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.
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.
Would you believe it if I told you that I get woken up everyday while I’m sleeping for work by—are you ready for it??— an ice! cream! truck!
Yes, that little boxy kind that plays music and has images of all the ice cream treats all over it. I have so many questions.
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.
07/03/2020
My life largely revolves around my work. I go to work; I work; I think about work; I talk to others about my work. One of my roommates is a fellow ICU nurse and the other is an EMT. My best friends are nurses. I talk often in therapy about situations I encounter at work.
My point is: I know medicine.
And I am once again flabbergasted by reports about police practices for “suspect” control that is dangerous, unnecessary, and I’m sure used most often against black men. Police are enlisting the help of EMS to inject those in their custody with Ketamine under the guise that they are suffering from a condition called “excited delirium.”
https://www.nbcnews.com/news/us-news/elijah-mcclain-was-injected-ketamine-while-handcuffed-some-medical-experts-n1232697
I regularly use Ketamine in the ICU and have assisted in procedures in the ED (emergency department) with it. I know why it’s used, it’s effects/side effects and most importantly the adverse effects that can occur with use.
07/14/2020
Sometimes I feel like this moniker, which is often applied to healthcare or other frontline people who interface with vulnerable populations such as the very old or very young (teachers, I’m looking at you!), was a part of my personality before I became a nurse. And honestly, I do feel like everyone has a responsibility to help watch out for each other—or at least they should… because if we did, maybe we’d all be a little safer. Sometimes, though, it also feels feels like a burden, which is why I’m sure so many people turn the proverbial blind eye towards unsafe and potentially life threatening situations.
But the question that raises for me— how long can the blind eye truly continue to not see. Does the spirit see what the mind refuses to acknowledge? Is witnessing dangerous situations and yet doing nothing worse for your health than just finally mustering up the courage and admitting that it takes very little time to call someone for help?
I am a person who calls. Who reports. I believe that the consequences of not getting involved will impact me, as well as the victims of whatever violence or harm I am intervening in.
This started when I was in middle school, I realize now. I noticed a girl in my gym class with lots of injuries under her clothes while changing, and I talked to the guidance counselor about it. That counselor then reinforced my instincts about those types of injuries and the types of things I should tell her about. So funny to think back to so long ago to my childhood doing that for a classmate when I probably should have been trying harder to protect myself. But that was a different type of threat I was dealing with.
When I first moved to the “big city” I was also the “naive” girl who called police about the homeless person passed out on the park bench. I would still do the same, but I’d probably try harder to wake him up first, and I now know who to call for homeless outreach before the police (if it’s not a medical emergency).
I’ve had to report suspected elder abuse at work in the hospital… I’ve had to report actual abuse, once a sad case where an elder lady living with her grandson feared for her life and told us she was being forced to use drugs. Patients being abused by their spouses have refused help. I have reported things to Child Protective Services that I definitely shouldn’t talk about.
One thing I always struggle with, however, is how to report dangerous but not criminal behavior of individuals in the community that I think may be a risk to themselves or others. In other words, how do I get help for an acutely mentally ill person acting erratically who may or may not also be abusing some sort of substances?
My general rule is avoid doing anything unless the situation seems immediately life threatening. Erratic behavior +/- mental illness +/- substance abuse +/- person of color is not a good fit to police + weapon + restraint + jail.
But I live in the Bay Area, which has loads of homelessness and with it substance abuse and mental illness. Actually these three things are so linked that it is sometimes hard to tell which came first in any specific individual’s life. Twice I have had to call 911 because I needed highway patrol (the famed CHiPs) to come help a homeless person running around on the Bay Bridge— and no, not the part with a pedestrian path! A person running across 5-6 lanes of traffic on a bridge suspended over an ocean. Someone’s gonna get killed…. Someone might even be trying for that end?
I always have to stop and think before I call, though. Is this necessary? Will this do more harm than good? Is there imminent danger to the person themself or others? If there is immediate danger, I have to call. Even if that means someone spends the night needlessly in jail. It’s still better than a 20 car pileup on a freeway.
Should you call? Are you turning a blind eye? Is someone you know being abused? Are you being abused? Don’t be silent about it. Don’t let domestic violence just happen. Our silence about it perpetuates it. The same with violence against children, the elderly, the ill— whether physical or mental. Take a chance and use your voice. Now that we have learned the damage that silence causes, let us not continue to be silent about these issues. About black lives! About women’s lives! About children’s lives! About the lives of our elders and the mentally ill!
Resources:
National Alliance for Mental Illness
Project Homeless Connect Resources (San Francisco)
How to report suspected child abuse (federal)
National Domestic Abuse Hotline
National Center in Elder Abuse
National Sexual Assault Hotline
On my middle night shift this week, a grueling 14 hours with multiple assignments and emergencies and ending in a tad bit of humiliation but NO EXCUSE, I witnessed something as I pulled out of the hospital parking garage that at first I didn’t even really process. But seconds later, as I turned right, the image absolutely set my mind and heart racing.
The exit of the hospital garage is oddly narrow, and this particular morning, there were a few cars coming and going. Approaching the exit, I noticed some security guards huddled together a few feet away from the temperature screening checkpoint. As I turned right at the corner, I kept thinking: Why were there four security guards squatting like that? Were they on top of a person? Was there a code blue happening because there were no doctors or nurses there… do they need help and should I turn around and go back??? Rapid fire thoughts were rushing through my mind. At this point, I was 2 blocks from the hospital. I could still turn around. But if it was a code, wouldn’t the day team have arrived by now and wouldn’t they all be more useful than an exhausted off-shift night nurse???
But then another image came to mind. These were security guards. Four of them. Huddled around and possibly on top of a person laying on the ground. WERE THEY RESTRAINING SOMEONE???? ON THE GROUND? Were four large security guards holding down a person, probably a black man, near our hospital entrance, and was it possible this man could die this way?
In my head was just a stream of panic. Surely something like this could never happen at MY hospital in MY town… by now I was six blocks away. Freaking out and lucky I hadn’t caused a distracted accident, I pulled over and had an idea. I called a colleague on the day shift, the nurse who was acting as our Rapid Response Nurse (RRT) that day and who I had trained personally a few years earlier. I knew she was ballsy enough to get a guy out from under security and skilled enough to save his life is she had to.
She understood immediately and told me she’d get back to me.
I took a few centering deep breaths, knowing I’d taken the fastest action I could based on where I was. But vowing that I would not keep driving next time my brain even hinted to me that something wasn’t right. I need to stop immediately in these situations. I owe it to my fellow humans, to people of color especially who find themselves unfairly targeted in a society plagued by both overt and institutional racism that extends through through every level— from basic human rights and healthcare to policing to employment policies to the way the government as a whole is run.
And I especially owe it to those I work with, if these events are happening where I’m employed. Healthcare needs to be better. We need to set an example for how people should be treated. And personally speaking for our security guards, I want them to feel enabled to find new ways of dealing with people that is less dangerous. Security guards (or officers as they’re called at my hospital) exist in that space also occupied by police where the culture can lean toward a violent military style. But is this necessary? Is this right??? Should this be the first line tactic if most of the people dealt with are 1) agitated & aggressive patients, 2) homeless people living around or seeking inappropriate care at the hospital or 3) family members on drugs or alcohol who abuse medical staff? I think not.
I arrived home that morning to find a text from the nurse that I’d called for help. She told me that when she’d gotten there, the guy wasn’t on the ground anymore. He was sitting in the back of a cop car. “Being arrested, don’t know what for…” her brief note read. I felt a small bit of relief that he’d survived his encounter with being restrained on the ground. But now I also felt another twinge of sadness. I wondered if he was just a homeless person who had been bugging the temperature screeners. Maybe a schizophrenic off his meds? Maybe never on them. I wondered if being arrested was really necessary. I texted this in response. But the message I got in return made me sad: maybe there was a restraining order against him. Maybe, but in this case I’ll never know. Maybe I’m too soft, but I think there are other ways to wait for the police to arrive than with a person restrained on the ground.
It took me a whole extra day to recover from my three night shifts this week. And, no, I’m not being sarcastic. I usually sleep for the greater part of 24 hours after three 12+ hours nights in a row because you only ever get to sleep about 5, maybe 6 hours, in between if you’re lucky— and nursing is just a physically and emotionally exhausting job. This week, though, it was more like 48 hours.
Covid19 patients are back in force, and just like the news reports say, it is mostly young people this time around. Don’t let your guard down!!! This is not over, everyone! There is no safe place to just take off your mask and relax, maybe not even at home, depending on what your “housemates” are up to….
This week, a colleague had her last day. She’s moving back to the east coast and I’m going to miss her like crazy! We’ve been wishing her goodbye in crazy ways for weeks now— because you get really close to your workmates when it feels like you’re at war together. Sunday night was Filet o’ Fish night. I can’t even explain the in joke really, just that there were piles of sandwiches and lots of hilarious fish jokes to be had.
Monday night was like an old fashioned flogging. One admission after another. And the patients just got sicker and sicker. It took all night, and more, to stabilize a patient who came out of the OR (operating room) with a new liver but also possibly no blood in his body. We used a rapid infuser to push nearly 40 units of combined blood products into him in 2 hours while starting dialysis to correct his metabolic acidosis, drawing labs every 30 minutes, and then identifying the source of his bleeding—- preexisting esophageal varices (which bled nearly 4 liters once we put in a tube to suction his stomach!). And so, I had a “first” in the ICU— hard to do after more than a dozen years. We put a Minnesota tube in a fresh liver transplant patient. If you’ve never had the luxury of working with a Minnesota tube, it’s like an octopus you wrangle down someone’s throat and then inflate the head and one leg to put pressure on bleeding areas of the upper stomach and esophagus. It’s a hot mess.
When I got back Tuesday night, my Last night for the week, I was happy to find our liver patient doing well. He was still critically ill, but it looked like the liver had started to function— so he had stopped bleeding. As we like to joke in the hospital, we blamed all his problems squarely on the anesthesiologist for “under rescuitating” the patient during surgery. Of course, the course of a surgery, especially a transplant, is much more complicated than that…. but we like to joke about someone being to blame and since anesthesia is never there to defend themselves…. hahaha oh. I may have even said we should make an anesthesiologist voodoo doll. Is thus taking it too far? Hmm, seems memeworthy to me!
When it’s my last night, I need extra coffee. Extra to wake up, extra to keep going at midnight, and extra for the ride home. There is literally nothing I love more than coffee. Luckily, we have a way of showing each other the love at work by making coffee and sharing a little love note by the coffee machine too. Keeps us going!
