Tag: icu

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Quick Notes

Pep talks and missed meals

Last week, everyone was still happy for the overtime and could see the $$$ in the missed meal breaks. Everyone was chipping in, picking up extra and actually in buoyant spirits (if that can ever be said about ICU nurses).

I actually texted this image stolen from Pinterest to a colleague in my happy and helpful bliss last week… perhaps it was delirium?

For my first few shifts this week, though, the nurses were just not feeling like doing as much OT. I can’t blame them. Our patients are incredibly sick. Our job is incredibly hard both physically and emotionally. There just isn’t as much support available as there should be even if people volunteer to work OT because nurses on overtime just aren’t working their best.

Also, it makes me sad to say, but the patients aren’t getting the best then either. As nurses we want to be THE BEST we can be for our patients, especially in the ICU, but when you’re working hours 12 through 16.5, you can’t always give your best. It’s sorta like the Rolling Stones’ song, loosely “translated” to this scenario: you can’t always give what you want, but you give at least what patients need.

On a happier note, though, I ended my week with a fully staffed night shift that gave report to a fully staffed day shift! First time in 3 weeks.

Categories
Quick Notes

Real things families said to me, # 2 & 3

A family of a terminally ill covid19 patient (who now has multi-organ failure on dialysis as well as bacterial lung infections on top of the damage done by the severe ARDS caused by the covid19 virus) asked that we call a doctor in Texas to discuss treatments with alien dna that could help. They were referring to “Trump’s doctor” Stella Immanuel who also swore by hydroxychloroquine, which is now disproven as a treatment for covid. One question: where do we get the alien dna?

Another family of a terminally ill patient (who also has multi-organ failure on dialysis plus more than 15 surgeries that started as a complex hernia repair at another facility) asked that we try a high dose cayenne pepper derivative to cleanse their loved ones blood and raise his blood pressure. I assured them that the medications he was on were much stronger than cayenne.

Categories
pandemic

Covid Continues

We have as many covid+ patients now as we had in the initial surge. The problem is they’re just not getting better like the first surge did. We were part of the remdesivir trial early on, and now we’re giving per the compassionate use allowance of the FDA. We’re also using dexamethasone, as a trial has supported that, and convalescent plasma.

Proned, paralyzed, and praying for recovery…

But yet here we find ourselves, a young gentleman who after ALL these treatments is still not doing better. He’s still paralyzed and prone 16 hours a day, and now his kidneys are failing, requiring initiation of continuous renal replacement therapy (CRRT).

The battle is still real. And we are still fighting it.

Categories
intensivecare nightshiftlife pandemic Quick Notes

Everything is on fire

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…

Brown sugar boba, yes please!

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.

Categories
intensivecare nightshiftlife

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.

Someone changed all the CRRT (read: dialysis) bags and left the old (read: dirty) ones in a chair. Then threw a pillow on top, like a cherry on a sundae.
Categories
nightshiftlife

The week in review, late of course

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.

We were all pretty surprised that McD’s fish is hand caught, lol

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.

Ok, it doesn’t really look like an octopus… but it’s red and slimy when covered in lube and ready to insert!

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!

It was someone else’s Friday too!

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!

Categories
intensivecare nightshiftlife

I really did this to myself…

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???