PixelRN

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.

In the weeds...

I really got beat up the other night. It was my first my first nightshift with two ICU patients. I came on at 7PM and both of my patients were missing 6PM meds that hadn't yet come up from the pharmacy. Looking back this seems like a minor detail and yet it was enough to put my entire night into a tailspin. I never felt fully in control, and with each hour it got worse. My preceptor was close by the entire night but she purposefully left me alone. I know this is what the preceptor is supposed to do. Otherwise, "how am I supposed to learn?" Persistent thoughts kept cropping up… "How am I ever going to be able to handle this?" and "Why did I not become a psych nurse?" I could be sitting in the day room right about now, playing UNO with the mentally ill… So now I am spending my precious free time composing a cheat sheet of all the commonly used protocols that I will be using… Calcium, Heparin, Insulin, Potassium…all the major players. It's one action that may or may not contribute to my perceived loss of control. I will also go to work and hour early and plan out my night. The rest of the time I will repeat in my head: You can do this you can do this you can do this. And hopefully somewhere in this process I will remember why I am doing this. It reminds me of when I was 19 and I got my first waitressing job in Ocean City, NJ. I lasted two days and finally gave up, thinking, "I will never ever be a waitress because I totally suck at it." Instead I took my fallback job as a pretzel roller at one of the first Auntie Anne's franchises. I was actually trained to make pretzels by Auntie Anne, herself. Little did I know that I would eventually go back to waitressing and it would end up being a 10+ year career.

I can tell death is going to be an issue.

It seems like the majority of the patients on my unit don't make it out alive. Most people who work on the unit say, "If they ever try to bring me here as a patient, shoot me first." They're not kidding. It really hit me the other day. I was looking through my alumni magazine (from the other degree) and in the "deaths" section I saw the name of a patient I had cared for. I was surprised because as far as I new he did make it off the unit and his wife had written a thank you letter to the staff. I yelled out, "Oh my god! It's (blank) (blank)! I cared for him in October!" My husband replied, "Don't tell me that!!! Remember HIPPA!!!" I briefly wondered if HIPPA applied to the deceased. Of course it does. On Thursday I was on the unit for an orientation day. I walked down the hall and I just happened to look into a room and I saw a patient dying. It was so strange. Her family was gathered around her. She was still as a statue with yellow, waxen skin. Her eyes were wide open. I felt fairly certain that she was already dead. How strange to think it will soon become an ordinary part of my job. Here I am with my orientation binder in my hand, going to the next class and there is death, just a few yards away from me. And with no ceremony, or outpouring of emotion. It was just ... there. So there's a lot of death on my unit. There's even a smell that I associate with death. Inwardly I think of it as "that MICU smell" and I've come to believe it's the odor of dying cells. I've suprised myself by how quickly I've gotten used to it. I can actually eat lasagna in the break room while I'm smelling it.