IV Starts

I can change the trachs of 3 month old babies. When I say "change the trach", most people assume that I mean changing the inner cannula. If you are not a pediatric nurse, you may not realize that pediatric trachs don't have an inner cannula. The entire trach is removed and a replaced with a new one approximately once per week. This is scary for pretty much every nurse until you gain confidence in your ability to manage emergencies (such as being unable to insert the new trach). I've had lots of experience. Doing this routine procedure does not bother me in the least.

I can insert foley's and straight cath patients of all ages and sizes. Again, doesn't bother me in the least.

I can give injections. No problem.

I can insert nasogastric tubes. No biggy.

I can pack stage IV decub ulcers down to the bone. I enjoy wound care.

So why in the hell can't I start IVs?!? I get nervous as all get out. I psych myself out before I even start. My hands shake scaring my patient half to death. I know I certainly wouldn't want to see me coming at me with a needle in my state! Why does this seemingly simple procedure get me so nervous? I just don't get it. I've done a lot of things much more difficult than this.

I got to spend a day with the IV nurse doing nothing but IV starts all day. I thought this would cure me. Big Fat NO. Out of about 7 attempts, I managed to get 3 in all by myself. The others I either missed entirely, blew the vein, or had to step aside to allow the IV nurse finish what I started because for some reason that I can't figure out, I couldn't advance the catheter!

It's not the actual IV stick that gets me so worked up. It's the thought of failure. Of missing that IV, of having to tell the patient I need to stick them again, then, when I miss for the second time, of telling the patient that I will get another nurse to try because I'm a big fat failure that has tortured you enough for one day. I get wound up just attempting to look for a suitable vein, especially when I can't seem to find any!

I know I'm psyching myself out. What I need to figure out is how to get outside of my own head.

It's starting to come together

The last two days have gone very well. I'm starting to become more organized and better at getting my assessments, charting, and care provided for one stable patient. My goal for next week is to accomplish this for two stable patients. I've accurately interpreted all my heart rhythms thus far, though I haven't had any real difficult ones. My preceptor is telling everyone what a good job I'm doing so that makes me feel good. The best part....I am absolutely LOVING my job. I love talking to my patients, getting to know them, getting to help them, getting to teach them. Seriously, there is nothing I dislike (so far).

I loved pediatrics. But I do believe, I'm loving this even more. I'm probably an "all around" nurse. Meaning, I love working many different specialties. I love peds, adults, elderly. Age doesn't matter. I'm loving critical care. I loved med-surg when I did that as an agency nurse. I loved home care. I loved long term care. There were always aspects that I didn't particularly enjoy (such as the under staffing in LTC or politics in homecare), but really, I love all areas of nursing. I truly hope that one day I can add ER nurse and even flight nurse to my list.

One thing I have noticed, critical care nurses are VERY opinionated about a patients DNR status. They tend to get worked up and upset when somebody whom they believe should be a DNR is not. Either the doctor "convinced" the patient to not be, or the family can't accept that death is part of life, or whatever reason is applicable at the time. I have my own beliefs, but I don't have an opinion on what others choose....yet. I'm sure after I've cracked the ribs from doing compressions on a 90 year old frail lady or gentleman a few times, only to prolong pain and suffering for another month or two, I may feel a little differently.

As a new person on the unit, I feel like an outsider looking in sometimes. I see things that I aspire to do and be. I see things that I know I don't want to do or become. But I also realize that I don't really "know" yet, as I've got SO much to learn. All I know is that I hope that I can keep my passion for nursing burning well into my career.

Why I became a nurse

I've been struggling with my desire to share this part of myself versus the difficulty in writing this and the memories it stirs. Ultimately, I think I will share, but I believe I will leave out a few details as it's just a little too painful to talk about.

Growing up, I was my mother's best friend. She had this innocent, child-like soul. Emotionally, I was often more mature and responsible. Not that that was a bad thing. It just was.

She also had many ailments that plagued her. Often “sick”. Now that I know the things that I know, I wonder how much of it was psychiatric in nature. When I was a preteen, my mother suffered an injury that led to her paralysis from the waist down.  One that I also now believe was psychiatric in nature. I was her caregiver for many years.

In my late teens, she suffered another injury. A 22 gauge shotgun discharged, with the barrel resting against her chest. Her injuries were extensive. She “died” several times in the first couple of weeks. She spent months in an intensive care unit. I was young, oh so young. I was terrified. I was grieving. I was confused. I was angry. I was a mixed bag of so many emotions I couldn’t even begin to recognize them all.

The nurses in the ICU were absolutely wonderful. Not only did they care for my mother, they cared for me. They were a source of emotional support. They were patient and understanding. I was so thankful for the care they provided us. I was so thankful that there were these wonderful kind souls who were willing to sign on to do all of the undesirable tasks that nursing entails. They were my mother’s lifeline. They were my lifeline.

After many months, my Mother WALKED out of that hospital. It was a miracle in of itself that she survived. How was it even possible that a woman who was paralyzed for 7 years not only survive such horrendous injuries, but regain feeling in her lower extremities and relearn to walk? I never believed in miracles until that day.

Fast forward 5 years. I had made a bit of a mess of my life, but I had finally gotten my shit together. I had some thoughts over the years about what I wanted to do, but finally got to a point in my life where I was able to take action. I enrolled in school to become a nurse. I wanted to do for others what those wonderful nurses did for my mother and me. I wanted to help, I wanted to be a resource for families and patients, I wanted to help people in their time of need.

I became an LPN first. My mother was proud of me, she encouraged me the entire way. She was my motivation. When I started classes part time for my associates degree, she was again proud and my source of motivation. She lived long enough for me to achieve the title “RN”.

That year, her health rapidly declined. Her problems were directly related to complications of her injuries from the gunshot accident. She passed away prior to my making the leap from pediatric homecare to critical care. She was proud of me throughout nursing school, she was proud of me when I worked at the nursing home, she was proud of me when I worked in homecare. I miss her so much it hurts, but I know she is up there smiling down on me, and I know she is proud of me now.

The Next Chapter

It's been a wonderful experience, but I'm ready to move on to the next chapter. In my 5 years in home care, I've seen alot of things. I've gotten to know alot of wonderful people: grandparents, parents, children, other nurses, and the staffing coordinators worked diligently to ensure that families didn't go without a nurse for the day/night. I've also seen a lot of not so nice things: dilapidated and dirty homes, homes with rats, mice, cockroaches, and a myriad of other unwelcome critters, neglected children and their stoned parents, shootings outside the child's bedroom, drug deals, unwanted sexual advances from fathers.....the list goes on much longer than I have time to type. But those things came with the territory. Children with medical needs come from all walks of life, but they all have one thing in common: They all depend on someone to provide them with the love and care that they need.

I gave my employer over a month's notice. Telling all my clients that I was leaving was the hardest thing I had to do. Most were upset I was leaving. There were a few families that I didn't think would mind so much but surprised me the most by their level of disappointment and fear that I was no longer going to be their clinical manager. I reassured everybody the best that I could and hugged everyone one last time. I will miss them all.

The job interview went well. Very well. I interviewed them as much as they did me. I toured the unit. Spoke with a few nurses that worked there. Overall, I had such a positive vibe when I left the hospital. It was less than a week later that I got the phone call and official offer of employment. It's a small critical care unit in a small town hospital. I will be driving about an hour every day to get to work, but it will be worth it. Even though I'm not a new nurse, I'm new to acute care and they will be giving me 6-8 months of orientation before I'm expected to function without my preceptor.

I'm ready and looking forward to my new career as a critical care nurse!

Erin

I was fond of all of my clients. But there were a few that really tugged at my heart strings, even more than the rest. Erin was one of those. She was a beautiful baby girl that I had cared for since she was 2 months old. I remember very clearly the day I met her. It was just before she was discharged from the hospital. I went to visit her so I could meet her mom and dad, and learn some of her care. Mom was holding Erin, and she was smiling at her mother. I didn’t know this at the time, but that would not only be the first, but also the last time I’d ever see Erin smile.

Her condition quickly got worse after she came home. She was trached, and on the vent 24 hours per day. They did all kinds of genetic testing, but were never able to figure out what was wrong with her. All we knew was that it was a metabolic disorder.

She developed seizures, went into heart failure and got to the point that she no longer responded to anyone. She couldn’t track you with her eyes, she never looked at anyone. It appeared as though she were looking through you, not at you. She didn’t laugh or smile. She only cried or lay in her crib with a blank look on her face. She started having these sympathetic responses that were very sudden. Her little heart would race well over 200 beats per minute, I was scared she’d have a heart attack, and her oxygen sats would drop to less than 50-60 percent in less than 10 seconds. She would turn blue and we’d have to bag her with 100% oxygen while trying to calm her. It was scary. I loved that little girl like she was my own.

Now keep in mind, I am a firm believer in not treating special needs kids any differently than other children. Even though they have a nurse at their disposal all night long, other kids do not, and are expected to sleep through the night (once they are old enough to do so). So I really try not to intervene unless medically necessary. I provide the care they need, keep them comfortable, but try to let them be otherwise. I care for them, show them love, but I certainly do not coddle them. To treat these kids differently from other kids really does a huge disservice to the kids and their parents.

But Erin was different. She was never going to recover and I knew she would not survive. She was getting worse every day. So for months I just held and rocked her all night long and gave her as much love as I possibly could. She never responded to me and I often wondered if she knew she was loved and knew that we were all there for her.
Eventually the parents made the decision to make her a DNR and made the agonizing decision to remove her from the vent. They decided to wait until just after her birthday so that she would at least live to see her first birthday. Erin kept getting worse and fell into a coma. We didn’t think she’d make it much longer. It was heart-breaking, but unlike with Gary, I was determined to stay and help that family. I was NOT bailing.

I had the night off and I was at home relaxing with my family.  I got a phone call from the regular day shift nurse. Erin had just passed away. We knew it was going to happen but I was still stunned. I cried and cried with the other nurse on the phone. She was only a week away from her first birthday.
I was still crying, but got it under control as best as I could as I drove to their house. I was very unsure of myself, if I should really go to see them, and wasn’t sure if the family would want me there or not. I was scared of imposing on them since I technically wasn’t working, and I certainly wasn't family But I couldn’t stay away. I cared for the family just as much as I did for their daughter.

When I got there, the family embraced me, hugged and kissed me, and thanked me for coming. I had made the right decision. We were all crying and it was so so sad. The physician was just leaving when I got there, he had pronounced her, and she was already removed from the vent. It was so eerily quiet without the sound of all the equipment running. All you heard were people crying and hushed voices. The family had decided to wait to call the funeral home so that they could have those last moments with their daughter before they came to take her to the funeral home.

At one point I sat down in the rocking chair where I had spent so much time rocking her each night. Mom brought Erin to me and placed her in my arms. I got to hold, kiss, and rock her one last time. I know this sounds so sad, and maybe even morbid to people who don’t understand, but I will forever cherish that memory. That family gave me their daughter during their precious last moments with her, so that I may hold her and say my good-bye’s. I will always be grateful to them for allowing me to have those final moments and for allowing me to be part of their lives.

In a way it was a blessing that she passed on when she did. It spared the family from having to face removing her from the vent and letting her go. This awful decision was taken out of their hands. I'm glad they won't ever have to live with the grief or possible self doubt over the decision to take her off the vent. This family endured something so tragic and fiercely loved a child they will never see grow up. I can't even begin to imagine what that is like. I'm just glad I could be there, and help in whatever small way I could.

Before I finally left for the night, Erin's mother gave me my Christmas present since I wouldn’t be back. It was a beautiful ornament with Erin’s picture in it. I hang it on my tree every year.

"Gary"

He was 5 months old when I began caring for him. He was the first infant I cared for during my career in pediatric home care. Prior to Gary, I cared for mostly older children with brain injuries. Gary had a genetic disorder called SMA (spinal muscular atrophy). SMA causes paralysis of all the muscles in the body including the respiratory muscles. He had type 1 which was the most severe form and most of these children don’t survive past one year of age. Gary was not on a ventilator, nor did he even have a trach. His parent’s opted not to take these extreme measures. He was a DNR. We did feed him through a feeding tube. He was such a beautiful baby. Alert and cognitively intact, he just couldn’t move any of his muscles, not even to smile. His health gradually deteriorated, and he began to have more and more difficulty breathing. He was on a very high percentage of oxygen and we were giving him morphine injections every couple of hours to help ease his respirations. I’ll never forget the way his eyes had this haunted look to them. He would just look at you with these huge blue eyes and it was so painful to watch him struggle to breathe. We were basically watching him suffocate. It was terrible. We did everything we could to keep him as comfortable as possible. Near the end I just knew I couldn’t do it anymore. I had never taken care of a truly sick baby before, much less one who was dying. I felt the family deserved to have a nurse who was more experienced and would be able to provide the support they needed when he finally did pass away. I was scared I’d be too emotional to be of any good to the family. So I called my agency and they took me off the case at my request. The agency staff said they understood. I felt terrible for doing it even though I knew there were other good nurses available to take my place. I felt like I was abandoning Gary and his parents, even though I believed my intentions were in the right place. He died a week later at the age of 7 months. I was devastated. I went to the funeral and was surprised that the family was glad to see me. They took comfort that some of the nurses who cared for Gary came to say goodbye. They hugged me and thanked me for being there. They thanked me for the good care I provided their son.

It wasn’t even a week later that I called my agency back and told them I was ready to start taking care of babies again. I realized how much I was able to help these families and that I had the skills and knowledge to do it. I knew it would be very sad and heartbreaking at times, but I also knew that I wanted to be there for those families to help them. So then I took classes and learned all about the vent and started taking babies on vents. It was scary at first but I’m a quick learner and I loved what I was doing. I learned to get over my fear. Caring for someone in the process of dying is never easy, especially when it’s a child. The grief and pain from the parents and families are always so strong that you can’t help but feel that pain in the air around you. But now I know that I do not need to be scared of this, that I CAN help them, that I WANT to help them and that it’s OK to cry and be sad. I also now know that it’s ok if the family sees the nurse shed a tear. It allows them to visually see and know that their child is truly cared for.

Entitlement

I take care of children and babies (and a few young adults) with varying degrees of health problems. Some of these children have disabilities that makes them dependant on others to provide the most basic of care. Someone to feed them, someone to bathe them, someone to turn and reposition them. Daycare centers won’t accept these kids into their programs because of the level of assistance they require. Therefore, these kids often rely on a home health aide to provide this care so the family can maintain their employment. I also care for children who have greater needs. Kids that are dependant on receiving their nutrition through a feeding tube. Kids that are dependant on the patency of a tube that is inserted into their neck to enable them to breath. Kids that are dependant on a ventilator to do the work of breathing for them. These children (and their parents) rely on the assistance of a nurse to assist them with their care needs.

There are various waiver programs and state assistance to help with the costs of caring for these children. It’s a wonderful, good thing. These kids are given the opportunity to stay in familiar environments, to remain at home with their families where they can grow and thrive. Otherwise, many of these children would end up in institutions. In addition to this, it costs FAR less to provide this care in the home versus in a long term care setting.

Now please forgive me for a moment. I LOVE what I do. I love helping families and I love helping my patients. But I need to rant for a moment.

I’ve had quite a few experiences now where these families have taken advantage of the system. It’s frustrating. There’s the Mom who I suspect of Munchausen’s by proxy. Who has first one child that gets nursing services, then all of a sudden, whose other child begins mysteriously having “health problems”. Somehow she manages to defraud the system to gain nursing for BOTH children so she can go tanning. Yes, tanning. She WAS supposed to be working, but she used her time more wisely. Not. She didn’t last long before she was caught committing fraud.

Then I have the mom who becomes angry when her very healthy daughter is denied continued nursing coverage. This child does have a feeding tube in place, but has NOT used the tube in quite some time (seriously, why don‘t they just remove it already?) I’m quite sure the mother is somehow deceiving the child’s physicians to believe that she still needs the feeding tube. She has had services for most of her life, but this child has overcome her feeding difficulties, and is completely independent for all of her activities of daily living…as much as any other preschooler. She can feed herself, she can use the bathroom independently, she can tie her shoes. Why the hell does she need a nurse?!? She wouldn’t even qualify for a home health aide!

This mother should be ashamed of herself. Yes, I know her child had a difficult start. Yes, I know that can be a difficult thing for a parent to deal with. there are tons of children that are FAR worse off. Children who are terminal. Children who will never get better. Children who will never *not* need the assistance of another person for their most basic care. If this mother gets her way, it will cost taxpayers approximately $9,000 per month. You read that right. $9,000 per month to provide approximately 200 hours of skilled nursing care. $9,000 per month, when these parents can spend $50 to $80 per week to put their child in daycare just like all the rest of us working parents.

I’m all for state assistance for children with chronic health problems. Those that manipulate the system and twist facts to get their way? When….. and note, I say when, not if….. When they get caught, they should have to pay back every penny plus interest.

I'll Never Understand

A pediatric patient of mine refuses to eat. She is fed mostly through a feeding tube because of this. The goal is to attempt to get her to take as much of her feeding by mouth, then give whatever she doesn't eat through the feeding tube. So I'm talking to her mom about this and notice a small piece of a baby carrot on the child's bouncy chair tray. I pick it up and take it from her and explain the choking hazards to the mom. She just laughs while saying her son must have given it to her. Then she turns around and hands her daughter a BBQ chip. This patient is around 6 months old so I suggest to the mom that she feed her daughter either stage 1 baby foods or pureed table foods if she wants to give solids. The mom's reply? "But she'll lose weight! We want her to drink from her bottle!"

 *sighs*

No matter how hard I tried to explain, I just couldn't get through. Instead, the child will be fed chips and have twice the amount of formula prescribed dumped down her tube "so she doesn't lose weight". No wonder she wont drink it from a bottle. Her poor little belly is stuffed.

Pediatric Home Care Nurse

I currently have another blog that pretty much encompasses the many different facets of my life. However, as I am in the midst of a job change, I'm finding that I'm wanting to post more on the aspects of my life that pertain to my career. I'm also beginning to see how it may be preferable to both myself and my readers to separate the nursing stuff from the rest of my ramblings. So here we have it: The Random Ramblings of a Critical Care Nurse.

I'm currently making the transition from pediatric home care to critical care. Until that transition is complete, expect that the topic of most of my posts will pertain to pediatric home care.