PixelRN

I am so very normal.

Thank you for that comment, beenaroundtheblock; it?s becoming a theme in my development as a competent critical care nurse nurse. Case in point: The other night I was working side by side with the nurse who chewed me out after the worst day ever. Now, I never did end up confronting her, as my nurse manger would have liked. I decided the best course of action would be to continue to hold my own, and to use the lessons I learned from that very terrible day. (yeah, yeah, I know, I'm a chicken. I hate conflict.) So this nurse, I?ll call her Barbara. I feel a little awkward around her, seeing as I had an emotional outburst right in front of her and she seems to support this rule that there is no crying in nursing (!). But I go out of my way to work with Barbara as harmoniously as possible. When I need advice or help I don?t shy away from asking her because she does happen to have a lot of experience and knowledge. She does not seem to reciprocate this harmony. In fact, I have noticed that she will go out of her way to ask everyone for help, except me. I?m not sure why this is, or even if I was imagining it, but the other night is was made especially clear. My patient was next door to hers and she had an extremely busy assignment. How do I know it was busy? I had the exact same assignment two nights prior and ran my butt off from 7pm to 7am, stopping only once, briefly, to sit down, do some charting and eat a candy bar. I thought it was just me, being new and all. Man, you should have seen Barbara go. She was in the weeds, big time, and she absolutely would not ask me for help even when I offered it to her. So one of her pumps started alarming. I waited a few moments and then went to fix it for her because I knew she was busy in her other patient?s room. I noticed she was out of this medication and it was a med that had to be specially obtained from pharmacy with a fax. I knew this because I had started the patient on this med two days prior. I went next door: ?You?re out of high concentration fentanyl. I added some more volume but you are almost completely out.? From her ?Thanks.? ?Do you want me to fax pharmacy to get you some more?? ?Nope.? ?Are you sure?? ?Yep.? A half an hour later I heard her say this to another nurse: ?Shit!!! I?m out of high concentration Fentanyl and I have to get it from pharmacy!? I hate that I am even writing about this. Heck, I hate that I am even participating in it. (I can't say I wasn't gloating just a smidgeon when she ran out of the medication.) It seems so petty, and not at all what I imagined nursing would be like. It seems ridiculous to play these stupid games when we all have a job to do. After all, we work at GHOAT. We should be loftily discussing the merits of computerized charting, or the latest developments in ARDS research, or new treatments for sepsis. Maybe next time. I rotate back to day shifts this week so perhaps there will be some new loftier tales to tell on the horizon.

You want fries with that Atropine?

I know there are a lot of nursing students out there, as well as new nurses. I think it?s important to let you know that things do get better, especially if you have any experience waiting tables. With that in mind, here is a follow-up to the worst day ever. Over the weekend I had another particularly difficult assignment. One patient was an FTW (failure to wean ? meaning he was unable to be weaned from the ventilator.) He had about a bazillion dressings that needed to be changed and documented on. He also was just awake enough to mouth words and attempt to communicate with me. This always gets me. I have this habit of dropping everything I?m doing in order to try and understand my vented patient as they mouth words to me. I just cannot read lips, no matter how hard I try. For now, the best I can do is ask: Are you in pain? Are you warm enough? Are you comfortable? Do you need to be cleaned up? Do you want the TV on/off? That?s about it. I find it pretty hard to do my job while my patient is looking at me, trying to tell me something, and I am powerless to figure out what it is. Can you imagine being say, an accountant, and sitting at your desk trying to crunch numbers while someone is sitting next to you, silently pleading with you, mouthing words you don't understand? Can you imagine getting any work done at all? So mentally, I?m in a state of frazzledom. My other patient was admitted 2 hours ago, which means that she is busy! Lines to be placed, X-rays to be taken, CT scans, cultures, new meds, you name it, they are ordering it! Luckily she is comfortably sedated, and not mouthing words to me. So I am just barely keeping up. I?m merely treading water but my patients are still alive, dammit! Doesn?t that count for something? It?s toward the end of the day and I?ve almost gotten everything done for one patient, and ready to move onto the next. And patient #1 goes into V-tach. Just like that. This was not part of the plan. And just like that he bounces back into his regular if not somewhat tachy heart rate. So now the docs are at his bedside, coming up with all sorts of new things for me to do. This does not fit into my plan either. The time I allotted for his care is finished and now he is eating into the time of patient #2. So the treading stops and the drowning begins. But this time, I enlist the help of the charge nurse. Not only do I ask for help, but I tell her that I am drowning. She starts to take care of V-tach-er?s new orders so I can finish up my tasky stuff for patient #2. The charge nurse tells me that she took care of patient #1 last week and he was so busy that she was unable to leave his bedside the entire shift. Nice to know it?s not just me. In the end, everything is finished on time. But I go home thinking I am just not getting it. A good night?s sleep leaves me ready for round 2. I am even hoping that I will have the exact same patient assignment. The devil you know?

Part 2: Be careful what you wish for...

In morning report I find out that yes, I do have the same patient assignment and also that the unit is extremely understaffed and everyone will be busy. So more of the same. Only this time the v-tach-er has turned into a de-sat-er. He keeps dipping down into the low 80?s. I bump him up to 100% and suction. Bump him up and suction. Bump him up and suction. The theory on him today is that he has a mucous plug, and he is to be sent for a thoracic CT to confirm this. So I call the respiratory therapist in to see if she has any ideas. She does. Bag him, lavage him, THEN suction, with a longer suction catheter! Brilliant. I bag, she lavages and suctions, and together we pull up a couple of big gobs of mucous. Yay! Problem solved! We leave him alone for awhile and he is satting 99%. Moral of the story #1: When you have a patient with a Bivona trach and you are using an inline suction catheter, you may need to switch to a longer catheter that will go deeper. It?s funny, if I read the above statement in a textbook I would never remember it. Instead, I saw it in action and now it will forever be in my arsenal of ?things to do when my patient desats.? In nursing school I had this one professor who loved to rant about the saline bullet. She would always tell us that there is no evidence that routine lavaging and suctioning with a saline bullet improves outcomes. In my literal-minded nursing student head what I heard was, ?Saline bullets are evil! Only bad nurses use saline bullets!? So I never used them. Of course now I will. I think what she needed to make clear was that ROUTINE suctioning and lavaging should not be done. Every once in awhile, if the situation calls for it, it can be quite useful. At any rate, I got through these two shifts quite well. I did, however, confess to the charge nurse that I felt like I was not getting it. ?Please,? she said. ?Take a look around. Even the most experienced nurses on this unit have crazy, busy days. It?s just part of the job.? This was kind of an ?aha? moment for me. It?s just like waiting tables. You get in the weeds (waitress speak for ?I am totally freaking out of control right now and every single one of my tables wants something!?), and then you get out of the weeds. When you are in the weeds, you can?t see the other side of the weeds. When you are out of the weeds, you can even laugh about being in the weeds. One extremely important difference, though. When a waitress is in the weeds, someone might not get their chicken on time. When a nurse is in the weeds, someone might not get their (you fill in the blank?blood products? Pain meds? Epi? Atropine?) on time. Moral of the story #2: If you are a nurse and you find yourself in the weeds, ask for help. Your patient?s life may depend on it.

God - 1, MICU - 0

The hospital where I work - we?ll call it: GHOAT, "The Greatest Hospital Of All Time" (or so human resources would have us believe) - is often seen as the last stop for some patients. Other hospitals send their patients to my unit when they have run out of options. As a new grad, I often wonder just what it is that we do that is so different from other hospitals. Do we have some secret technology that we guard and use only for special cases? Do our docs and nurses have some sort of super-natural diagnostic and healing powers? Families seem to have this notion that "If anyone can save my loved one, GHOAT can." We end up with some disappointed families.

One of the things that we do is to pump unit after unit of blood products into a person who is bleeding out of their GI tract. At GHOAT, GI bleeders go straight to the MICU. And while I might sound cynical, I have to point out that I have also been amazed. One patient that comes to mind had 60 units pumped into him, on three separate occasions (The blood bank hates us!) The third time I really thought it was his time, but he survived. When I was an orientee, I had a patient who managed to start bleeding, get a cordis placed, received numerous blood products, all while I was at lunch and my preceptor was watching my patient.

So GHOAT received one of these GI bleeders the other night. The primary nurse was a friend of mine whom I had gone through orientation with. She had recently confided in me that she was miserable working on this unit, and that she was even questioning whether she was cut out for nursing. She knew this patient was going to be diffcult so she quickly enlisted the help of the entire unit. A table outside the room was turned into a makeshift assembly line, with bags and bags of fluids, flushes, and tubing. The Level One was in position and ready to go. There was nothing left to do but wait. Then we heard the ominous sound of the helicopter landing. Minutes later she was there. It was a young woman with cancer. She had a huge mass in her lower abdomen and was bleeding from somewhere in her lower GI tract. She was lying in a pool of blood. She was awake and alert and I think that's what made it so difficult. So everyone on the unit began working on her. The teamwork was amazing. Each person there seemed to effortlessly shift into a task. Someone was hanging pressors. Someone was checking blood. Someone was putting in a line. Someone was making runs to the blood bank, someone was manning the level one. Someone was giving oxygen. Someone was doing chest compressions, as she went in and out of conciousness. Someone was getting out the emergency drugs. Someone was holding her hand and telling her that we were taking care of her. Any nurses who were not in the room were making sure all the other patients on the unit were being taken care of. This went on for about two hours until the patient gave up and died. We were pretty despondent. There really was a point where it looked like she was going to survive. The unit was a mess. There was blood everywhere, being tracked around on the floor. The patient was lying in her own personal pool of blood. Her face was swollen from the rapid infusion of fluids. One of the nurses was very upset. "Where was the family? Why did this woman have to die surrounded by strangers? What chance did she have with her cancer?" And of course the answer to all of these questions is that she came to GHOAT, and that's we do at GHOAT. You want everything done for your family member? Take them to GHOAT.

Since the very beginning of my critical care education, this issue has always loomed large. How much do you do for the dying patient? When is it time to let go and just help the patient die in peace? Everyone in this field has a strong opinion on the matter, one way or the other. I'm starting to learn that you can't generalize this issue. You have to take it on a case by case basis.

The next night the palliative care nurse paid us a visit. Someone had told her about the recent death and she felt that we could use a tiny bit of counseling. She is no stranger to the MICU and thank God for that. In the MICU there are so many reasons to build up an emotional wall so you can continue to take care of business. I think she helps us to preserve a little piece of the emotionally vulnerable side. The wall is necessary, but you have to leave a little room for escape. So we talked about what a horrible blood bath it was, how it wasn't right that her family didn't get to see before she died. How it was so awful to see her face puff up like that. How the whole thing was futile because of her cancer. The palliative nurse's reply to all of this was completely surprising to me. She said, "You are all heroes." She pointed out that we joined together and made every effort possible to save this woman. Every person on the unit contributed in some way towards the effort. We did everything we possibly could do. And every step of the way there was a nurse speaking softly into her ear, telling her what was happening, and holding her hand.

So the above title is pretty corny, I know, but when she was saying the whole hero thing, I was mentally conjuring up this Michelangelo painting, where God and the angels were calling for this woman, and the MICU team was working on the ground, fighting to make her live. And my friend, the primary nurse who was thinking of giving up nursing? She did an excellent job. I said to her the next day, "You can't possibly be thinking that you're not cut out for nursing." "No," she said. "I'm thinking about transferring to the ER."

Bloggin' 1999 style

I love the Internet. Back in 1999 I visited a remote part of in the hopes of finding where my ancestors hailed from. This place, called Fanad Head, was one of the most breathtakingly beautiful places I had ever seen. I met a woman there who was interested in preserving the history of the place and she took me round and introduced me to some of the elderly people who lived there. We ended up at a dead end but she promised to help me follow up with my search. Unfortunately I lost touch with her and my search just kind of halted. Fast forward to 2002. I find an email list for people who are into Fanad. I leave a message asking the members if anyone knows this woman and how I can get in touch with her. No one knows her, which is strange, considering the population of Fanad is probably about 100. Yesterday that same woman?s daughter happened to have found my message and chose to email me and will put me in touch with her mother! The search is back on! In light of all this, I was inspired to dig out my old website. When I first started designing, back in 1996, I came across this website advertising a Liz Claibourne scent called, "Curve." Their concept was to have two friends go on a cross-country road trip, and chronicle their adventures on the Curve website. I'm pretty sure the two friends were invented, as was the entire trip. The whole thing was just a little too much of a GenX, Reality Bites sort of contrivance. But eureka! What a concept! You could actually travel, and then describe your travelling as you go via emails and websites. WOW. Remember, young ones, this was back when the Internet was new. Back in the early 90's if you wanted to communicate with people while you travelled, you used postcards (actual paper postcards with stamps!) and pay-phones to call your friends and family. At any rate, I decided that I would someday go on a roadtrip and chonicle my adventures via the web. In 1999 that is what I did. While I?m at it, I found this and that, which I designed in Flash. My aim was to design an online portfolio that I could use to get a kickass web design job. This was back in the days when I was all PIXEL and no RN. You may wonder why the RN ruled out over the PIXEL. There's some good reasons. First of all, I had a tiny little dregree in FINE ART. As much as I didn't want that to ruin me for the world of commercial art (i.e. in which you actually get a paycheck), it did. I became an art and design snob, which makes it really hard to "pay your dues" in the world of graphic design. My first paying job as a web designer was actually for a doctor (how ironic!) who was trying to advertise his services to ambulance chasing lawyers! My second job was for someone trying to sell golf clubs. I can't say I wasn't forewarned. One time I took graphic design class in which the instructor warned us that, "Once you get out into the real world, you won't be working on all these cool projects like we do in class. Most likely you will be designing ads for Purina Cat Chow." Lovely words of advice for a young student, so hopeful and encouraging. Unfortunetly those words are close to the truth. So where did the RN come from? Quite simply, one day someone said to me, out of the blue, "Have you ever thought about nursing?" I hadn't even considered it for one solid reason: I was afraid of blood. "Are you really afraid of blood?" that someone asked. I replied, "Well it may be something I could get over." It was and I did. Three years later I was working in the ICU. And what a surprise, I actually love caring for patients! Most days I go home thinking, "I love this job. It's rewarding, challenging and never boring." It's the anti-Purina Cat Chow. So that's the story of how the PIXEL became the PIXELRN, and not the FINEARTRN, or the FINEARTPIXEL.

The Worst Day Ever

09:45: This is where it starts. I am admitting a patient, a young NICU nurse with Crohn's disease, being worked up for possible liver failure. She was A&Ox3 and scared as HELL. And in pain. With a PCA. As much as I consider PCAs a wonderful invention, they always tend to exasperate me. The user interface kind of sucks. I think it's required to suck, so the patient can't figure out how to reprogram it. You also need a second RN to witness every change you make. It also involves heaps and heaps of documentation, including a computerized pain assessment form. Filling it out feels like trying to shove a square into the circle hole. Thanks, JCAHO. This young patient tells me that her mother is flying in from another city, where her 30 year old brother has just had surgery to remove his jaw. He has throat and neck cancer. So at some point I need to intercept the Mom and make sure she's not hysterical. I am starting to tear up, myself. As a new nurse, I have not yet developed that hardened exterior which prevents me from with over-emoting on the job. Back to the pain issue. I consider this a priority considering she's A&O and hemodynamically stable. She's also scheduled for a CT scan, so I want to get this issue wrapped up before she has to be transported. I had to negotiate with the resident 3 separate times to increase her dosage. He kept upping the demand dose by 0.1mg, which was ineffective. He was finally advised by the attending physician that it was okay to implement a basal rate of 1.0mg/hr. So each time he rewrote the dose I had to reprogram it, and find an RN to witness. This whole process took an hour. While I was admitting this patient, my other patient was being extubated after about 2 ? weeks on the ventilator. A precarious situation at best, I wasn't sure if he would fly. So I had to leave my new patient several times to coax my other patient to take deep breaths and get his 02 sats out of the 80s. So now the docs are rounding on my first patient. I really want to participate (and am expected to participate) so I can figure out where they are headed with her diagnosis and plan of care. Unfortunately I am busy re-programming the PCA, after having flagged down yet another nurse to witness my dose change). And now she's off to CT. It's noon. The docs have just ordered about 20 labs on her. She has one peripheral IV with D10 running through it. I need to stick her and am horrible at phlebotomy. I will deal with this when she comes back. I assess my other patient. He's fine so I sit down to work out this whole computerized pain flowsheet that I must document. I need to document every change I made, with an assessment to match, I need to document every aspect of her pain (quality? Duration? Onset? Who actually feels like answering these questions when you are, in fact, in pain?) I need to find the macros (tiny embeddied programs which add the pain assessments to my vital signs flowsheet) I am not sure which ones to use. I ask another nurse for help. She prints me out the official pain protocol. Nice of her to do so but it's really not helping me. My nurse manager walks by asks how I am. I tell her I'm really frustrated at the moment with the PCA and all the documentation associated with it. She suggests that maybe it's because I'm new and inexperienced with PCAs. Thoughtful of her to point this out but it's not helping my current situation. Not one iota. I look up at my monitor and realize that my extubated patient is not flying. His sats are down, pressure's up. I go in to find him very upset and agitated. He points downward. I lift up his sheet and see that he's lying in a massive pool of old bloody stool. His fecal incontinence bag has suddenly burst. He has had 3 massive GI bleeds in the past 3 weeks. The end-product was now in his bed. I grab yet another nurse to help me clean him up. We lay him flat and start to roll him and his 02 sats go down even more. He has audible wheezing. We straighten him back up again. We tells the docs, who order a chest x-ray. We then decide that if we crank up his 02 and get two additional nurses to help us, we can get this poor guy cleaned up. We were wrong. This time he desats AND bradys down to the 40s. One of the senior nurses tells me that if he has a choice between breathing and laying in bloody stool, he must choose breathing. Or else die. By now it's almost 2PM. My other patient has been back for awhile and I am woefully behind in her care. The charge nurse is telling me I must go to lunch. I am supposed to report off to another new nurse who is on orientation. I tell her I don't feel comfortable with this, there are too many tasks that need to be done. She tells me, "Well, the orientee has to learn, and if she can't do it then you need to delegate to someone else." Okay. So I find the orientee. Her patient has just returned from CT and his blood pressure is falling dangerous low. We collectively decide that I will delegate my tasks elsewhere. I find a nurse to help me and she agrees to draw all of my labs (yes!). While she is doing that I take the opportunity to catch up. I'm looking through all of my new orders. We use a computerized Physician Order Entry system (POE). When a patient gets transferred, the screen has a tendency to look very messy, with the current orders and the discontinued orders all culminating into one big cluster you-know-what. In the back of my mind I remember that my patient had a dangerously low blood sugar at 4:30AM. I am expecting the physicians to write an order to check blood sugars once an hour but I can't find this order. I did check her blood sugar at 11:00am (it was 150) and know the labs that were just drawn will give me another blood sugar, so I forget about this. I also have an order for vancomycin from 10AM. I seriously doubt that you can hang vancomycin and D10 so I'm wondering what to do. I investigate the matter and find out that it's an old order that should have been d/c'ed but never was. Now it's 3PM. The charge nurse insists I get off the unit and go to lunch. On the way the intern stops me and says that if her labs look good, we could probably transfer this patient to the step-down unit!!!! Great!!!! That would mean that this young scared patient would have been tranferred to 3 different units (as well as the CT scan) in less than 24 hours! How wonderfully efficient! I head down to the cafeteria. On the way I realize that something is going on with another patient I have had many times in the past. She's status/post lung transplant and has been intubated/reintubated at least 3-4 times in the past year. I am sensing that she is going to die today, as I see many of her family members around. I've gotten somewhat close with them over the past couple months and it frustrates me that I don't even have a single minute to spend with them and maybe give some comfort. That changes once I sit down to eat my cold pizza. The husband of this dying patient approaches the MICU lunch table and says tearfully, "I just want to thank you for all of your caring and support." I jump up from my chair. "Has Beverly passed?" "No," he says, "but she's going to." I give him a great big hug and burst into tears myself. Then I am back at the table and I've swallowed my tears. So much for emotional decompression. By 4PM I am back on the unit with renewed courage and resolve. Unfortunately my day will tailspin into a complete and total mess. My young patient? Her electrolyes are in the toilet. I need to replace them and I have no IV access. She has now begun continuously vomiting and has diarrhea, with no bathroom in her room, not even a commode. My other patient? He is more and more agitated. Since he tolerated laying flat for the physician to pull one of his central lines, I decide I will risk cleaning him again. Boy, was I wrong. This time he bradys down to the 30's. And all the other nurses are in the break room. Eating cake. For a baby shower. (If you've read my earlier posts you will know that I've been trying to conceive for two years now.)

PART TWO...

I am now giving my report to the night nurse. I preface this by saying, "Look. I've had a really terrible day. I felt like I never quite got caught up. I'm sure there are some things that I've missed." She shrugs this off and I continue on with report. We get to the part where we go over recent lab values. She says, "I don't care about her labs." I reply, "Well at least let me tell you about her abnormal electrolytes," and proceed to do so. Then we get to the part where we each review the orders of the day and sign off on them. She is already walking away from me. I ask, "Aren't you going to go over orders?" She just dismisses me with a wave of her hand and says, "I don't do that." It is our unit's nursing policy to review labs and orders. I am too tired to argue with her. Plus she has 10+ years seniority over me. I go home for 10 hours and return in the morning. I have given myself many pep talks so I can face the new day. Despite this, I feel extremely low. When I go to get report from the night nurse, she pulls me into an office and shuts the door. "Listen," she says. "I had to report you to Patient Safety Net." Apparently there WAS an order for 1 hour blood sugars. I had looked for it but I could not find it. Somehow it was there all along and I did not see it. Also, I left the potassium pills in the young patient's room. In the midst of her vomiting and diarrhea storm, I forgot to throw them away. She then proceeds to lecture me on everything I did wrong. She wants to know why my patient was admitted at 10AM and why my labs weren't drawn until 2:30PM. I guess she didn't realize that the labs were actually ORDERED AT NOON and that my patient was OFF THE UNIT FOR A CT SCAN. I try to defend myself to her. She comes back with, "In a court of law it doesn't matter! You have to CYA! You have to protect your license." Remember, folks. This is the same nurse who failed to follow nursing policy and review the orders and the lab values with me before I left for the night. So I did what I absolutely did not want to do. I burst into tears. Night nurse leaves the room to go get someone else to handle my emotional outburst. So after crying to the nurse educator for about an hour, I leave the unit. I am ill-equipped to handle patients that morning. I am thinking that no amount of pain is worth this. I am thinking that ICU nursing is probably not for me. There's a local psychiatric hospital that would hire me (if not admit me) on the spot. And people wonder why there's a nursing shortage.

Imagination in the ICU

I don't think I would admit this to my colleagues, but I find some of the expressions used in the ICU to be kind of heartwarming, if not downright charming. For example, when someone is about to be extubated and the nurse might say, "I really don't think he's gonna fly." The vision of a coughing, sputtering extubated patient turns into this: Or when someone is "bucking the vent" (which means the patient is breathing over the ventilator) the sick, struggling patient turns becomes this: Or my absolute favorite, "The Renal Player." This simply means a patient who has kidney problems. Whenever I hear this, I picture a bunch of dialysis patients sitting around playing poker in Las Vegas. For more interesting ICU imaginative stimuli, check out Bob's Dreams. This patient actually recorded his dreams after being vented and sedated with ARDS.

ESP & SVT

I dreamt that my patient went into V-tach, or something like it. As commotion ensued, I was trying to remember everything I could about ACLS (which isn't a lot). What kept going through my head was that you have to shock V-tack, but for almost everything else you start with drugs (atropine, epinephrine, etc.) So the essential theme was: Shock? Or drugs? Shock or drugs? Shock or drugs? WHICH IS IT??? Then my patient got up and ran away before we had a chance to do anything. In real life, I got to work and in morning report heard that the patient I had previously admitted did, in fact, go into V-tach, then received amiodarone, and synchronized cardioversion, and was stable now. And it gets better. The docs were about to round on my patient when the resident from the previous night told me what had happened. She was trying to insert a central line in him and as the catheter got close to his heart, he started in with this crazy arrhythmia. The residents collectively decided it was Supraventricular Tachycardia and decided to give amiodarone. Meanwhile the charge nurse was yelling at her "You have to shock him! It's V-tach!" The resident was very upset with the nurse for yelling at her, particularly because the patient at the time had a pulse. So it was a lot like my dream, except that my patient never got up and ran away. Instead he flew away. More on that later. Meanwhile I think it's time to go out and get my ACLS certification.

A Baby Story, Part 2

If you haven't already, you might want to read A Baby Story, first. I just happened to be 20 minutes early going to work when I got the phone call that the baby was born. I was so excited; I mean, what are the chances that I would actually be early for work on that particular day? So I was able to visit with them in the morning and during lunch and share their first joyful moments as a family together. They are both very close friends of mine; you could actually say I was instrumental in getting them together, so I was very grateful to be able to share these moments with them. I went back to work, absolutely beaming with happiness. Then the second set of troubles started. Before you read further, please don’t anticipate that there was any trouble with my friend’s baby. He is healthy and thriving. No, the trouble was with me. It is after all, my blog. I will preface this by saying that my husband and I have been trying to conceive a child for the past year and a half, without success. It’s a very frustrating situation, but I guess I didn’t know just how frustrated I was until the afternoon I was deluged by a mob of pregnant women at work. To set the scene: It was a half hour before shift change and I was receiving a new patient. Picture 5-7 people in a tiny ICU room, each person doing a different task in an amazing display of teamwork, in order to get the new patient settled in. It was my admission, but everyone was so competent and quick and more experienced than I, that they kind of took over. I tried to absorb everything and contribute what I could. It was so second nature to them that they immediately fell into this animated conversation that had nothing to do with the patient. It in fact had everything to do with…pregnancy. One of the senior nurses has this odd psychic habit of dreaming of fishes each time a nurse on the unit finds out she is pregnant. She had recently dreamt of fish and the charge nurse was telling us that she believed the dream was about her. Squeals of delight ensued, everyone was ecstatic. I looked around the room and realized that out of the group of nurses that were helping me, two of them were already pregnant, another one had just given birth a month ago, and the charge nurse was announcing that she was pregnant. Well. That was just a bit too much for me. I could feel the tears about to come, the flood gates were about to open. But like Tom Hanks says, “There’s no crying in baseball.” Thank god for the face shields that we wear when our patient is on isolation. No one could see that my eyes were welling up. So I swallowed it down and continued about my business. Eventually the patient got settled in and everyone left to go get ready for shift change. Now that I was alone I couldn’t stop thinking about what had ensued. The events from the past few days flashed through my mind: the brain dead mother with the expelled fetus, my friend’s baby downstairs, and now this. The floodgates broke. At that exact moment, the charge nurse (who is a wonderful person, by the way, and I felt horrible for inwardly raining on her parade) came back around to see if I was okay. She saw my tears and immediately handed me some tissues and sent me to the back office to let it all out. Then she set about tying up my loose ends for me. So let it all out I did, wiping my eyes down with the sandpaper-like hospital tissues. The charge nurse came back and I explained the whole awkward situation to her. Coincidentally, she just happened to be the one who guided me through the whole deceased pregnant woman situation, and she was very understanding. Later that night, I had a premonitory dream about the patient that I had just admitted.

A Baby Story

There was a 26 year old patient that I took care of the night before I left for a long weekend in San Francisco. She was found unresponsive in her home with her 18 month old baby running around the house naked. Her insulin pump was off. She had a history of poorly controlled diabetes and she was 12 weeks pregnant. It was unclear how long she had been unresponsive, it could have been as long as 48 hours. The night that I cared for her, she had just had an MRI which showed cytotoxic edema and a good portion of her brain was no longer functioning. In short, not a good prognosis. The death of brain cells is almost always permanent. And the fetus was simply too young to be sustained, even if the woman was kept alive on life support. Although interestingly enough, this had just happened with a Virginia woman. So it was a very sad night. Her husband and some family members were at the bedside. They had been explained the MRI results and the poor prognosis, but it hadn't seemed to sink in yet. For myself, that was the most heartbreaking. I watched them trying to wake her up and falsely interpret her eye movements as hopeful signs that she would get better. Later the husband slipped her baby's shirt under her still hand and went to the waiting room to try and sleep. The shirt had a tiny little baby food stain on it. On the upside, I got to perform neuro checks on her every two hours and was able to see some features of brain injury that I had never seen before including decerebrate posturing, doll's eyes, and positive Babinski reflex. So I went to San Francisco for a few days and when I came back to work I was given this patient again, only she had died fifteen minutes before the start of my shift. This meant that I was responsible for her post-mortem care. I was somewhat apprehensive, as I had not done post-mortem care during my orientation and so this was, in fact, my first time. The unit was somewhat busy but I managed to find another nurse to help me lift the patient onto the stretcher to take her to the morgue. When we entered the room to do this there was a strange but somewhat familiar odor. We pulled away her sheets and saw that she had expelled the fetus. The site was both disturbing and mesmerizing. How often do you get to see a perfect thirteen week old fetus? I certainly had never seen one. The perfection of it was amazing. So tiny, and yet each little toe and finger were perfectly formed. Then the troubles started. No one really knew what to do about the situation. In the whole history of my unit this had never happened before. What do you do with the fetus? I told the team of physicians who were rounding at the time. The matter was further complicated by the fact that they hadn't yet asked the family if they wanted an autopsy. And this factor would determine where I sent the fetus – either to pathology, or to the morgue. And what do I put the fetus in? One senior nurse said to just wrap it up with the mother and take it down. But what if the fetus was missed, or got thrown away by accident? What if the family wanted to bury the fetus? All of these issues had to be dealt with and yet I had never even done post-mortem care on a regular deceased patient! And I was caring for another patient the whole time this was happening. Everyone involved from the charge nurse to the attending was quite unsure what to do, and it wasn't exactly a priority considering the rest of the unit was filled with patients who were still alive. I was frustrated, confused and kind of in a state of shock. Finally, like an angel, the palliative care nurse swept through the unit, came and grabbed my hand, looked me in the eyes and said, "You shouldn't be going through this alone. Let me get you some help." I almost burst into tears. I felt like a small child who doesn't cry when they fall if no one is watching, but the minute someone takes notice, they cry. I did not cry, however. Not at that particular time, anyway. One by one, all of my questions were answered, and I was able to properly take the mother and the fetus to the morgue. 24 hours later, a very good friend of mine gave birth to a beautiful, healthy, baby boy in the same hospital, 5 floors below my unit. And on that note, I'll end with a lovely picture I took at Big Sur. PS: Tommy died in the MICU last week with his headphones on, listening to Radiohead.

Liver Head

Since coming off orientation I seem to be caring for a disproportionate amount of liver failure patients. At first I saw this as a bad thing, but now I've come to think of it as an opportunity to learn all I can about hepatic encephalopathy. Which isn't much. This is what normally happens: You body digests proteins, and ammonia is left as a byproduct. The liver gets rid of the ammonia and that's that. When the liver fails to function, the ammonia particles hang around the body like so many unwanted guests at a party that's been long over. This ammonia is toxic to the central nervous system. And this is as far as I got. No one seems to know why or how it's toxic – just that it is. And the treatment for this ammonia overload? The dreaded lactulose enema. So caring for the liver failure patient means dealing with his crumbling neuro status, while trying to make him poop out as much ammonia as possible. Your patient ranges from being slightly confused, to acting somewhat psychotic, to eventually landing in a hepatic coma. The first patient was 27. I'll call him Tommy. Suspected alcoholic liver failure, but this could not be confirmed. He was past the mildly confused stage and heading towards psychosis. Where I went wrong was that I was fresh from orientation and so I was nervous, scared and somewhat hesitant in my care. He sensed this, and so viewed me as a threat. When his family came to visit him I went in to draw my noon labs and he started thrashing in the bed and trying to kick me. His dad asked him what's wrong and he pointed at me and said, "She's trying to hurt me!" My heart started racing. I left the room, got the charge nurse to draw the labs and watch over him for the next hour or so. I went to lunch and this was what I was thinking: My patient wants to kill me. This nursing thing just isn't for me. But more importantly: How in the Hell am I going to give him his lactulose enema when a. he already thinks I'm trying to hurt him, and b. I've never given an enema before. Thank God for co-workers. They listened to my story, gave me assorted pep talks, and all promised to help with the enema. I was ready to go back for Round Two with Tommy. I will spare the details and just share with you what I learned. When a patient is liver-confused, they will take cues from you as to how they should feel. Tommy saw that as I was scared and nervous and he mirrored this back to me. I started to convince myself that Tommy was harmless. He was a scared little boy that needed my help. I was his nurse and I was there to help him. I started changing my vocal tone to sound more soothing. For every moment that he did not get threatening or agitated with me I praised him in a sing-songy voice. I felt funny doing this but the bottom line is that it was working. By the end of the shift he actually let me start an IV on him! Later it occurred to me that I was using things I had learned from obedience training for my dog: Praise when being good. The dog takes his cues from you, so don't show fear.