Category: intensivecare
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The heart, 2 views
These 2 X-rays are from the same person. I find them amazing. Looking back and forth— the power of the heart, the speed at which things move and shift in our chests each second or less. Literally breathtaking!
Metaphorically and literally, we are crispy in California right now.
Last weekend was hot with crazy storms that set off a chain of many wildfires. Most of the fires have new types of names to symbolize this new catastrophic cause: “lightning complex” fires. Many lightning strikes hitting dried out & ready-to-ignite brush (it is wildfire season, after all) and then the small fires come together quickly, fueled by high winds, to form the larger “complexes.” I certainly wish I’d never had to learn that.
And back in the ICU, we are full of patients and short on nurses. For three of my regular shifts this week, I’ve been doing the work of 2 nurses (actually, more like 5– but that’s impossible so I focus on doing 2 and let the chips fall where they may). I’ve also worked extra shifts.
The amount of overtime I’ve seen people working is truly astonishing. In many ways, our team is really pulling together and doing the best we can with what we’ve got. This is what we’ve always done as nurses, and will continue to do. Even when it means no one gets a lunch break. Or the charge nurse is also the rapid response nurse is also the code blue nurse is also the break nurse is also the resource nurse….
You know what gets us through? Laughter! And kindness. I always end my shift huddles during times of high stress by reminding everyone to help their neighbors and be kind…
You know what else helps? Food and beverages! We order boba, pizza, fried chicken, sandwiches, Thai food… and if the coffee runs out? Omg, a national disaster!
It’s Sunday morning now. I’m preparing for a new week by washing my scrubs, washing and chopping my face work snacks: celery carrots and apples. If they’re not precut, I won’t be eating them… I made three sandwiches for three nights of work, and I ground some coffee beans to take with me tonight!
I have my go bag packed, in case I have to evacuate because of a fire. Last year, one jumped a body of water near a bridge (the wind carried it) and came within a few miles of my house. I pack for work the same way, like everyday is a small disaster— scrub cap, face masks, stethoscope, food and water supplies. Today the main difference is that the smell of fire and the poor air quality is here to remind us that emergencies will continue to occur— now we just have COVID too.
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Not your nurse mom, nope
There are a lot of things that bug me about how other people practice nursing. But I’ve been a nurse long enough (more than a dozen years!) and through enough failed relationships (plus one marriage!) to know that you can’t really change people. Plus, at least in nursing there are actually a lot of ways to get the job done.
Some RNs will always be better talkers than doers. Honestly, those nurses get assigned to the patients who literally need someone to just listen to them, while more organized self-starters are going to take the busy potentially unstable post-ops.
I’m ok with this and try to value each nurse on my unit for what they’re good at— and help them both grow and deepen current strengths as appropriate.
There are 2 problems with this laid back philosophy: first, there are always some nurses who want everyone to be like them—and these are usually the very Type-A quick & bossy types. These nurses are usually very good at their jobs, earning them coveted roles such as float nurse or RRT or frequent 1:1 assignments.
But as I mentioned, there are many ways to nurse. And sometimes you need the quiet and patient (read: slow) nurse for a patient who reacts badly to too much change. Sometimes you need a nurse with social skills to smooth things over. Sometimes you just need the biggest strongest guy on duty to make sure the sexually inappropriate young male patient with a TBI doesn’t act out with the female nurses. This list goes on and on. Patients develop specific tastes or show preferences that we try to accommodate in order to prevent resistance to treatment. It’s both ridiculous and sensible when you think about it.
But I digress. So what is the first problem with my laid back attitude to the variety of skill/methods in nursing? Well, that one groups of nurses I mentioned who are particularly type A and like all the other nurses to be like them? Well, let’s call them the A Team.
The A Team terrorizes all the other nurses. In their misguided desire to “improve” the unit, which to them means make everyone like them, they bully all the other nurses and often managers too.
Then I have to follow behind them saying “don’t worry, they’re just being dramatic.” And trying to unruffle everyone’s feathers. This can reach crisis proportions when the other nurses start fighting back. It’s really hell on my days off, though, as I get flooded with text messages from both sides.
Oh, and what’s the #2 problem for my laid back ways? Sometimes people develop bad habits. And bad habits are hard to break. IV med bags in the patient’s sink is one of my biggest pet peeves. Also leaving your trash for someone else to clean up in med room. Here’s one I found while sending a nurse on break. Note: I did nothing. I’m not your nurse mom & I’m not gonna clean up your mess.
07/31/2020
Would you believe if I told you that I haven’t posted in (insert # of days/weeks like I even bothered to look) forever because I’ve been busy? Well, I’d be lying. I have been working 3 or 4 days a week then having 3 or 4 days off and repeat. I like to think I’ve been busy but to be honest, no.
On the 3 days in a row when I work, there is literally no time for anything else though. I wake up between 4:30 and 5pm. Get ready for work, including make lunch (praying there’s food in the house since pandemic grocery shopping is the worst), and leave at 6pm. I get to work usually around 6:35-6:45 depending on traffic and take a few minutes to “print my list,” which is my giant tree-killing summary of each patient in the ICU and their one-liner H&P, chief compliant, and major events. This one-liner of course is more like a one-paragrapher…
We start each shift with a huddle at 18:55 and then I’m off to the races for the next 12 hours. I spend my shift breaking nurses, admitting patients, communicating with family members & doctors, in rounds, putting out fires, wiping butts, assisting in procedures, and getting report for the next shift. Whatever the night may need. After giving charge nurse report on an average of 26-32 patients, I only hope to leave before 8:30 when the parking garage will charge me $8 to get out. If I’m leaving this late, something bad happened. And it happens about once every two weeks.
I get home on average at 9am and try desperately to fall asleep by 10. Sometimes the adrenaline is still rushing through me from an end-of-shift emergency, or I have to eat because I simply didn’t have time to all shift–and I will not be able to sleep on a stomach that has likely been empty since a protein bar inhaled on the way to work at 6pm yesterday. Days like this, I hope not to be checking the time on my phone, which is shoved under a pillow next to me as I sleep.
And I get up and do it all again.
For those 3 days, I am, yes, “crazy busy” but then comes my three or four days off in a row… These frequent days off are the reason some people joke “how can you be tired; you only work three days a week?” Oh hell, I think there’s probably even a meme for that…
So then, those days off? What are they if not busy? The answer is complicated, especially since I work night shift. When I get home from my third shift, I go to sleep by 10 like normal. But I let myself sleep until whenever I wake up– usually until 6 or 7. I wake up like a zombie, stumbling to the kitchen for coffee and food. I’m pretty useless at this point, still tired from the work week. I stay up to watch some tv, maybe do some laundry– although as I type this, I’ll admit that is unlikely. And I’m back in bed by 10pm. My first day off, spent entirely sleeping…
There are weeks where no matter how much I sleep, I don’t feel rested. Days when co-workers are restlessly texting me about this problem or that, and I feel a weight of responsibility as I take their confessions
But as this pandemic and its necessary quarantine continue into its sixth month, my colleagues and I cling to each other. We are bound by what we’ve seen and done. We are a “quarantine family” of essential workers–and though we wear our masks, we cannot control how close we get to each other. Some days, we work shoulder to shoulder–arms crossed–to turn and lift patients, to hold pressure on bleeding wounds, to change dressings.
Now that we’re doing elective surgeries and the first three months of strict shelter-at-home orders, the ICU is busier than ever. Way too many cases of pancreatitis from months of heavy drinking, severe heart failure from heart attacks overlooked when people were too scared to go to the hospital. Kidney, liver, and heart transplants. Drug overdoses, and cardiac arrests–sometimes it seems like 5 homeless or near-homeless people found down and resuscitated every day. Their u-tox reports telling the story of despair and mental illness and drug addiction that plague our cities: meth, opiates, sky-high alcohol levels.
I spend my days off thinking about these patients. That first CT scan showed a lack of grey/white matter differentiation, a very poor prognosis and likely anoxic brain injury for our Joe Doe cardiac arrest patient. What had happened to him? Did they find out his name? Did the police have to come fingerprint him? And what about the woman whose chest we opened at the bedside? We all watched as the cardio-thoracic surgeon retracted the ribs, suctioning out & washing away blood and clots from around the heart. Then he searched for whatever might be bleeding, suturing tiny blood vessels and covering with small pieces of dissolvable clotting material.
I walked into work last night at 18:30 with a giant smile, hidden under my mask of course, and a pep in my step. It was night 3 if 3, but it was going to be a great night, I proclaimed! Because I had woken up to a full pot of coffee already brewed and waiting for me. Nothing a night shifter loves more in life than coffee.
I even had to brag about making all 26 assignments that morning and not having a single person complain to me or ask me to change their assignment— either before or after start of shift. It was unprecedented, and I was feeling pretty good about myself.
Fast forward only a brief 30 minutes and three people were asking to go home at 23:00 if we were overstaffed, and a hospital that had accepted a transfer patient tried to refuse once we called to tell them that the transporters were about to leave and the ETA was 45 minutes.
We solved that problem but then also kept busy for the next few hours with transferring 2 more patients out of ICU, providing end of life care for an end stage liver disease patient whose illness surpassed her body’s ability to fight back, and we accepted 3 admissions from outside hospitals and 1 admission from the emergency department. Not to mention making sure all 25 nurses on duty get breaks…
The next 8 hours didn’t get any easier. There were multiple simultaneous rapid response calls (RRTs) with one that turned into a Code Blue. We accepted and then un-accepted more transfers because we kept getting calls for more urgent cases. We had a way-too-young patient brought to us after a out-of-hospital cardiac arrest with several more in-hospital cardiac arrests (all in a short time frame) that needed ECMO placed for full heart/lung failure. Because of this, we had to refuse a Tylenol overdose in liver failure, also a life threatening condition—but not as time sensitive at that moment.
Another unexpected transfer from an outside was a patient with recent cardiac surgery who had suffered a stroke and whose brain was swelling. This patient needed emergency neurosurgery but was at a hospital without a neurosurgeon.
Luckily, by which I mean not, we had already been waking up the neurosurgeon frequently because one of his other patients with a hemorrhagic stroke was also having some pretty serious problems. Her ICP kept rising, and she was starting to have cardiac complications from the myriad medications we were using to keep her from bleeding into her brain more. Her heart was having 15 second “pauses” which honestly, is enough time to almost make everyone else have a heart attack.
While adjust her medications so that her heart stopped stopping, just 2 rooms down, a cardiology patient admitted only the night before was decompensating as well. She came in with what was presumed to be heart failure and fluid overload. But upon closer inspection also appeared to be harboring severe signs of sepsis. There was a battle going on however between what we as nurses could see going on with patient and what the cardiology team wanted to do.
Also, we had an unfortunate problem in this case. A family member who is a cardiologist, and actually a cardiologist who trained at our hospital but now works elsewhere, wanted to 100% dictate the care. And they let her. She chose the attending cardiologist, she set the treatment plan. There was to be no changes.
To make a long story with a lot of history and precedent much shorter: The patient was DNR. Her heart rate, which had been in the 120s to compensate for the infection and cardiac issues she was having, dipped to the 60s and then quickly into the 30s. At this point she had no pulse and was having a PEA arrest (pulseless electrical activity). Someone called me to the room by literally screaming to me as I valiantly tried and failed to get a cup of coffee. I got to the room as a young baby doctor with fear in her eyes stuttered indecipherable things while looking at her phone.
The nurse whom I trust implicitly looked straight at me as I entered the room and told me what I needed to know as I saw her heart rate. “She’s a DNR.” The nurse is calmly standing on one side of the bed, hand on where the patient’s radial pulse would be, if she had one. I cross to the other side, take the patient’s hand. She is cold, not breathing. The heart rate on the telemetry monitor reads 33 but the heart is not actually pumping. There is not pulse. Another nurse comes in to help and I shake my head no to her as she looks at the monitor.
The doctor is on the phone with her supervisor asking about pacing or this or that. We close her eyes. Take off the oxygen mask, turn off the IV medications and disconnect them. I look at the doctor as she gets off the phone. I shake my head. At this point, we have turned off the patients monitor. There was no longer any visible vital signs.
As the doctor leaves the room to call our patient’s family, we begin washing her. This is a most important step for us to take to give dignity and pay respect to those who pass away in the confines of the ICU.
But it is only 04:00. It will be more than 4 hours before I leave at the end of my shift. In that time, I send 2 more nurses on break. I review the charts for 25 patients. 2 admits arrive to settle in. And I give report on I-don’t-even-remember-how-many-patients-we-ultimately-ended-up-with to the day shift.
And it all started with me bragging about what a great day it was going to be because I woke up to a fresh pot of coffee already brewed for me. Also, we literally checked if it was a full moon at one point. It wasn’t— it was a new moon. So it was my fault. I’ll take the blame this time.
I’m still left to wonder though: why are nurses so superstitious???