The Worst

There are lots of stinky, drippy, oozy, things in my day. Most of them I barely register before moving on. Some register more than others, though. I used to think the worst thing I'd ever felt was the sensation of being buried elbows deep in the abdominal fat tissue of a patient. Tucking Kerlix (total: 6) into the far recesses of the subcutaneous tissues while the skin and fat lapped over my gloves onto my forearm was horrifying. I learned very quickly to wear the blue, plastic isolation gowns and sterile gloves, since they're longer than the nitrile for dressing changes.

But I was recently reacquainted with the feeling of an unstable chest. Long ago and far away, I had my first code blue. I'd been a part of a good many before this one, but this one was mine. Since it was my patient I felt, all in one moment, ashamed that I'd missed the warning signs, the shot of adrenaline that comes with the ohshit moment, and eager to prove my worthiness as a nurse. So I bounded into the room, cape flying, and purposed to give the best possible compressions that had ever been given in the history of CPR. On all 80lbs of my patient. The first crunches that accompanied my first compression are marked indelibly in my memory. The room spun and my vision narrowed momentarily. But I yanked on my bootstraps and kept compressing, tears running down my face. That patient didn't make it and I forever swore off compressions. I didn't know then that effective compressions, about 1.5 or so inches in depth, will often break ribs. I didn't know how to modify the force of my compressions to suit the individual. I certainly didn't know that at a future point I would be throwing my entire body weight into compressions, actually lifting my feet off the stepstool, and barely making a dent in the body habitus I was endeavoring to "save." I just knew when I got home after that shift, I spent a long time crying.

I was the recipient of someone post CPR the other day. The code was prolonged and bystander CPR was ineffective (it usually is). There was a high probability of irreversible damage to the brain and so all medications that might sedate were held for a period of time to see what, if any, neurological function was preserved. Eyelid opening did nothing, neither did nailbed pressure. I casually went to sternal rub my patient and immediate flashback. Unstable chest. Fractured ribs from compressions. Once again horrified, ashamed, de-caped as it were. I couldn't bring myself to inflict any more pain on someone who'd been through so much.

As bad as being inside that belly was, being outside those chest walls was the worst.

Dear Mom

I've seen a lot of you lately. Weeping mutely next to your son or daughter. Lovingly wiping his or her face with a damp cloth. I've seen you despondent and hopeless behind the bed so he or she can't see. I've seen you put off battling your own life-threatening illnesses to be at your son or daughter's bedside 24/7. I've seen the bags form under your eyes as the days go by without sleeping in a bed, showering in a friend's shower, eating whatever those who love you bring to the bedside. I've seen the weight you've lost, the grays form in your hair, the tightening of your mouth with the doctor's entrance. I've held you while you've cried and held you while you've celebrated. I've eaten the chocolate and homemade truffles you've sent. I've privately agonized with you while professionally ministering to you as best I can. And, to my eternal shame, I've sat next to you and held your hand while I advised you to withdraw care on your daughter.

I'm amazed and awed by you. What would render me completely incapacitated puts steel in your spine. What would have me curled up on the floor in tears strengthens your resolve. I promise you that it's your tender, everpresent, palpable love that heals your child. I provide the framework and some fancy drugs. But you do the healing.

How do you go from kissing a skinned knee to seeing your baby helpless in a bed, hooked up to monitoring equipment and life support? How do you look your child in the face after I let him or her wake up and ask them why they would take all that medication without crumbling? How do you restrain your anger and censor your accusations and just let your love pour out?

Mom, you are fabulous. You are lioness and mama bear. You are iron wrapped in cashmere. Your family derives its strength and cohesion from you. You are healing and sustenance.

And I couldn't do what I do in that room without you.

Burnout

Sometimes we get stuck in a physical location that just seems to breed discontent and mirror our internal processes. Case in point:

Beginning of the workweek:

Room 1: Jabba the Hutt with hoverfamily, all feeding into Prince Syndrome. I initially started with an empty bed in Room 2. I eyed it unhappily, expecting the typical ALOC/PNA/sepsis/UTI/anyother SNF bound, fully accessorized admit. I coveted the nurse receiving the balloon pump patient down the hall. But, not today. I jinxed myself. Admitted a woman, hx IVDA and EtOH, Hep B and C positive, end stage liver and kidney disease. So far uncompliant with BP, NH3, and other meds. Complaining initially of belly pain then became somnolent with periods of combativeness and generalized freakout requiring her family to call 911. Came to me after Vitamin A(tivan) in the ED, one 22g PIV, no foley, no NGT, nada. Breathing about 80bazillion labored breaths per minute, complete with preggerbelly indicative of a fuckton of ascites. The admitting doc was on the unit and I called him in to look at the breathing, oh and the BP of damnnearzero/notquitezero. He said the breathing was fine, baseline, but if I was going to be all up in a snit about it, I could get an ABG. Far from the respiratory derangement I was expecting, she was in metabolic alkalosis with a pH of a whopping 7.58. Still, the MD was not impressed. I did get an order for, oh, fluids, blood products, and more fluids. I worked on that most of the shift and got a BP of marginal/shitty. Long about an hour before shift change, the doc rolls around, spies the exact same breathing pattern that I had called attention to 10 hours earlier and decides that it's time to hit the ohshit button. In short order we're intubating and thanks to the sedation, the BP is back to nil/nyet. Now she's received 3L of crystalloids, 3L of colloids, 5 units of PRBCs (for an H/H 6/19... why she's labored, right? Diminished oxygen carrying capacity? My ass), 6 units of FFP and 2 units platelets for the pancytopenia she's got brewing. She should be able to maintain a decent MAP if nothing else. No go. So I finally get the Levo I'd been gunning for and we're shooting it through the one PIV we've got. Turn off the sedation, hook up the Levo at 10... no 30... no 75mcg/min! Through a 22g! And still marginal BP. I get her turned on her head, thusly distending neck veins enough for the doc to get a central line in and now we're playing for keeps! I move the levo to the central line and no, I didn't change the tubing yet, and get an order for vasopressin and neo drips. Start the neo at the max, 200mcg/min and tap my foot nervously for the vasopressin to arrive from pharmacy. Meanwhile, I'm getting pure blood out of the OGT I'm finally allowed to drop and 0ml of urine out of the foley I placed on arrival. I've got 3 more liters of NS running wide open and albumin on the pump at max infusion rates, switching out 500ml bottles every half hour. By the time an hour after shift change rolls around, I've got a decent pressure, I'm running PRBCs in about as fast as she's losing them, and I can sign off. I don't believe I've seen Jabba since 4ish; I'm thankful for the other nurses who've swung in and done my meds, coddling, etc. I come back in in the a.m. to find an endoscopy in progress and what it finds is not heartening; varices have burst all through the GI tract. Too hard to cauterize/clip/etc all of them. The family is called in, the decision is made to withdraw. She dies a slow, lingering, destructive death.

Two days later I'm back, same room assignments, similar story in Room 1. Another Jabba, still in excess of 300lbs and just shy of 5'1"; all pannus and no periphery. Same empty bed in Room 2. This time it's a floor transfer. I get a bullshit report of "I think he came in with pneumonia, but his bowel sounds are great. His BP is 50/48... do you think we should turn the Dopamine up?" God, I wish we had some semblance of a rapid response thing going on here. Yes, I think you should turn up the dopamine and just get him down here. Nevermind that I believe 50/48 is impossible and you've failed to recycle the cuff. I can hear him yelling in the background. You can't cerebrate if you can't circulate, but whatever. And then I see it: three RTs and 2 RNs hauling ass around the corner, bagging en route. I don't funk around this time: I yell for the charge and charge relief to bring the slide board, the intubation tray and a central line setup. Miracle of miracles, they do. And it's the same doc. This time he says maybe BiPap will fix dood. Um, nuh uh. I bought your line earlier in the week. I ain't buying today. I stare at him as our monitor gets hooked up and sure as shootin', sats are... subpar. We gown up, mask up, bonnet up and away we go. But he's got this jacked up rhythm, too, and I can't feel anything. I can't hear anything. The doctor magically does, so I've got one hand on his carotid pulse (nothin' there), my stethoscope in my ears with the diaphragm on his chest trying vainly to even hear breath sounds (since the intubation happened even before we transferred beds), and the other arm hitching up his not insubstantial pannus while the doc tries to get another line in. I hear a strained "get me an art line setup" and we lock eyes over the umbilicus. Seriously?? Well, shit, we haven't been able to get anything other than 40/doppler since he hit the unit, so an art line sounds great, even if it's unintended. I spent a sum total of 4 hours in the room, soaking my scrubs through and yanking every joint out of place maneuvering to look, listen and feel for anything that would indicate cardiac activity, giving epi, running pressors wide open, running fluids, again with the gastric sanguine fountain only this time I was treated with a top-down exodus. Something deep and important had opened up in his gut, something an endo wasn't going to fix. Again, Jabba II was forgotten except by the grace of other nurses. And I still had 4 other nurses in my Room 2, all performing critical, vital functions. Eventually we got him stabilized. Another family conference, another decision to withdraw. But tomorrow, if we could. More family is arriving from points unknown. And so we acquiesce, warning that no promises can be made. Yes, he's still a full code, to give the other family their best chance to say goodbye. And he makes it through until I come back the next morning. And everyone comes in, tearful and muted, and I shut off the pressors while my RT extubates. He never took a breath. And his blood, my sweat, and the family's tears all for naught.

I wonder why neither of these two were DNRs. They both had end stage disease that we in the unit didn't know about until we'd flogged them away from the last inch of their lives, but both families were well aware that that inch was only an inch away. Nobody informed us early enough to make their deaths peaceable and dignified. Don't get me wrong, I'm an adrenaline junkie. I'm in my element pushing fluids and tubes and lines and calling out orders. And I'm grateful for the opportunity to practice high stakes medicine instead of the fluffnpuffing I'm normally doing. The withdrawal orders were appropriate, but comfort care at the outset would have been the humane thing to do. I'm so tired of futile care. I'm so frustrated with doctors that spend their evenings pulling the splinters out of their asses from riding the fence all day long. I'm short on patience and not able to suffer any lapses in judgment gracefully. From anyone. I'm grumpy and sad and have reached critical mass. What am I doing? Who am I saving? I went through over 20 units of packed red blood cells on dead bodies. Those units could have gone to someone that had a reasonable shot at using them through the lives of the red cells in them. I don't necessarily believe in battlefield triage in the ICU, but damn. What did I do that lasted any longer than a wad of chewing gum in a dike?

Dear Family or Friend of my patient

I will be your nurse today.  As such, I want to make just a couple of things clear.

I do not love your loved one.  I do not share your history, memories, admiration, or intentions.  I do, however, care that he or she receives absolutely the best care possible with the best outcomes in mind.  I will stop at nothing to make sure pain or other discomfort is relieved, you are kept in the loop, and the doctor has all information necessary to make informed decisions about the treatment plan.  I will do oral care, peri care, skin care.  I will turn and reposition every two hours at a minimum.  I will comply with all measures to prevent pneumonia, UTI, DVT and ulcers of the gastric and dermal varieties.  I will monitor vital signs, lab results, and perform an initial as well as ongoing physical assessment.  Sounds good, right?  Now let's talk about what prevents me from doing this.

1) The doctor disagrees or won't listen to my findings.  In that case, I'm bound and constrained by his or her orders.  No matter how much you think differently, short of you contacting the doctor directly and duking it out, there's not much I can do.  The corollary to that is if the doctor is practicing negligently or unsafely; in that case I have a chain of command I may utilize to rectify the situation.  Grandma's super expensive, noxious smelling lotion does not qualify.  Don't ask again.  And don't put it on when you think I'm not looking.  I'll smell it and wash it off.  There are reasons for that that you don't know and no, I'm not going to explain it to you.  It falls under the category of "because I said so."  

2) I do not have the ordered medication, treatment, etc currently.  In that scenario, rest assured I am working to get it.  The more urgent it is, the more persistent I am in getting it.  But if the treatment happens to be something like "clean patient's toenails" and I have another patient in pain, you lose.  Routine chest xrays for a patient not in distress or not intubated are about mid-level on my list of priorities.  If you come out to get me to ask me to pour water from the pitcher to the cup in your family member's room, you lose.  

3)  You.  Pretty simple, isn't it?  Your demands for the same information repeatedly, for things that are nonurgent in nature, or your bad attitude can all factor into the mix.  I will be totally honest here: if you are an asshole, I and my coworkers will minimize our time in the room and interaction with you when at all possible.  Realize that screaming at the top of your lungs that you have things to do and you will not wait for me to contact the doctor does nothing but make me walk a little slower to the phone.  I won't be checking in when I have a free minute just to see if your loved one needs anything.  Us wanting to be away from you means we're not in proximity to our patient.  Don't get me wrong, we won't ignore the call light or allow anything untoward to happen physically.  We can see all of his or her vital signs on our slave monitors outside the room and we're watching them.  We're also probably watching on the camera.  But we're not going in the room until we absolutely have to.

Another way to guarantee a tight lipped, minimally interactive nurse is to attempt to do what we call "splitting."  That's when you tell someone who wandered in to answer your call light how much better they are than your current nurse.  We talk amongst ourselves; we know when you pull this stupid shit. Or when you ask one doctor if he agrees with another's assessment and plan. Here's a tip: even if he doesn't, he'll never tell you.

If I have to part the seas because you and your family, extended family, neighbors, acquaintances, postman, pastor, and dentist are piled three deep at the door I will avoid the room.  And possibly call security.  How are you irritated by the lack of practitioner presence when no one can even get in the damn door, much less walk across the room to your family member?  There are visiting guidelines for a reason.  Oh, and here's another tip: because of the recent H1N1 outbreak, we are following the CDC guidelines on visitors.  Which means no one with flu like symptoms, no more than 2 people in the room, and no one under the age of 16.  Period.  And just stop your sputtering to think about this for just a second: knowing how many people around you potentially have H1N1, never mind MRSA, VRE, C.diff, why would you want to bring your infant/toddler/child/tween in?  And that's just the stuff people know about.  The people in the beds are protected for the most part.  You aren't.  And neither are your kids.

Lastly, I'm not a member of a "death panel" so no, I don't want to kill granny.  But I also don't want to flog granny.  This is pretty simple to translate: granny has reached the ripe old age of 81/88/92/whatever.  She has Alzheimers, arthritis, gout, heart disease, TIAs, diabetes, obesity, peripheral vascular disease.  I do not want to shock her to restart her heart.  I do not want to break her ribs doing compressions.  I do not want to put her on a ventilator that she'll never come off of which will then necessitate a tracheostomy and feeding tube.  I personally don't care if she's a chemical code; all we're going to do is put drugs in her noncirculating circulatory system.  If you love granny, you'll request I withold electrical therapy, CPR, and artificial respiration.  You'll at least listen and think about enacting comfort measures.  Yes, we'll put her on morphine.  No, it won't kill her.  Yes, she'll go out of the ICU.  No, she won't be ignored.  She'll go to a floor where people do comfort care for a living and the nurses are accustomed to guiding patients and families through the dying process.  Let it happen.  And do not.  Do not let me know that you want me to prolong his life so you can continue getting his checks.

You do your job.  Let me do mine.

I don't care where you're from

If you:

Tell me my patient is shivering because his body temp is 36.5 I will think you're stupid.

Tell me that my patient's kidneys won't start working until I stop the CRRT I will think you're beyond stupid.  If you then tell the nephrologist that and disbelieve him when you are schooled to the contrary I will think you should choose a new career.

Tell me that the person who awake enough to answer yes/no questions and has broken through two sets of soft wrist restraints trying to self extubate is "comatose" I will always provide you with plenty of subsequent telephone conversations regarding level of arousal.  You are wrong and I will badger you until the end of time, or the end of my shift, until I get what the patient needs.

Tell me to paralyze my patient instead of sedating her I will report you as far up the chain of command as is necessary to have you in time out long enough to think about what an asshole thing that is for you to do.  If I can, I will ensure that you are paralyzed without sedation should you ever need to be intubated.  I want you wide awake to experience what you made sure you would not witness the first time.

Tell my patient's family that their family member is in pulmonary edema because they (read: I) gave her too much fluid yesterday for "low blood pressure" I will find a way to embarrass you as publicly as I can.  You know as well as I do that not only did I not give any fluid for hypotension, I was on the phone to your lazy ass all day for beta blockers for the hypertension/tachycardia YOU caused by previous unfavorable decisions.

I will not accept that you are "culturally" impaired.  You are here now.  You may only bring your MD license in the door.

We (the nurses) will continue to save you from yourself all day every day and save our patients from your bad decisions too.  But remember: there will come a day when your poor decision will not adversely affect my patient and I will leave you out to dry.

Once in a while

It's been twice in the last couple of months now.  Someone who shouldn't be sick is sicksicksick.  No previous medical history.  No risk factors.  No reason.  Nothing isolated, nothing cultured, absolutely no reason at all.  But there they are, in the ICU.  Sedated, morphine or dilaudid drips, possibly paralyzed to boot so they don't buck the vent and we try to slow down the insidious progression of ARDS.

So down down they go.  And because they're young they compensate until they just can't.  So the spiral is quick and tight.  Quick, intubate.  Quick, start pressors because the addition of PEEP and propofol has knocked their blood pressure in the gutter.  Try to maintain a MAP that will keep their kidneys and brain alive.  Quick, run fluids wide open.  Quick, draw labs.  Quick, start every broad and narrow spectrum antibiotic, antifungal, and antiviral we can throw at them just to be sure everything's covered.  Quick, get that specialty bed.  Then everything slows down to an interminable crawl.  

Now we've got APRV and CVVHDF and IPV and the kitchen sink on standby.  CPS is a possibility.  We're flogging the heart with pressors because we hope it can take it.  It's only 20 ish so it... should anyway.  Day by day try to wean APRV to A/C.  Try to wean PEEP from 15 to 5.  Try to wean FiO2 from 100%to 75%.  Try to wean pressors.  But their kidneys just aren't coming back.  So quick, change the dialysate or replacement fluids.  Quick, try to keep up with their bicarb, calcium, potassium then quick, take them back off.  Then wait some more.  And the mothers and fathers who thought they got their kids past the "dangerous" ages of crossing streets and stranger danger and high school drugs; parents who just want to rewind and get a do over or fast forward to the day when their son or daughter opens their eyes with recognition.

And when you get home at the end of the day, once in a while, for these kind of patients, you aren't just spinning your wheels.  You aren't intubating 88 year old grandma with more effusion than lung tissue.  You aren't maxing out neo, levo, and vasopressin on grampa with an EF of <10%>

So once in a while, you throw everything you have into your shift, use every brain cell at your disposal, tax your body to its limits and give a part of your heart to a boy or girl you've yet to meet but lovingly change sheets and wipe eyes and perform passive ROM on.  And you hug mom and put your hand on dad's shoulder.  And instead of coming home depleted from all of this giving, you come home wired and excited at the small gains he or she made that day.  He kept is PaO2 > 50 on FiO2 100%.  Her K came down from 5.7 to 4.9 just by changing the dialysate solution.  

Once in a while you come home with more than you left with in the morning.

No new orders.

I'm waiting with bated breath to see how Nurse K responds to HH's "no new orders" post.  I have the gauze, adaptic and tape ready for his inevitable blistering.

I did stop to think a moment about why I document this.  And I'll admit it is primarily a CYA measure.  Since the docs at my hospital are not employees, they are not subject to the HIPAA/JCAHO/DHS bullshit that the rest of us are.  They can blissfully "look at the whole picture" while not signing telephone orders, chitchatting about their patients in the middle of the hall, and generally flaunting their immune status.

I am intelligent.  I've been doing this a number of years.  I've developed an ability to size up a patient and determine which needs are critical and which can be addressed later.  But I am required to call you for things that Those-Who-Do-Not-Practice have deemed critical or noteworthy.  I understand a K of 3.3 probably won't kill my patient, nor will an INR of 2.3, in the absence of other mitigating factors.  And when I call you and inform you of something we both know is not truly critical and I receive "ok" as a response, I have to document what the result of my call was.  You guessed it, no new orders.

BUT, when I call you for a Hct that has dropped significantly, the patient's belly is so hard you could bounce a quarter off of it and the IAP is 32, the NG output is > 1L/shift, and I'm having to increase my pressors I want answers.  If, given this information, you are still unsure of what our plan is, I will document specifically what I told you and that you gave me... wait for it... no new orders.  Because I'm not allowed to document "Physician Cavalier was notified of all s/sx of incredibly bad process, requested surgical consult.  Physician said "what can you do for a belly?"  Physician is incredibly dense or incredibly stubborn, either way he's risking this patient's life and my license and I will not have it supposed that I failed to understand the gravity of this situation."

But I will also document that I have called you prn with the patient's deteriorating status and lack of new orders until you give me what I want.

You can document my assessment lacks substance (unlikely BTW) or that the IV pole was beeping or that the patient was sitting in stool when you rounded.  That's ok.  Those things are directly controlled by me and I have an acknowledged responsibility.  But pull your head out of your ass long enough to see that I've walked into the room with you, answered your questions, then sent my aide off to get another full bed change for this patient while I head to the med room to replace the empty bag.  Or look in my other room to see that the stool ranks as low as you being called for a Tylenol order when my other patient is unstable or actively coding.  Or don't.  Just realize that those things do NOT affect your practice or licensure in any way but I am ultimately responsible for every single individual, department, and substance that interacts with my patient at any time.  If PT drops the patient, my responsibility.  If the patient has a med reaction because you ignored a cross-allergy, my responsibility.  If my patient has a low RBS because you've made him/her NPO and I haven't reminded you to throw some dextrose into the IV, my responsibility.  

Recognize it or not.  Either way I will keep calling you.