PixelRN

Gen X Nurse

I'm a Gen X nurse.

What does that mean?

In the most obvious sense it just means that I was born in 1970 and I'm a registered nurse. I try not to put too much stock in all of the generational stereotypes, but I have always felt like I was Generation X to the core. Gen Xers tend to be cynical. We're hard on ourselves and others. We have this reputation for being slackers, not because we're lazy, but because our standards are too high to just grab whatever old McJob comes our way.

When I graduated from college in 1992, I had a liberal arts degree and no clue what to do with it. I wasn't interested in graduate school. At that point I was ready for the next step. I wanted to play the game. I wanted to get a paycheck.

The conventional wisdom at the time was to pick a company. (How? Based on what?) Get an entry level position (doing what?) Establish yourself and move up the ranks (to become what, exactly?) It was all so nebulous.

So I got a job in a bakery. I have always loved working with food. It was extremely low-paying but that was okay. I was happy.

I knew it was a dead end job though, so I started taking community college courses. First in psychology (I thought I wanted to be an art therapist) and then in graphic design. Meanwhile I "moved up the ranks" and became a waitress. I started to make a lot more money and it was a job I rather enjoyed.

I did this for 10 years. I travelled a lot. Bought a house. Always in the back of my mind was, "You have a college degree! You should be doing something else!" But that voice was never quite convincing enough.

Then in August of 2001, I attended the funeral of a close friend's brother. He was a young, wonderful, hard working person who was ruthlessly killed by a drunk driver. Nothing like a funeral for a young person to send you into an existential tailspin.

I fell into a temporary despair. I desperately tried to come up with ideas for what I should be doing different, how to change my life.

And then September 11th happened. Despair turned into anger, followed by numbness. My existential tailspin was curtailed by the need to just go on living. To try and make sense of day to day things without being overcome by rage. I thought about joining the military.

8 months later I made the decision to start nursing school.

Sometimes it takes a tragedy to make you see what's really important. And the important thing for me was to do something that I could define, something that had meaning, and something I could take pride in. Sure I could pay my dues and work for a company, sell things, market things, design things, manage things, get promoted. But nursing is different. It's so much more simpler:

What does a nurse do?

She takes care of people when they are sick. And gets paid for it.

And that's why despite all the bitching and moaning I like to do about cleaning up poop, I'll probably always be a nurse.

Nurses: Do you have an exit strategy?

A slightly disturbing thing that I noticed this summer was the amount of nurses who have an exit strategy for leaving the bedside. It seemed like the majority of nurses I worked with were planning their exodus from bedside nursing in the form of CRNA school, NP school, or perhaps even just getting a MSN in order to obtain a more administrative role.

It certainly doesn't leave one with much hope for the profession. I wonder if other professions experience this phenomenom (i.e. how is the best way to put in my 2 years of drudgery and then advance?)

On the other hand, one thing I noticed was the advantages of raising a family when one parent is a nurse, because there is such a variety of shifts you can work. Here are some examples - these are all people I know:

• A nurse who does home health care during the day so she can be home when her kids come home from school.

• A nurse who works 4 weekend ICU shifts a month and spends the rest of her time staying home with her young children.

• A nurse manager who works M-F, 9-5 and has her kids in day care.

• A male nurse who works nights and weekends so his wife (also a nurse) can stay home with the kids

• A female nurse who works agency so her husband can stay home with the kids

• A nurse who mostly stays at home with her child but picks up contracts here and there when the family finances call for it (guess who that one is!)

• And I know a plethora of nurses who do the conventional ICU schedule (every other weekend, rotating days and nights) while raising a family with a spouse who quite often works an opposite schedule.

This last option is hard. Extremely hard. But if planned right, it can work to maximize the time that your family spends together.

I remember reading in one of my nursing theory textbooks that these types of nurses who fall in and out of the profession and will only work full time when it's convenient for them and their family are very bad for nursing. They don't contribute at all to advancing the cause of obtaining more power and respect for the profession.

And yet where would nursing be without them? For the most part they are the ones who aren't working on an exit strategy, because it all works out so well for them.

What Does it Really Take to be a Good Nurse?

I've often heard the complaint that nurses aren't handmaidens and shouldn't be treated as such. Head Nurse does a great job of addressing this in her post Handmaidens, Helpmeets and the Problems of Nursing. As much as I want to believe this, though, I have never been able to convince myself that this isn't true.

To illustrate my point, I'll give you a day in the life of working in the recovery room:

The charge nurse hands me a paper with a very minimal patient report. It usually includes the name of the procedure the patient had, any outcomes of the procedure, current vital signs, sedation and any other meds the patient might have received.

The patient is rolled in to the recovery room. I hook them up to the monitor and do a very minimal assessment (Are they awake? Are they in any pain? Are their vital signs within normal limits? Is the incision/puncture/drain site dry, clean, and intact? And most importantly, do they have a ride home?)

When I'm finished, I call the waiting room and let the family member(s) know they can come in.

I record vital signs and check on the patient's site every 15 minutes for an hour. Sometimes this is extended to every 30 minutes for the next hour, sometimes it isn't. If the patient is hungry or thirsty I'll give them a beverage, perhaps some crackers, maybe even a turkey sandwich. Sometimes I will help them on to the bed pan. If the patient is nauseous, I call the doc and ask for some phenergan. If the patient has pain issues, I call the doc and ask for some Tylox.

If the patient's vital signs fall out of wack I page the appropriate MD. If they fall precipitously out of wack I will have someone go to the procedure room of the appropriate MD and grab him or her. If they have no vital signs I will imediately call for help and start ACLS (this has never happened.) Sometimes the patient will bleed, or develop a hematoma at the puncture site. If this occurs, I hold pressure until it stops and notify the MD.

If the patient is being admitted I call report to the floor nurse. I unhook the patient from our monitor. If the patient is going to a monitored floor, then I hook them up to a transport monitor and take them to their floor. If the patient is going to a non-monitored floor, then I arrange to have a patient escort take the patient.

If the patient is going home, I give them some pre-printed discharge instructions, verbally explain them to the patient, and answer any questions. Then I remove the patient's IV(s) and send them on their way.

Is what I'm doing skilled and technical? Yes.

Am I using autonomy or intellect? No.

Am I using my skills of compassion and care? You bet I am. One of the only things that make the tedium of nursing bearable for me is when I get a patient who is anxious, or has questions, or wants to talk about their disease. They talk, I listen. I might even hold their hand. I answer questions. Sometimes I ask them questions because I know that they just need someone to talk to. They want someone with medical knowledge to help them process what is happening to them. I'm happy to be that person.

To further illustrate my point I'd like to say that some of the best, most effective, and knowledgeable nurses I've seen are either diploma nurses or associate degree nurses. It doesn't take a bachelor's degree to do what they do. So why is there this big movement to "intellectualize" the profession of nursing? At the university level they like to teach about the politics of the profession, and what nurses can do to gain more power. If that's the agenda they want to push forward, fine. Maybe some day they will gain power and change our healthcare system for the better. But I think it does future nurses a disservice when they find themselves in their first hospital job, expecting to have all these autonomous, intellectual tasks but instead find themselves doing all the skilled, technical, and menial stuff. Sometimes I think that what the nursing shortage really comes down to is that there are these tasks surrounding patient care that need to be completed around the clock, and there aren't enough nurses willing to do this kind of work.

But if the nurses aren't going to do it, who will?

It's Good to be a Nurse

Here's a diagram of post-procedural patient flow that I made, because that's just the kind of geeky nurse that I am:

 

As you can see, I recover radiology patients and cardiology patients.

So what do you call a radiology patient that has an acute MI in my recovery room?

DAMNED LUCKY!!!

I had written a long, finely crafted post to tell you this story, but then I read Phil Baumann's post on HIPAA and I remembered exactly why I typically do not blog about patient encounters.

So here's the Cliff Notes version, scrubbed of details:

(imagine the following paragraph being recited by an auctioneer)

"You just had a radiology procedure done and you're lying in the recovery room after your procedure when OUCH! you're having chest pain and the 12 lead was done and HEY! the cardiologist happens to be right here and OHHH! there happens to be a clean procedure room so we are going to cath you now and LOOK! there's a complete blockage of one of your coronary arteries and you could have died but we just stented it and now you're stable so it's off to the CCU don't let the door hit your behind on the way out. ADIOS. And don't forget to tell your family to rub the toe of the Jesus statue."

Several people came up to me afterward and said, "How does it feel? You saved a life today?" And I said, "I can't possibly take credit. It was the whole team, and a good bit of karma, all working together."

I still felt spectacular, though, because I was a part of the team that saved a life.

And that's why it's good to be a nurse. ( :

Should a Nurse have a Mission Statement?

I've been reading a lot of books lately on successful business strategies and the topic of mission statements often comes up.

It got me wondering, can nurses benefit from having a mission statement? Many of you already do, but you don't even realize it. A mission statement can be derived from your philosophy of nursing. For example, what does being a nurse mean to you? What makes a good nurse? Answer these questions and there is the beginning of your mission statement.

Why Would a Nurse Want a Mission Statement?

Quite simply, because it adds meaning to what you do. This can be a great help, especially to those who are suffering from nurse burnout. If you take a moment to reflect on your mission statement, it could serve as a source of inspiration on those days when you just feel like you are just running around in circles, and not really accomplishing anything.

Here's an example: As a recovery room nurse I often felt dragged down by all the repetitive, meaningless tasks that I was required to do (charting vitals Q 15 minutes, fetching ginger ale and crackers, removing IVs, etc). What if instead of dwelling on these things, instead I focused on the following mission statement:

For all of my patients, I am going to help them to be in control of their health care process. This would include:

• Making sure they know when and with whom to schedule a follow-up appointment.
• Making sure they have the proper educational tools; e.g. if they have a nephrostomy tube placed, do they know how to care for it? If they have a pacemaker placed, are they aware of what the settings are, and what these settings mean?
• Do they need copies of their lab values for their personal records?
• Have the doctors answered all of their questions related to the procedure?

Sure, most of these things are part of the job anyway, but if I view them in the context of my mission statement, it might make my job more meaningful, and hence, more satisfying.

If you had to choose a mission statement as a nurse, what would it be?

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.