From the Beginning: Chest Pains

Since my posts here have become a little sparse, I thought this might be a good time to consolidate my nursing school posts from an older blog. Here's a post about interview letters, originally posted September 13, 2008:

This is the start of a new blog, and I'll update with back story as we get further along. But for now, I'd just like to get a post on the books.

Wednesday in my nursing concepts course, the Dean of the nursing school dropped by. She was there to relay information that the nursing school has changed their application process, and instead of submitting a writing sample, the HESI A2 exam would be used to assess verbal and written communication skills. This wasn't news to me as I'd already taken the HESI as a part of my application process for Spring 2009. The exam did not prove strenuous and thankfully I scored very well. Apparently however, there were 4 applicants for the Spring 2009 class that did not take the exam during the appointed times, and thus their application was incomplete. Since ours is the first applying class to use the HESI, the nursing school has made arrangements to allow those 4 students to take the exam anyway, though the deadlines are past. I'm not sure I agree with that--the nursing school did send two letters and numerous emails about the HESI, but I suppose compassion is the best policy. Especially if I were one of the 4.

Anyway, during her 5 minute spiel, the Dean mentioned that interview letters for the Spring 2009 applying class had been mailed two days earlier, on Monday. Sitting in my seat, I got goosebumps. I knew that this could very well mean that if I were selected for an interview, my letter was probably sitting in our mailbox at that very moment. I had to strongly resist the urge to gather my things and slip out.

Alas, when I arrived home, there was no letter in my mailbox.

Now, for perspective, I live about 10 miles from school, in the same town. Mail usually travels within the city in one day. Mailed on Monday would have a strong possibility of being delivered on Tuesday, and almost positively by Wednesday. Stretching to Thursday was unusual, but not beyond the scope of imagination.

Thursday afternoon the mail arrived. No letter.

At this point I was getting concerned. My conversations with my advisor, and even the Dean, had led me to believe that I had a very strong chance of being accepted to the program, but I was beginning to have doubts.

On Friday, I made a special stop at the house to check the mail between a business lunch and my anatomy lab.

No letter.

Now I was relatively certain that a letter was not mailed to me on Monday, and the panic began to set in. My hands were shaking, my mind was reeling, and I honestly had chest pains. I'm not sure if that's how anxiety attacks feel, but I do know that I was not in a happy place as visions of our carefully laid plans came crashing down around me.

I knew that if I let things ride, I would be a wreck all weekend long. I needed action. I needed answers. As I drove my way to campus, I dialed 411 for the number to the nursing school and called to make an appointment with my advisor. Luckily she had an availability, even late on a Friday afternoon. Meanwhile, I numbly sat through anatomy lab, making small talk to my lab partners, and making all the incisions in our fetal pig for our group. (It's amazing what two trimesters spent dissecting a human cadaver for gross anatomy will give you tolerance for...or callousness to?)

As my advisor walked me back to her office, she asked how she could help. I tried very hard to remain completely calm and affable, and I think I did a pretty good job. I told her I was curious about my application, as I knew that the interview letters had been sent out, and I hadn't yet received one. In fact I was wondering how I might strengthen my application so that next semester I might be selected to move on in the application process.

She frowned at me and said, "But we mailed your letter just yesterday."

It turns out that since I have a professional degree already, I'm in a different applicant group than normal undergraduate applicants. My group's letters hadn't gone out until Thursday.

I'm certain my spontaneous relief was transparently obvious to her, because she apologized for having stressed me out so badly. She then made a copy of the letter from the duplicate in my file so I could bring it home with me.

All's well that ends well, right?

Well, one would hope, but now the system won't accept my login name to schedule my interview...

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.