nostalgia

back when i started on my unit, we took care of a lot of ENT patients.  as a new nurse, this was terrifying because most of the patients had jacked up airways....new trachs, fresh laryngectomies, all sorts of weird stuff.  i'll never forget some of the things i saw, like the bivona trach that stuck out of the side of this guy's neck, or the patient i had who had such bad stridor that he had a tank of helium in his room that he was supposed to be breathing.  but my best ENT story of all was J.  

J must have had some sort of head and neck cancer, i really don't remember.  all i know is that he scared the crap out of me.  he had a laryngectomy, so basically he was breathing through an open hole in his neck.  he had a huge incision down the side of his neck, with a couple drains and a bunch of swelling.  i remember that there was this little larry tube that i was supposed to be sticking in his stoma to help keep it open, and i remember that i was supposed to clean it with a tiny bottle brush.  being new then, and obsessive always, i cleaned that larry tube religiously, probably at least every couple of hours.    i took it out, scrubbed scrubbed scrubbed, and put it back in.  then J started to complain about shortness of breath.  i took vitals, and he was fine.  his pulse ox was good, and i wasn't concerned.  but his wife was a worrier, and she was freaking out.  this went on for awhile, probably close to an hour.  during one of my many trips into that room trying to calm J's frantic spouse, i saw him cough, and noticed something strange.  it looked like something was coming up out of his stoma.  so i did what any good nurse would do, and promptly stuck my pinkie finger down the hole in his neck that was also his airway and fished it out.  come to find out that the ENT doctors had packed his tunneling neck wound with gauze stripping, and that the packing had come loose and one end had fallen down his airway.  i had no idea that the packing was there, and had probably been pushing it farther down each time i took out and replaced his larry tube.  so i called the ENTs, and they came running (literally) down the hall with scopes in hand.  they determined that i had gotten all the packing out when i reached down there and grabbed it, and congratulated me on the pickup.  i wasn't feeling as celebratory as they were, however, just horrified by the whole experience.  doctors weren't always going to tell me important facts about my patient...what?  would i be frequently expected to shove my hand down people's throats?  it was one of the first moments that i realized that this new job of mine might be a little more than i bargained for, that my sunshine and sugar nursing school education may not have quite prepared me for the real world.  

so what brought on this wave of nostalgia, you ask?  you'll never guess who walked on to my floor today.  

j.  

three and a half years after the gauze/pinkie incident, J is alive and well.  he's living, breathing, walking proof that the weird, random things that i do every single day make a difference.  and THAT is an accomplishment.  

the long arm of the law is cramping my style

so i'm pretty sure that i discharged somebody to go die tonight.  my patient may or may not be a child molester.  he's tried to kill himself twice since he was accused.  and, somehow, it is my job to tell him, oh by the way, you're discharged now and the police just happen to be here to arrest you and take you to jail, where you will either a. be killed by the other prisoners when they find out what you're in for or b. kill yourself, for real this time.  i HATE this part of my job.  hate it.  the look on his face when the police came in....the palpable change in his demeanor and the anxiety that i could feel in the room...horrible.  he knew that i knew about this, and that i didn't tell him.  so where i was once his trusted nurse, now i'm just a messenger of 'the man', and also a big liar.  and as much as this man deserves to go to jail if he did indeed do what he's accused of, i'm the one who's feeling guilty.  he doesn't have a chance, and i was a part of that.  and say what you will about my bleeding heart, but the truth is, i could care less what people do to land themselves on my doorstep.  i have taken care of horrible people.  for example, the kid who shot two police officers when they came to his house to arrest him.  or the man who was drunk driving and killed a little kid.  or the guy who was drunk on his motorcycle and crashed into a truck, killing his girlfriend.  these people made bad choices, and some of them were just evil people.  but that has nothing to do with me.  i'm a nurse.  i give people competent, compassionate care whether they deserve it or not.  do i condone rape and murder?  absolutely not.  but while these people are under my care, they get what they give.  so if they are nice and polite, they get the same in return. 

so i feel guilty, even though i was just doing my job tonight.   because i led my patient out to be discharged like a lamb to the slaughter.  and i feel a little bit sad, because this is not what i signed up for.   

survival mode

there are nights for "extras" and then there are nights when the goal is pure survival.  you and me.  alive.  until shift change.  tonight was a survival kind of evening.  the kind of night where i gave report and had no idea what was even wrong with my patients.  phrases like "right arm...broke i guess...well at least all wrapped up...whatever" and "rib fractures i think...or maybe not...moving on" came flowing from my mouth.  2100 meds were almost two hours late.  no one got out of bed.  repositioning?  i wish.  I&Os checked?  not.  vitals?  hope they were ok.  pure.  survival.  

i ran all night, literally all night.  up and down the halls, assess one, two, three, four and pass meds.  chart.  then i picked up a fifth.  then i tied down a crazy lady who unscrewed her IV so blood poured out of the tubing.  for a little while, everyone was on the bedpan.  turn on, turn off, wipe, repeat.  i heard calls for help down the front hall, so i went on a mission and discovered a patient with a belly full of drains and a bed full of poop (my favorite...not.).   i answered a desperate call for help and almost got my wrist snapped in half by a trached brain injured patient who was hellbent on face planting on the floor.  after we put him in 4 point restraints, i ran to change the chest tube dressing on an accused child molester who tried to kill himself three different ways and yet is still alive.  i confiscated his metal fork (contraband!) and ran off to finish (read: start) passing night meds.  flush rectal tube...reposition...nighttime insulin...bed change...pain meds, pain meds, more pain meds...boost...linens...crush pills, mix in applesauce, is she aspirating?  my bet is on no...turn, clean, try to scrape old cream off butt...try to figure out which tube of 6 creams at bedside goes back on butt, can't figure it out and give up...gown up for isolation, then run into other isolation room ungowned because patient is halfway out of bed.  run.  run.  run again.  bedside VAC change at 2330, stick finger in patient's belly to see how deep the wound tunneling is and it goes all the way in.  patient across hall is yelling for help again, then the phone is ringing and no one will answer it, so i do.  oh, another admission?  great.  then chart, chart, chart...punch out so overtime will not be used against me at eval time and continue to chart.  drive home, and think about closing eyes in the car.  contemplate being a patient, and force eyes open.  

brain=mush.  patients=alive.  therefore, tonight=success.   

    

the weekly roundup

5: the number of admits that we got on our shift even though we were down a nurse and all going up to five (pretty high acuity, i may add) patients apiece and generally running around the unit in a panic.

8: the number of units of blood that this guy required in surgery today.  his crit was down to 15 in the OR...for you non-medical folks that's about a third of normal, and basically means you have next to no cells carrying oxygen around your body.  i'm not going to say i told you so.  but it's implied.

45: the number of dollars our patient who is a pimp (literally) tried to beg off his nurse so he could get a hotel room upon discharge.  apparently business is bad?

1: the number of vail beds that we have on the floor right now.  try getting out of this, squirrelly brain injured patient.  (picture a small, beat up man trying to vault over the siderails of his bed, yanking off his arm splint and having full conversations with it, and yelling "hey ho" to people walking by his room.  now repeat times 4092902345 and you have my night.  thus the bed.)

10: the number of minutes i had to bite my tongue for while being screamed at by a patient because someone moved his linens to the bottom of his bed and closed his blinds.  literally, i spoke not one word.  mostly because everything in my head started with "i hate you".

100: the mEqs of potassium that i gave to my lady with the lasix drip tonight, which makes a grand total of 280 mEq of KCl in 24 hours.  this is the most potassium i have ever given a patient, and was just enough to make her K hit 3.0, which is still low but finally not critical.  i consider this victory, and worthy of a small happy dance in the nurses station.

and lastly.

105: the number of minutes of overtime that it took me to dig myself out of the hole that was today.

please excuse me, i'm 'bouts to go sleep for the next three days.

MCCs and impending doom

continuing on with the theme of summer, that being "get on your motorcycle and die...almost", lets have a little story.

we have this kid with bones poking through his skin, because a car hit him when he was riding his motorcycle.  to hold his snapped femur in place until surgery, he has a huge metal pin that got pounded through the bone.  on the other leg, he has a VAC that is sucking frank blood out of his leg.  on each side of his chest, he has chest tubes the size of garden hoses shoved between his ribs.  on the left, he has a hematoma the size of my fist.  

today he has lost almost 1500ccs of blood: 750 in surgery, 300 in the VAC, 250ish in the chest tube, and another couple hundred within the hematoma and all down his back from the leaking chest tube dressing.  his blood counts are down to half of what they were at admission.  he's scary pale.  and now he's throwing up.  this equals?  bad.

he is making my nursing spidey senses go all tingly, meaning that he gives me the feeling of impending doom.  because it's not a matter of if he's going to crash, it's when and just how bad it's going to be.  here's about how it will go:  he'll get really tachy, drop his pressures, and his blood counts will come back at something ridiculous like 5/18.  because it's summer and there is no end to traumas, the team won't be able to make it out of the ED to see him.  and because it's summer and the hot messes are plentiful, there will be no ICU bed if he gets really really unstable and sick. 

arrg, the anxiety!!

seriously, i would pay money to have access to the computer chart at home so i could obsess over his vitals and labs like the sick sick nursing stalker that i am.  but, alas, i will have to wait until tomorrow to see if anyone will wise up and give him blood before totally tanks.    

i will end with some words of wisdom:  if you at all value living, and prefer that your internal organs stay on the inside of your body, NEVER GET ON A MOTORCYCLE.  thank you.  

second chances, or lack thereof

trauma is hard.  i go to work every day and am thrown into the middle of some of the most horrific situations that one can imagine.  and yes i get frustrated with the incompetence of certain residents, and yes i occasionally get patients and families that are so ridiculously demanding that it makes me rue the day i became a nurse, but that's not what really wears on me.  the hardest part about trauma is that it's just so REAL.

we're all taught that life is full of second chances.  you don't like something about yourself?  change it.  you can be what you want to be, and you can do what you want to do.  make mistakes!!  no apologies, no regrets.

do you know what's really hard?  coming to terms with the fact that this carefree, consequenceless life that we're all encouraged to live is a total lie.  some things are just irreparable.  some mistakes can't be undone.  there are lapses in judgement that, when made, can change the course of your entire life.  and there are things that happen in an instant that can ruin you.

cases in point: two 21 year olds on a motorcycle.  they crash, unhelmeted.  he's in the ICU fighting to live with a chunk of his skull missing and she's on the floor with me barely responsive.

the tension in her room is palpable.  will she wake up?  will she ever be the same again?  and will her boyfriend live?  will he have permanent deficits?  what are the odds that these two will ever be what they were?

so much is unknown.  so we wait.  and she IS getting better, every day.  and he's still breathing, still fighting.

it bothers me, that these two got on a motorcycle without a care in the world, probably thinking how great it was to be so young and wild and free.  and in an instant, life turned on them.  and that's how life is, i guess.  but it just seems so incredibly cruel.

maybe these two will get a second chance.  or maybe only one will.   either way, their lives will never be the same again.  and they will never be quite as young or carefree as they were.

hand holding and other frustrations.

i would like to announce that i have become a surgeon!!  oh no, wait a minute...i'm just doing their jobs because THEY ARE TOO STUPID TO EXIST.  seriously.  seriously.  it's june, should i really still be holding your little hands and walking you through your job step by agonizing step?  show some initiative!!  get out there and be a doctor!!

the following is a list of things i should not have to do:

1. tell you to assess your patients.  how do i know you're not assessing your patients?  well first of all, your note is the same every date, cut and re-pasted.  secondly, if you were assessing your patient you would notice things...for example, that his arm is hugely swollen and that he probably has a giant chunk of windshield in it.  i'll take a thank you for pointing that out, and also for giving you the opportunity to cut something open which is, in reality, the only thing that you really care about.  oh?  no thank you?  only a barely concealed hostile glare for daring to imply that you need to enter a patient room?  so sorry for the inconvenience.

2.  tell you to give your patients the plan of care.  hey, do you know who should not be telling people that they're going for a procedure/surgery that you have not bothered to discuss with them?  me.  do you know who is not supposed to be interpreting test results/reading scans to patients?  also me.  now i understand that you couldn't possibly manage to go and report the results of a CT to a patient's family without needing to be reminded, but honestly, do i need to pick you up, throw you over my shoulder, and carry you to the bedside?  should i really have to tell you to talk to the family, and then tell you to talk to the family again an hour later, because now they're mad and we all look bad and unprofessional?  the answer is NO.

3. diagnose your patients for you.  i can't help but notice that you're obviously not the brightest crayon, but lets for a minute assume that you actually did go to and pass medical school.  your patient has a fever, and a white count, and a CT from yesterday that reads "basilar opacities in the lower lobes of the lungs, left greater than right, most likely indicative of pneumonia".  so what's the diagnosis?  THE ANSWER IS NOT BACTEREMIA!!  blood cultures are great and all, but i'm guessing that they're not going to prove his pneumonia, you know, seeing as how they're not a chest xray.  but that's ok, lets just hang out another day and see what happens before we actually treat the real problem.

bang. my. head. against. the. wall.

four years

for the last two and a half years, the floor has been my home. i've learned SO much there, about nursing sure but also about life in general. the lessons that i've learned about death and loss will stay with me forever. the patients that i've met and the situations we've gotten through together have made me different. two and a half years ago i was a quiet girl who would do anything to help anyone. most days, i cried because nursing was so hard. i threw my heart into everything i did and just about killed myself to be good at my job. well that sort of dedication can't be maintained for long, and here i am. i am exhausted. i have the "alligator skin" that was promised to me when i started on the trauma floor, but it came at a price. more and more i have been feeling that who i've become is not who i AM. i am increasingly negative and unsympathetic, and some days i don't even recognize myself. in short: i am burning out. fast.  


i recently found this post that i wrote awhile ago, but never had the heart to put out there.  at the time, i was applying for ICU jobs because i was losing it on the floor.  i was in a place where i was trying so desperately to make my career what i wanted it to be, what i felt that i was PROMISED in nursing school.  i wanted to feel like i made a difference.  i wanted to be treated like i wasn't a brand new nurse.  i wanted to be respected by my peers, my patients, my residents.  i wanted perfection.

well, turns out it doesn't go like that.

i was told that the first year of nursing was the hardest.  and it was really hard.  seriously, i cried almost every single day.  i cried in the utility room, in the med room, in the pharmacy office, in the bathroom, and when i was still unpresentable to patients i would turn off the lights so they couldn't see me and cry in their rooms while i was passing meds.  in retrospect, it's shocking i didn't have some sort of nervous break...but i made it!!

so when i was done with my first year, i expected to feel as if i had "arrived".  well, joke was on me, because after the first year THINGS WERE STILL REALLY REALLY HARD.  at about a year and three months, i had a patient throw a PE and code in front of my face.  and that messed me up for a long time.  i felt all the things you feel when someone in your care dies: shock, and guilt, and fear that i would have to see that again.  and for a long time, i wasn't really sure that i could 'do' nursing.

after i had been a nurse for two years, i felt like i could breathe a little.  but it still wasn't easy.  i got a little lost in the middle, hence the above post.  if all i did was cry the first year of nursing, then all i did the second was vent.  in short, i felt cheated.  like everything they told me in nursing school was a complete lie.  all the "nursing matters" and "nurses make a difference" propaganda was just that: pretty words.  i wasn't making a difference, i was treading water.  but i kept on going.  

after i had been a nurse for three years, it finally started to click for me.  i had enough seniority to start throwing it around a little and making some changes in my patient's treatments.  the trauma team started to recognize my face and (i hope) see me as someone who is competent.  because of our crazy turnover rates, i was one of the most experienced on my shift.  i was the one to ask questions to, the one who got called in times of crisis.  and i was finally done crying, and done ranting (err...mostly?) and done being angry because nursing was not what i thought it should be.

and now i've been a nurse for four years.  the past six months have been so...sweet.  finally things aren't as hard as they used to be.  so much of what i do is habit, muscle memory, things that i can do in my sleep.  and this means that i can focus on the things that i REALLY want to do, like connect with my patients.  critically think about them and make changes and advocate for what they need.  have discussions with the team and present ideas and make good arguments for my requests.  THIS is what i thought nursing would be.  THIS is what i signed up for.

now trust me, not every day is roses.  i still have to clean up c-diff poop 6 times a shift, and drop everything to run for the bed check and some patients are still crazy/entitled/really crazy.  but it's better.

THANK GOD IT'S FINALLY BETTER!!

and i'm hoping that it will get better still.

the lord is testing me.

tomorrow i plan on waxing poetic about how much i love my job.  so, naturally, tonight i will get all my wrath out.

i swear, the ED has a personal vendetta against our floor.  ok, so maybe that's dramatic.  what it comes down to is the ED has 95% great, smart, savvy nurses who provide their patients fabulous care and are fun to chat with on the phone.  then there are the other 5%.  i'm not sure that they actually have degrees, come to think of it.  they may be homeless people off the street.  or circus clowns.  these are the nurses who send up suicidal patients without sitters, who transfer ICU patients to the floor on accident...also the nurse who sent me the patient once who was about 85% dead.  these are the nurses who i curse today.

so we get this ED admit.  long term trach, oriented x 0, biting and hiting and crazy.  yum, my favorite type of patient.  she rolls up to the floor flat on her back with a trach just bubbling with secretions.  according to transport, she's been like this since they left the ED.

oh no you DIDN'T.

ABCs, people, and A does not mean admit patient to floor so you can go about your business.  AIRWAY.  as in what this patient is unable to use because she needs to be suctioned like 10 minutes ago.

so we suctioned her, and of course she immediately begins to vomit up bile that smells like stool and is now coming out of her trach.  ooo, lookie!!  aspiration pneumonia.  greeeaaaaaaaat.

let me break it down for you.

1. please suction your patient.  thanks.
2. if your patient has been suctioned and still sounds like she's drowning, maybe someone should come with her on transport so she doesn't die.  yeah, i know you're busy.  send a tech.  or better yet, send a respiratory therapist.  frankly, i don't care if you send a circus monkey that knows how to work a yankaur suction, anything would be better than nothing.
3. also, would it kill you to give meds for the BP that's over 200 systolic?  or maybe you want this patient to have a stroke too? (18 hours and an ICU transfer later, we found out that this patient did actually stroke out).

seriously, i looked at this patient and i wanted to take the time to trek over to the ED and back just so i could smack that nurse upside the head.  i really had to hold myself back.

but then i was too busy to plot my revenge, as the patient began to drop her sats and continue to aspirate on her vomit.  so then we called a rapid response, sunk an NG, took a million vitals, and suctioned her.  like 10 times.  and then she basically became a 1:1 floor patient (my favorite, again) and was continuing to be unstable with pressures of 250s/130s as i dragged my sad tired self home.

thank you, incompetent ED nurse, for ruining my night and almost killing your patient.  i look forward to our next rendezvous, in which you will undoubtably continue to act as if you are indeed a garden gnome and not a licensed professional.