, but the subsequent workouts definitely up the ante.

I had a hiccup last week where I wasn't able to finish a workout. I'd gone to the gym immediately after a counseling session, and unfortunately that was all I could think about on the treadmill. Oddly enough, even when said in a "safe" place, incredibly hurtful things are still hurtful. Especially when they come on the heels of laying your heart and soul bare to highest level of vulnerability. Fortunately, 2 days later I was able to complete the workout without problem, and at a faster speed yet. I'll not be going to gym after counseling again. Too painful. Too many kinds of pain.

That's all for now I think. More soon. Sorry it's not witty or particularly interesting.

The "S" Word

My day at work started off nice and quiet. No heart surgeries scheduled, 1 cath scheduled, and 6 patients. Lots of staff because two interns on orientation were there with their preceptors, along with two other nurses.

Then someone said the "S" word.

I'm sure it was just a casual mistake. A slip of the tongue. Probably didn't even realize what they'd said.

"I'm so glad we're slow today."

And then the other "S" word hit the fan.

Two CABG's hit the books, three scheduled cath's (and we got them all even though they sometimes go to the floor), two STEMI's came through the ED, along with a drug OD (47 y/o whose wife of 30 years left him.) Not to mention the 20 y/o woman with a history of lupus and ESRD who ended up tubed because she kept desatting. Turns out the "pneumonia" the docs were treating her for was actually bleeding in the lungs of unknown cause. She got a PICC line, a Quinton, and bronched. She had a rough morning.

At one point the nurse I was working with was tripled with the lupus/ESRD girl, a fresh CABG, and a fresh cath. They were rolling in faster than we could call staff in.

Rough day.

On a different note my wife and I started marriage counseling tonight. A step forward, but not an easy one.

And I'm getting sick with the snotties. But now I'm just being a baby.

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.

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.

Rejected, Officially

From my inbox:

Thank you for applying for the Summer 2010 Student Nurse Extern Program. We have filled all of our allotted positions and cannot accommodate you this summer. We appreciate your interest as well as your talent and skills. We had a record number of qualified applicants.

If you graduate December 2011 or later we would be glad to consider you for the program next summer.

Please keep in mind that [our hospital] has an excellent Graduate Nurse Intern Program. We train new graduate nurses in many pediatric specialty areas. We interview for this program in Feb/March for May graduates and October/November for December graduates. Please apply through our online application system during this open window.

Best wishes to you as you continue in your nursing program.

I have to say that while it is nice to finally get an official confirmation of my rejection, I had figured that out on my own given that the program started June 1st.

Just to be sure I understood that they didn't want me, they sent me the rejection email 3 times.

And yet, I'll probably still be applying for their "excellent Graduate Nurse Intern Program" in October. Sigh.

Meanwhile nurseXX's unit (my dream unit) just hired 5 GN's, NOT from their intern program. Double sigh.

When Nurses Harm Their Patients

I've had to deal with this head on in a couple of situations over the last week.

Scenario 1: (By word of mouth, but from a couple different sources that were highly corroborative.) Patient goes in to deliver baby, ends up heading to the OR for a C-section. Sometime after recovery, nurse draws up a dose of insulin, has a coworker cosign the dose, and administers it to the patient. The patient? Not a diabetic, and the wrong patient completely. The "dose"? 100 units, and the wrong dose. The patient's blood sugar? 3 mg/dl. Patient in a coma, nurses both fired.

Scenario 2: My patient at work. In for acute renal failure, 6.9 pH. Most likely septic shock--pressures 80s/50s while maxed on dobutamine, vasopressin, and norepinephrine, lactic acid over 13, anion gap 47, H&H was 7.2/24, zero bowel sounds, frank blood from the OG tube. Dead gut? Patient is vented. Past medical history reads like a patho textbook--100 year pack history, COPD, diabetes, CAD (s/p CABG), PAD, hypertension, hyperlipidemia, etc, etc. The patient was sick, sick, sick. Throughout my shift we'd managed to keep her stable enough. Minimal sedation, and minimal bucking of the vent--we were able to calm the patient by talking to her and repositioning. The night shift nurse comes on and receives report. Her first question is inquiring about what we've been using for sedation, and when she hears, "Nothing," she runs off muttering about how she wasn't going to have her patient bucking the vent all night.

Minutes later she comes back and says, "The patient has an order for propofol, I'm going to hang it."

My preceptor and I both freak out, saying, "With a pressure like that?"

She replies, "It's ok, I have pressors."

"But you're maxed out on all three of them!!"

I was actually planning on staying several more hours, but it wasn't very long before that nurse did indeed hang the propofol. I left, and went home.

I stopped in to work a couple days later and inquired about the patient. The patient coded and died that night. It seems her pressures bottomed out, and they couldn't get her back.

Scenario 1 just leaves me in awe. I hear she had to use two syringes to draw that dose--wouldn't that kind of trip the double-check-o-meter right there? And the nurse that "cosigned"? Oh my. I'm so going to be the un-cool nurse that demands to see the syringe and vial both when cosigning medications. I think that most people think that that procedure is in place to catch those newbie nurses with no experience that are bound to screw up. To me, those nurses aren't the ones to worry the most about. The really dangerous situations are when the nurse is experienced, and a level of trust has developed with coworkers. "I'm busy right now, but go ahead and give it and I'll cosign it later." And then some shift, just like any other shift, an experienced nurse makes a silly mistake and someone gets hurt, and the procedure has been worked around and failed. I believe the safety policies are most importantly in place to catch mistakes of that nature.

Scenario 2 frustrates me. The patient was clearly very sick, and quite probably was going to die. But I can't help but wonder if her death wasn't hastened on by the administration of a drug that is known to drop pressures, often precipitously. But what should one do when faced with such blatant disregard for critical thinking or patient safety? Who do you report things like that to? Do you report it? What happens when you have zero trust in the staff person you're handing a patient off to, or getting a patient from? How do you protect your patient and yourself in situations like that?

Any of you with more experience care to comment?

Abstract Thinking

One of the requirements for admission into the externship was writing a single page abstract answering the following two questions:

1. What do you hope to bring to this experience?

2. What do you hope to take away from this experience?

I wrote mine dutifully, with much thought and planning. I was pretty proud of it, but it wasn't mentioned in my phone interview.

So I thought I'd post it here--at least get a blog post out of my hard work.

Bring, Give, & Take Away—Children’s Medical Center Summer Extern Program

I bring a thirst for knowledge and excellence—the desire to learn and to be better. I still have so much to learn, and I believe the best way to gain that knowledge will be to live it.

I bring a multi-disciplinary point of view that has always centered about pediatrics and holism. As an older student I bring life experience, world experience, parenting experience. I have seen things, done things, experienced things that help me to meet people where they are; to respect, if not understand different points of view. My previous clinical doctorate affords me the essential basic skills of assessment, diagnosis, and perhaps most importantly, critical thinking.

I hope to give my time. As a husband and parent of three children, my time is quite valuable to me. There are few things that I deem important enough to take time from my family. This is.

I hope to give love, warmth, and respect to those I encounter. I will bring compassion, integrity, and professionalism in the hope I can give a part of myself to the patients, families, and staff that I come in contact with throughout the program. As I look back through my life, the people that have affected me in the most positive ways have embodied each of those traits. I hope that I too can affect people in a positive way—to make a difference.

I hope to give patient care that actually contributes to each patient’s recovery. I am so ready to begin making an impact as a nurse. I can hardly bear the wait until graduation, licensure, and practice.

I hope to take away a sense of ownership in pediatric nursing. My wife is a pediatric ICU nurse with 8 years experience, and I’ve consistently and actively sought out new experiences during nursing school clinicals—I feel I’ve seen the true face of pediatric nursing, but I want to own it.

I hope to take away 10 weeks of all-important, real-world experience. My clinical experiences through nursing school have been fantastic—but they always leave me wanting more.

I hope to take away a sense of pride in a job well done; a sense of accomplishment from a program that selects so few from so many. Being selected for the extern program would be an honor and a privilege.

I hope to discover my new job home, to take away long term plans and a view of my future. I hope to become a part of a well respected organization, and by that association become better for my experience. I do not deny my desire to work for Children’s Medical Center after graduation.

Networking

My wife and I attend a good sized church--about 10,000 members. It's big enough that we felt a little lost for awhile, and were torn about attending there at all. That is, until we got connected with a small group, and that made all the difference. But that's another post.

It turns out that our small group is led by the facilities director at the church, so we're often privy to a behind-the-curtain glimpse of what's going on. Considering the number of people on the church campus every Sunday, my friend decided it might be a good idea to have an emergency medical response team put together. In the process of recruiting volunteers for this team, he met a CRNA. Of course my friend mentioned that I was hoping to go to CRNA school in a few years, and the CRNA asked him to give me his email address.

I emailed the guy, we exchanged phone numbers, and I finally got to talk to him on Monday.

He spent about 30 minutes on the phone with me, answering all my questions about CRNA school, the CRNA job market, where he thinks the future for CRNAs will go, etc. Back when I was contemplating medical school, one of the biggest reasons I let go of that dream was the responses I got to the question I put to most of the physicians I'd interact with: "If you had it to do all over again, would you still choose to go to medical school?" Rarely did I get a physician tell me, "Yes, absolutely." And when they would say yes, it was always with qualifications or reservations. Mr. CRNA answered unequivocally that yes he'd do it again, no reservations. He loves his job.

I cannot even begin to tell you how much peace of mind this gives me. This is a running theme I've noticed with nearly every CRNA I've met. They're funny, engaging people that are a blast to be around. My guess is that it's because they're HAPPY. Nurse friends, tell me how many docs that you interact with, you can just tell they're HAPPY.

Anyway, back to the story. It turns out Mr. CRNA is not only a CRNA, but he owns a private practice that staffs two day surgery centers. But more than that, he is also a regular lecturer, at the school I want to attend. With. friends. on. the. admission. committee.

I have never met the guy, but he has already told me that if I do the work to get an interview (grades, work experience, GRE score) he'll sit down with me and help prepare me with actual questions the committee might will ask me. Then if he feels good about that, he'll call his admissions committee friends and drop my name.

Oh, and he wants to get together for lunch in the meantime.

God is good.

PS: No word from the externship hospital, yes, or no. Beginning to wonder if it was an organization I actually want to be a part of in the first place.

Disappointed

Things aren't looking good for getting into the pediatric externship. I was told that they take 2 applicants from each school, and 2 of my classmates have gotten phone calls. I called this morning and was told that there are only a few spots that haven't been offered yet, and that they were hoping to offer those to people out of the area. But she said she'd look at my file again.

I'm a little confused. I had a really great interview. I was told, "We really like our male externs, the patients respond really well to the males. We're extremely interested in you, so if you get an offer from another hospital before you hear from us, please give me a call before you accept, here's my direct number."

Of course, thinking about it now, the HR people aren't who make the final decisions anyway, so I imagine her words didn't hold as much water as I was hoping.

Everything seemed to be pointing that I was headed down the right path--the positive interview, an unsolicited yet amazing letter of recommendation from my pedi instructor.

I do know that the two girls from my school that got the externship both know someone there, so I'm sure that certainly didn't hurt their chances. I think it really does come down to relationships in the end, and I guess I just didn't have the right relationships in place.

This is a pretty major setback to my PICU dream--there's only two pediatric hospitals in town, my wife works in the PICU at one eliminating it from my choices, and I just got rejected by the other. It doesn't look good.

I guess I'm going to have to find a way to be ok with that.

Demented Curmudgeon

I first met Mr. Jones* several months ago when he was admitted to our unit from an Alzheimer's home with severe dehydration. His lytes were all over the place (along with accompanying dysrhythmias) and he was severely anemic. We patched him up and sent him up to the floor, but not before he earned a reputation here in the ICU.

There's pleasantly-confused dementia, and then there's the-world-is-out-to-get-me-and-I'm-taking-you-down-too dementia. Unfortunately, Mr. Jones fell into the latter group. Bad enough was his constant profanity-laced muttering under his breath. But he quickly earned a reputation for taking hostages by violently grabbing arms, hands, whatever was in reach, and not letting go. Sometimes his steely grip could be peeled back finger by finger, but more often it required getting on the call bell and pleading for reinforcements and rescue.

I remember being struck by the juxtaposition of his violent tendencies and the tender devotion of his wife. She was there every single day for morning, afternoon, and evening visiting hours. Knowing full well he must have been a good and decent man to deserve such loyalty, I remember thinking how unbearable it must be for her to sit by day after day and bear witness to the slow corruption of his mind and character. There were moments of crystal clear lucidity, and honestly I think they were worse than the dementia--because she had her husband back for one brief instant. She never knew for how long--sometimes long enough to reminisce. Sometimes only for the breadth of an "I love you."

After he was transferred upstairs, I'm not sure if he was ever discharged from our hospital or not. But I do know at some point he came down with pneumonia, ended up intubated, and right back in our unit. He's trached now, and vented. He can't talk, and his mentation has deteriorated to the point that he's mostly unresponsive, constantly agitated, and generally belligerant.

Today was a super busy day on the unit. We're full, and with sick, sick patients. From hepatic encephalopathy to CVVHD on a post-op CABG patient to a 232 kg woman bouncing between Mobitz type 2 and 3rd degree heart block.

As shift change approached, I was making my rounds helping reposition patients one last time. The last bed on my tour happened to be Mr. Jones, and as we got him turned he opened his eyes, looked me square in the face, and grabbed my arm. He's much weaker now and I had little trouble pulling free of his grip. When I did, I noticed he was more agitated after I let go. Putting my hand in his to hold onto seemed to calm him.

I sat down in the chair next to his bed and held his hand. He drifted off to sleep fairly quickly, much to our surprise. But each time I'd try to extricate my hand, he'd wake up and become agitated again.

And so I sat, holding his hand, letting him sleep. My shift was supposed to be done at 1915, but I stayed until 2000 when his wife returned for evening visiting hours.

It was just 45 minutes, but it was more than long enough for this indelible truth to reveal itself--that even in the midst of a completely demented hell, the human soul reaches out, grasping, searching, yearning to know. To know simply that we are not alone.

Thank you Mr. Jones for taking time out of your day to teach me this profound truth.

*Of course Mr. Jones isn't really named Mr. Jones.

Nursing Self-Dx

Overwhelming anxiety r/t waiting to hear about a pediatric summer externship program AEB short temper, excessive flatulence, and clumps of hair falling out.

They SAID they'd make a decision on April 15. They SAID if we got into the program we'd find out the 3rd week in April. They SAID if we weren't selected we'd get the obligatory up yours courtesy email by the end of the month.

It's definitely past April 15th. And we're almost done with the 3rd week of April. And the end of the month is approaching with all the delicacy and grace of a speeding 18-wheeler...

My phone simply refuses to ring. Every text message that vibrates sends me scrambling for my phone. I've nearly caused 2 wrecks on the highway trying to get the damn thing out of my pocket.

Don't think I haven't been obsessively checking for celebratory announcements on the Facebook pages of people I know who have also applied for the program.

This program is such a huge stepping stone, I can't even begin to explain. This is THE hospital I want to work in, and this is my chance to impress the unit I want to work on, the staff and managers. It's practically the only way to get hired into this fabulous hospital as a graduate nurse. Especially to the unit I want to work on.

The wait is literally giving me an ulcer.

No Report

I am a nurse extern at a medium size regional medical center just a few miles from my house. My home unit is the ICU, and I love it. The hospital is only 3 years old so everything is new, and it is in fact a beautiful building--gourmet chef to boot. The ICU is only 16 beds, but we do get our fair share of cool stuff. There are several heart surgeons who do surgeries, and our cath lab is super busy. About the only thing we don't see is major traumas--which in all reality is just fine by me.

One Saturday we got notified by the house supervisor we'd be getting a transfer from the floor. The patient was hypotensive (70s/30s), bradycardiac (low 40s), and her last blood sugar had been 28. My preceptor was the nurse open for the next admission, so the patient would be ours. I began setting up the room for an incoming patient and my preceptor did a quick look-in on our other patient while waiting for the floor nurse to call report.

No sooner had we turned our backs, then guess who came rolling through the door--without calling report. The floor nurse was in a dead panic, you could see the shell shock in the glazed look in her eyes. Even the transporter was sweating.

And the patient?

Well this sweet woman in her 80s smiled sweetly back at me from her comfortable hospital bed, and gave me a little half wave.

"Uh...how are you m'am?" I ask, more than a little incredulously, turning to look at the floor nurse.

"Fine!" is the response I got.

Now, I'm just a nurse extern, but super critically hypotensive, hypoglycemic, bradycardic 80-something-year-olds don't grin and say "Fine!"

We got her into the room, got a set of vitals and a blood sugar. Her pressure was 100s/60s, her HR was low 50s, and her sugar was 88. As I'm entering them into the computer I notice that these values are pretty much consistent with where she'd been running since she'd been admitted a few days ago. I also noticed that if the scary findings had been retested to verify, they certainly hadn't been put into the computer. Even more importantly, nothing had been done! No volume, no atropine, no D-50. Nothing.

Not sure why the floor nurse panicked quite so badly, but needless to say she was more than a little sheepish as she was finally giving report to my preceptor, and then quite defensive once she realized how silly she looked.

Meanwhile, the patient was prattling on about her 3 kids and 246 grandchildren, happy as a lark.

She got transferred back upstairs by the end of the shift.