Code Blue

Today was my first full blown code. Young guy had a suspected PE, went into respiratory failure, and shortly after, cardiac arrest. It was horrible. That is all I can say.

The code went smoothly for the most part. Everyone worked very well together. ACLS prepared me for which meds to push, when to push them, when to shock and when not to shock. ACLS prepared me in how to work together with a team, how fast to perform compressions and how to ventilate a person with an ambu bag.

What ACLS did NOT prepare me for was how I would feel during and after the code. ACLS did not prepare me for how physically tiring and hard it was to do effective compressions on a 250lb muscular man for 40 minutes. ACLS did not prepare me for the look of the patients lifeless eyes staring at me from only 2 feet away as I pumped his chest. ACLS did not prepare me for the surreal experience of fighting to save a man's life as a priest performed the Last Rites over the patient. ACLS did not prepare me for the tangible emotion, disbelief, and pain from the family as they watched a short distance away. ACLS did not prepare me for the sorrow I felt when the physician called the code.

It was horrible. That is all I can say.

12 Hour Shifts....Bleh

These 12 hour shifts are kicking my ass. It's more like 13 actual hours at work. Then add in about 1 1/2 hours drive time round trip. That makes it 14 1/2 -15 hours dedicated to work including travel time. That leaves 9 hours left in my day. 9 hours left to eat, shower, take care of the dog, and sleep. After 3 working days in a row, I'm beat. I'm too tired to do anything anymore.

Torture?

There are some days that I feel like I'm working in a torture chamber rather than a hospital. Elderly confused patients who clearly do not want the interventions that are being forced upon them: Are we doing more harm then good?

Restraint Comic

Yeah, this pretty much says it all.

"Never trust doctors"

Me: Doctor, my patients heart rate has been consistently greater than 110.

Doctor: Ok, lets try metoprolol 12.5mg IV every 6 hours. We give that, right?


Me: Ummm, yeah? Metoprolol 12.5mg IV every 6 hours, correct?


Doctor: Yes.


Me: Ok, thank you.


*hangs up phone and shows my preceptor the order as I had jotted it down*


Preceptor: OH MY GOD! You can't give this! You'll kill someone!!! Are you sure this is what the doctor ordered??


Me: Yes, I'm sure. I read the order back to him. He asked me if we could give this. I didn't really know without looking it up.


Preceptor: We have to get this changed. Call him back and tell him we can give 5mg IV. 12.5mg is a PO dose.


Me: *feeling very stupid and unsure of myself*   Umm, Can you call him please?


*medical director peeks head around from the other side of  computer monitor where he was sitting about 4 feet away from me*


Medical Director: *in a kind voice*   This is your lesson for the day. Never trust doctors. We depend on you to keep us from killing patients.





I think it's time to be scared now.

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.

Dr. Dickhead

Background info:

morbidly obese patient admitted with DKA secondary to major cellulitis infection, consult with pulmonologist

Dr. Dickhead: So, I'm here to see you regarding your sleep apnea. Your sleep apnea would improve if you lost weight.

My Patient: Yes, I know. I've had a rapid weight gain of about 150lbs in the last year or so.

Dr. Dickhead:  I see that you have been noncompliant with your diabetes, otherwise you wouldn't be here. (patient's Hemoglobin A1C was on the low normal side)

My Patient: I check my blood sugar a minimum of four times a day. It wasn't until the past week that I couldn't get the levels under control.

Dr. Dickhead: What do you do for a living?

My Patient: Well, I have a Ph.D. and used to be a counselor. Now, I'm a pastor.

Dr. Dickhead: *saracastic tone of voice*   Did you used to counsel people on weight loss?

My Patient: Why yes I did.

Me: *picking jaw up off the floor while shooting the "doctor" daggers with my eyeballs*

You know you're tired when...

leaving work after a 12 hour shift, you attempt to use your ID badge to "swipe" into your car.

Cardioversion

It was a hectic day, but I'm loving learning all I can. Today I got to assist with my first cardioversion. The cardiologist in our unit loves to teach and he has spent many 1/2 hour long teaching sessions with me when the opportunity arises.

Today he asked me to come to the room next door when I was finished with my patient. I walked in and they were getting ready to perform a cardioversion. The patient was in A Flutter. The Life Pak was already hooked up and conscious sedation administered. The cardiologist explained everything to me about the process. Even though the nurse educator had already extensively gone over this with me, it's good to have a reminder when you're nervous.

I operated the Life Pak under the direction of the cardiologist. The patient went into A Fib after I had delivered the first shock. I admit, I jumped a little when the patients body jerked slightly with the shock. When I delivered the second shock, the patient sat straight up and said "Ow" before falling back onto the bed. I jumped again. But he was in sinus brady and all was well.

The cardiologist took the next 15 minutes to explain everything to me, review the meds used for conscious sedation and how the patient won't remember any of it. He even made a point to wake the patient up and ask him if he had felt any it, to which the patient replied "no".

It was a good first experience. The people on my unit are very supportive and understanding with new nurses and are quick to include us when there are good learning experiences. I look forward to the day when I can be that experienced nurse helping the new nurse.

My first code

All I can say is, "What the hell have I gotten myself into?".  It was a Sunday and I worked two back to back 12 hour shifts. I had the same 2 patients (who were very stable) as I had on Saturday and thought it was going to be an easy day.

Lesson learned: NEVER even think, "Wow, I'm starting to get this down, I think today is going to go pretty easy". Never.

One of my stable patients was taking a turn for the worse and I watched him go downhill all day while we did various interventions. Approximately one hour before the end of my shift I went in to check on him and recorded his vital signs which were actually starting to improve a bit.

1800:  My patient: Hey girlie! How ya doing?
          Me: Great thank you! How 'bout you?
          My patient: Doin' fine!

1813: My preceptor screaming from the direction of my patients room: I need help in here right now!!

Everyone just stopped to stare for what seemed like way too long before they realized something was wrong and sprung into action. I am pleased with myself that I did react so quickly. I think I plowed down the respiratory therapist as I made a mad dash towards the room. Really, it is all a blur but oddly at the same time it felt like everything was moving in slow motion. I was scared out of my mind, but it's a good sign that I ran towards the room rather than away from it, right?

Anyway, my patient had pulled off his high flow oxygen and quit breathing. He was gray and unresponsive but his heart was still beating. I was amazed at the number of people in the room, all working as fast as possible to get him intubated. It was exactly 12 minutes from the time my preceptor yelled out for help until he was successfully intubated.

I helped where I could, but mostly stood back and observed as instructed to do so by my preceptor. I wonder if I can do this. I KNOW I can, I will learn, but wow, after it was all said and done, I really felt like I didn't know my head from my ass. Is this what it's like to be a new critical care nurse?

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.

Delirium tremens

Last week I helped care for a Vietnam vet who had come to our unit with an extremely high blood alcohol level. High enough that most people would be in a coma, or even dead with a level as high as his. He was a chronic heavy drinker, consuming approximately 4+ cases of beer per week. He has end stage liver disease, and because of the DT's he was sure to face and a GI bleed, he was admitted to our unit for close monitoring.

We talked with him about all of his options. He knows he is going to die. He openly told this to us. His wife divorced him, his daughter doesn't speak to him, and he is sure that his liver won't last the amount of time required for him to be "dry" before he could even become eligible for a transplant. He recognizes that he could have done things better, but his feelings on the matter? "If I'm going to die anyway, I might as well keep doing the things I enjoy". At this point, I'm not sure I could blame him for not wanting to quit. Despite the hell he was going through, his cravings for a cigarette and a beer, his hunger from being NPO, and the pain he was in, he had to have been one of the nicest patients I had cared for. Always polite, respectful, and appreciative. I'm not sure I could have been as nice as him if I was feeling only half as crappy.

Today he was readmitted back to the hospital, though not in my unit. His blood alcohol on admission was only around 0.08 or so. I was amazed, and I paid a visit to him during my lunch break. He looked awesome! I couldn't believe it. He just looked healthier and in better spirits. He informed me that he had just had approximately 4 liters of fluid removed from his abdomen. He told me that he was really trying, and is currently down to about 4-5 beers a day. He looked very happy to see me, and told me how much he appreciated me coming to visit him. I think it's important to show people you DO care, and it can be doubly important for someone who doesn't have that family support system and believe that nobody cares about them.

He will have to continue to have fluid drained from his abdomen every 4-6 weeks. I hope he continues to try to improve his health. I wish him all the luck.

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.

First trip to the morgue

Yesterday I helped with the admission of a middle aged woman. She was crying in pain. Specifically her legs, her back, and her head. She had multiple tests done. All came back normal. I felt so helpless and didn't know how to help her.

Today, she went downhill fast.  She was actively dying and was a DNR.  All we could do was keep her comfortable. Her very large family was all present and stayed with her the entire time. A Catholic priest was called at the request of the family. We all held our breath and prayed that the priest would make it in time. She passed away within a minute of the priest arriving.

After the family left, I helped the nurse's aide wheel her down to the morgue. I must say, seeing it was not like what I expected. Not at all. Just a very small room with a metal table and scale. A walk in cooler that was big enough to fit only 2 stretchers inside. Small hospital, small morgue I guess. What happens if you have to take a patient down there, in the middle of the night, and the cooler already is at capacity? What am I supposed to do with the body? Nobody could answer my question. They all say "Oh, that won't happen".

Murphy's Law: It will happen to me. In the middle of the night. When I'm fresh off of orientation.

Dr. Dolittle

I'm sensing a theme in the unit. There is one doctor in particular who nobody wants to call, and who everybody avoids at all costs. I hear repeatedly from different people in my unit, in other units, and in other disciplines, how this doctor never does anything for his patients, and when he does, his orders are outrageously unsafe. I'm fearful that my meek, mild personality won't cut it when the day comes that I have to deal with this doctor.

Bath salts? Really?

Twenty four year old former heroin addict who bought a ticket to the critical care unit by shooting up with bath salts. She was fine, however, the 6 week old embryo she was carrying was not. Even though she blamed the nursing staff for killing her baby with all the "drugs" we "made" her take, I feel bad for her. I feel bad for her husband, and the two small children they have together. I truly hope she gets the help she needs.

I had no idea this is something that has apparently become popular with kids. This is a video explaining the risks of bath salts in case you are like me and haven't heard of this "drug" before now.

<iframe width="425" height="349" src="http://www.youtube.com/embed/V5kPXH-lMmE" frameborder="0" allowfullscreen></iframe>

Waste of a promising future:

Apparently chewing Fentanyl patches is the new craze. He was down for who knows how long before his mother found him unresponsive. The paramedics found the patch still in his mouth. It took 20 minutes for the ED staff to shock him back to "life". Currently on life support with very little brain activity. Seriously, how can anybody ever think this is a good idea?

Dealing with grief

Today I spent the day shadowing another nurse on the unit. She was absolutely wonderful about taking the time to explain everything to me, and teach me as much as she could. It was hectic and crazy right from the start. We only had one patient, who had come to the emergency room just a few hours earlier. His only complaint was shortness of breath. Within an hour, he declined so quickly he had to have an endotracheal tube placed and was put on a vent. When we received report, we had learned that he had pneumonia, and a suspected pulmonary embolism that was later ruled out. He was on maximum support on the vent and was receiving 100 percent oxygen. Despite this, his O2 sats were only in the 60's and stayed that way all day. He was septic and despite all of our interventions, he was getting worse. I felt sad for this man while helping to provide his care. I wondered if he could hear us despite the sedation, or how aware he could possibly be of what was happening to him. I wondered if he was uncomfortable. He was not expected to survive.

Many family members came to see him. I watched the nurse as she spoke to the family. I observed the reactions and listened to what all the family members had to say. One thing was said frequently by many, "But he was fine yesterday", "But he just said yesterday how well he felt". The wife, the brother, the sister, the niece, the son in law. They all said the same thing. I saw the shock on their faces. Their pain was so intense, you could feel it along with them. It was in the air around you. It was hard to witness this. I had to look away when the teenage granddaughter sobbed. It was so unexpected to all of the family, and in my opinion, that makes it all the harder to deal with.

I was on that side of hospital bed 15 years ago. My mother had a horrible accident that put her in the intensive care unit for approximately 5 months. She was not expected to survive either. Driving home after my shift, I cried. I cried for that man, I cried for his family, and I cried for my mom. I briefly questioned whether or not I was strong enough to do this. But I know I am. This is why I became a nurse, so I could help others in their time of need. I need to recognise that I'm human, that I have emotions, and that it is ok to feel these things, and cry if I need to. I called my grandma, and told her about my day. She cried a little with me, as we both remembered what my mother went through. She told me she was proud of me, and that  my mom is watching over me and that she is proud of me too. I felt better after talking to grandma, it was just what I needed.

The man was transferred to another hospital. I will probably never know if he pulled through.

Orientation

So I've begun my general orientation for my new job in the critical care unit. I realize that I have alot to learn. Yes, I've been a nurse for several years, and while I have plenty of trach and vent experience, none of it is in acute care. Home health is a completely different ball game from the hospital and I'm worried about my lack of nursing skills. I've never started an IV. I've never even had to do CPR (though I'm quite proficient at changing plugged trachs and bagging with O2 when necessary). I've had minimal opportunity to work with IV meds during my clinical rotations in nursing school. I've completely forgotten all about how to interpret EKG strips. I barely remember the common treatments for various disease processes that are more common in adults. I can't even  remember the indications, action, and side effects of alot of the medications commonly used by older adults because I've been in pediatrics for so long.

Luckily the unit I'm on is going to consider me a "new graduate" even though I have many years of experience under my belt. This means that I will get to work very closely with the nurse educator and a preceptor for a full 6 to 8 months. The drawback is that I'm not fresh out of school like the other new grad that started the same time as me. I'm hoping that I didn't forget as much as I think I did, and that as we review the material, it comes back to me fairly easily.

So far today is my second day working with the nurse educator. I really like her. She seems to love what she does, and she is very honest and direct. Her expectations are clear and seem very reasonable. She wants us to succeed and has told us that she will not set us up for failure. It seems that I will get the support and education I need to become a good critical care nurse. The fact that this hospital gives such a lengthy orientation makes me feel good that I can succeed at this.

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!