Keeping the faith

I see her as I step off the train.

She is sitting on a bench, slumped over several plastic bags and wearing a heavy winter coat, complete with furry lined hood drawn up over her head. I can't really see her face at all. It is June; coat weather seems entirely unimaginable.

I look at her and I want to fix it so bad, whatever it is that has caused her to be sitting on a bench wearing a winter coat in June with all her worldly possessions around her. As if "it" is just one fixable thing...

The rest of us are walking briskly past, all books and briefcases, earphones and telephones.

I am on my way to school. I miss actively working with people every day... God, I miss it. I go in and take my exam. It is a hard one. Then I retreat to the library to work on a paper, but write about her and how I feel instead. I try to keep the faith that this will be worth it, and I'll be glad I did it when someday I am back to work again...

Pondering the reasons we wait so long to make the call...

Check out this nice piece in the NY Times by Paula Span:

Avoiding the Call to Hospice

Maybe you shouldn't crack the chest

"We can't let families be present for resuscitation," he told me. "We crack the chest."

Well, maybe you shouldn't.

Vicarious Posttraumatic Growth

Who knew? There is already a name for the reason I love my work... "The term vicarious posttraumatic growth describes the phenomenon of clinician growth that results from witnessing positive sequelae of other people's experiences of trauma. This may include the clinician's feelings that his or her own life has been enriched, deepened, or empowered by witnessing the patient's or family's posttraumatic growth." (Kearney, MK et al. JAMA 2009, 301:11) WOW! I nearly fell out of my library chair when I read this... This type of enrichment is at the core of the powerful draw I feel to work with patients and families in crisis.

I discovered this term in this very interesting 2009 JAMA article by Kearney and colleagues titled Self-care of physicians caring for patients at the end of life. It is not only relevant for physicians, however. In the section on burnout, they describe six areas of work life that contribute to the burnout phenomenon. They are workload, control, reward, community, fairness, and values. Only a quick examination of nursing work life is needed to confirm that nurses are an extremely high risk group. Let's look at some of the areas.

Workload
Where do I start here? The nursing workload is off the charts on so many levels: physical, emotional, and spiritual. It is also extremely challenging mentally, but this tends to be more energizing than depleting, unlike the other three!

Control
Imagine having zero control of your work environment. Zero! You have no personal space (maybe a locker somewhere far away if you're lucky, but that's just to keep your valuables from getting stolen, since you can't ever get away to access it during the day). All kinds of other providers come in and, naturally, need to use the workspace to see the patients for whom you are caring. Now that I am one of these "others," I am often a recipient of the very icy treatment many nurses give to people. I am aware that I, too, have been guilty of this in my role as a nurse. I think one reason for this kind of behavior may be the lack of control over the environment, including personal space, but also the inability to control one's own workload and workflow.

Reward
Perhaps for nurses we might substitute respect here, specifically that not given by other HCPs. The other day a physician was teaching a session in my ACLS renewal class. He was discussing team dynamics during emergency situations, and making the excellent point that a team leader should always be open to hearing ideas from any member, regardless of his or her role. Two heads are better than one, you know? So he says, "I would never say, 'That's stupid, you're just a nurse, you don't know anything!' That's just not appropriate." The implication was not that it was untrue, but that saying it is not okay.

I'll leave community, fairness, and values for a less cranky day!

Must-read from Dallas Morning News

At the Edge of Life is an incredible series written by Lee Hancock, with beautiful photos taken by Sonya N. Hebert. At the center are the clinicians and patients of the Baylor University Medical Center's Palliative Care Team. Thank you Dallas Morning News!

Rolling down the window in December

I sit at the stoplight, behind the shiny car with the "Spoiled Bitch" sticker. He is limping in the median, like he does every day. He moves slowly up and down the long turn lane at this apparently lucrative intersection. It hurts to watch him walk.

I fish around in my pockets for a little money. The light cycle is on our side today, so I roll the window down as he moves close to my car and hand him the coins. We nod at each other, like always. The arrow turns green and I follow the spoiled bitch into the intersection. I wonder if she has ever rolled her window down for anyone.


Our city is full of homeless individuals, struggling with mental illness, substance abuse, past traumas, and so many other things. It gets very cold here. People pitch tents and tarps in plazas and line up outside churches in the afternoon, hoping for a meal.

Sharing at the stoplight may not be the most sustainable way to give, so we try to help in other ways, too. But I think rolling down the window sometimes is really important. When you see the same individuals-- face to face-- day after day, it keeps you present in the reality that this doesn't just go away. What looks to us like an unbearable crisis is just a continuation of daily life for another. That is true for so many of our fellow humans.

Let us always remember to roll down the window in one way or another.

Living with ourselves and our work

Beka has started a good discussion over at Medscape's In Our Own Words about compassion fatigue. Reading her thoughts and all the comments made me thinkg of something fascinating that happened the other day in our critical care course. Now, pretty much all the students are trauma/ER/ICU nurses looking to work in these settings as APNs. We were having a lecture on care of the critically ill elderly patient and discussing a really good article (Marik, P. Management of the critically ill geriatric patient. Crit Care Med 2006 34(9):S176-S182.) Anyway, I mentioned that I really liked the fact that Marik talks about how we need to reconsider the way we measure outcomes-- i.e. not survival to hospital discharge, but survival at 6 months or 1 year, or even more importantly, return to previous level of functioning. This, then, would give us some more helpful information about *actual* outcomes, and help health care providers, patients, and families evaluate whether therapies can really be of benefit! So I said this, and the room came alive. Suddenly, hands were going up everywhere, people wanting to talk about these very issues. Nurses need and want to discuss this, and the opportunities are not there. It was amazing to watch the discussion. Now, every unit has informal ways of venting and releasing tension, expressing horror and outrage at our daily activities. But we also need opportunities that are structured, have focus, and offer us some kind of hope for change and improvement! We don't usually get that in the break room during an often abbreviated lunch. I was heartened to see that my classmates want to talk about these things... there is hope, and change is possible. How, exactly, I don't know yet...

How to save a life

He was about twenty when he overdosed on something and fell out hard in the yard. He lay there cooking under the hot desert sun for quite awhile before somebody found him, and by then he was in rhabdomyolysis. This is basically the rapid breakdown of muscle cells. It commonly occurs when someone is "down" for a long time without moving. As the muscle cells die, all the proteins are released and circulate in the blood, clogging up the kidneys and causing major problems.

This kiddo was sick, terribly sick. He was one of the first really sick patients I ever cared for, on CRRT (continuous dialysis) and all that. He had a ventilator and a million drips, of course. His friends sat at his bedside constantly, radio playing. As you know, the commercial stations usually play the same 8 songs over and over, so you will hear the current popular tunes several times during one shift.

At that time, "How to save a life" by The Fray was playing all the time. I'll never forget listening to it as we worked intently, trying so hard to support his body while waiting to see if it could recover.

It could not; he would not. After days of sitting on chairs next to his bed while the radio played, his friends and family said good-bye.

I was surfing the radio today when I happened upon that song. I always kinda liked it from the start. I think for the rest of my life, whenever I hear that song I will picture that patient, that room. I will feel the cool temperature of the hospital air on my skin, smell the soap, and almost reach to do my hourly checks. I will go back again and again.

Reality Show: Life After Transplant

So I had an idea the other day for a new reality show. It would be called Life After Transplant. It wouldn't be very popular, I'm afraid, because so much of life after transplant is not that fun. I'm sure today's TV producers would only consider implementing a pseudo-reality version, anyway, kind of like the physician-centric medical shows. If they did that, they could include all the fun, happy parts but go ahead and portray it as a reality show anyway; they're really good at that.

The idea came while I was rounding with the MICU physician team in my role as charge nurse. The family of a man with end stage liver and kidney disease had elected to forego further curative treatment, remove him from the transplant list, and transition to comfort care only. He was not vented but nearly unresponsive and had very low blood pressure that we had been fighting with pressors. The Native American family notified us by quietly shaking their heads "no" to the nurse when she entered the room to restart continuous dialysis. The MICU team came and a discussion was had. Soon after, the liver specialists appeared on the unit. They were "very disappointed," they said, moving about with stern faces that clearly expressed their disapproval.

Inside the room, our attending was talking with the family. I could faintly hear him citing numbers and statistics, possibilities, the way this particular physician always does. The residents waited outside. Wouldn't they want to observe and maybe even participate in these kinds of conversations? I was mystified by that, as I always have been.

The reality show idea surfaced and I immediately shared it with the residents. They looked at me, perplexed. Now, I'm not saying I'm against organ transplants, or anything of that sort. I'm merely noting that the realities of medication regimens, rejection episodes, and consequences of lifelong immunosuppression are not what transplant teams advertise.

Consider this: A few months back we cared for an amazing woman who was 10 years out from a lung transplant. She had done remarkably well for 9 and 3/4 years. She carried her pills in a large box, way, way bigger than anything sold for the purpose of organizing medications. It was one of those plastic cases composed of many small squares that teenage girls use to organize their jewelry-making supplies. Each square held pills of a different shape and color.

This woman had lived to see her son grow up and get married and had many wonderful adventures in her post transplant life. She told us very clearly that, while she was beyond thankful for the time the transplant had given her with friends and family, she would not even consider doing it again.

There are so many things worse than death. I say that acknowledging that I don't know death myself, not at all. Sure, I've seen it many, many times-- been present for the changing, the leaving, the crossing, whatever you want to call it. But I've only seen it from this side, so I can't really know for sure. Yet there is something in us, something that responds to an apparent, perceivable peace that tells those of us who witness-- truly witness-- grave suffering, and the passing of lives, that death is not the worst thing that can happen to a person. Or maybe we can only say it seems unlikely that death is worse than some of those things we do know.

So much mystery.

All I know is, that would be one not-very-fun reality show. But it would be real, and it sure would be educational.

Anonymous, are you out there?

The comment from Anonymous on Pulmonary Hypertension just popped up, and I really hope she got to read on and see A little of this, a little of that, where I reported that Gina had come to visit post transplant, feeling good and on her way home. I don't know how or where she is now, but I like to envision her feeling good and carrying on normally with her family.

It's easy to get excited and think everything is grand when organs become available and are successfully transplanted. But the fact is, receiving a transplant is the beginning of a new way of life for everyone. Strict medication regimens, episodes of rejection. Of course, it depends on the organ; some are easier to swap out than others. So there is life, but the quality is highly variable.

On that topic, last week I cared for a man in his seventies who recently had a major abdominal surgery for treatment of cancer. The procedure he had is an extensive one. He spent 15 days in the hospital, went home, and came back with major complications requiring an urgent procedure in interventional radiology. Later that day, as I was monitoring him after the sheath was removed from his artery, he looked at me and said, "Why didn't anyone tell me about all this?"

"All this?" his wife and I said together.

"The tubes. No one told me I'd be going home with tubes weeks after my surgery." He was referring to the drainage tube and the feeding tube he and his wife had been maintaining at home.

Now, this is a good time to note that we patients don't remember most of the information we are told. So, the surgical team could very well have given excellent explanations prior to surgery. But, he still had a good point! He was not even remotely prepared for his experience, had no idea how significantly his quality of life might be impacted. And we must ask, then, how someone can give informed consent when they know so little about what to expect? It is not enough to talk about the procedure that will be done. Every effort must be made to share the quality of life issues that will be apparent in the immediate postoperative period and further along. To wit:

"They told me it would be a big surgery, but I didn't know what that meant. I had no idea it meant all this," he says, gesturing vaguely at his belly. He looks up at me sadly and says, "Do you think I'll need chemo after this?"

"I have no idea," I say honestly. "No idea. It sounds like you have some good questions for the surgical and medical oncologists. Sounds like you could use some more information to have an idea of what's coming up next, and what your options are." He nodded vaguely. "Every time you are presented with a treatment or procedure, I encourage you to ask lots of questions. Things like, how might my life change during this treatment? How long do you think it might last? How might things be different if I choose not to do it? With every choice, there will be benefits and drawbacks, and gathering more information can help you decide how to make use of the resources available so you can hopefully live in a way that is acceptable to you."

When I get back to work, he'll likely be gone. I really hope he gets some good time at home, free from complications and treatment related miseries.

To return to what prompted a response to Anonymous, I realize many of my descriptions are not very reassuring, but they are honest. They are my version of honest, of course, because we all have our own unique version of reality. I know that sometimes I may favor one side of the story more, but that's part of the therapeutic process that the writing is for me. Principally, I feel like we owe it to ourselves and our patients to do our best to be honest, all the time, about everything.

development

It's amazing, now, to see how I've changed. I am in the circle now, I am not afraid. If the team doesn't make room for me, I find my own way in and create a space for myself. I say what needs to be said. If I am not sure about something, I ask, no longer feeling that I can't afford to display any weakness. I am confident in my abilities and knowledge, and in my role. If I know something needs to be done, I push for it and I give reasons why.

I'm not sure the proper way to describe it, but I guess you could say I've finally actualized into this role. And now I'm ready for something different! What is that?!? I'm not sure I want a job where I will always have to force my way into new circles. Besides, my individual body can't really tolerate this kind of work, so I guess it works out just fine.

MICU RN reappears

Where have I been?

Still in the MICU, working away. But also, applying and being accepted to graduate school-- yay! And shifting to a new way of relating to my work, and my identity as a nurse. Getting a little distance. Considering a variety of trajectories and weird assignments, much like Beth over at PixelRN.

Why?

Well, sometimes the things that happen are so heinous, so horrific, that there is no room to relive them on the page. At least not for a while. Constant, minute by minute crisis management can be draining, to say the least.

Being a nurse is an awful big part of who I am. That can be fine, but it can also be dangerous when the role takes me into places no one should really have to go. So I've been figuring out how to make a little space for myself, I guess.

Hopping on here I noticed several pieces that I had drafted and never posted, so I'll put them up now.

Case management

I was hanging out with a buddy a while back, a nurse case manager. This was part of my quest for a new kind of practice, one that is still engaging, challenging, and meaningful, yet not terribly damaging to my body. I'm fine with the exposure to infectious diseases and hazardous chemicals, but the 13 hour shifts with a total of a twenty minute break are getting old. Sure, that doesn't happen every day, but it happens often enough. What's scary is we have excellent staffing-- of this I am sure-- when compared with our peers. Most importantly, and like zillions of other nurses out there, I'm having back pain. It's not magically going away. Every day at work, even with the utmost care, I push, pull, bend. I lean over patients for lengthy periods of time. I hurt.

Anyway, what is a case manager? Well, he spends his days going back and forth between patients, providers, hospital administration, Medicare, Medicaid, private insurance companies, skilled nursing facilities and rehabilitation facilities. This is the real deal. This is the heart of our health care system, and without this work your care cannot happen. Not in our system, anyway. It is incredibly tedious and in many ways disheartening.

When you are admitted to the hospital, someone (read: the nurse case manager) actually has to go through a big fat book put out by Medicare and make sure you meet enough criteria to qualify for "inpatient status." He or she may need to call your medical or surgical team and advise them that they *might* adjust the prescribed medications and interventions in order to meet criteria, or change the plan of care. Plain and simple, to some degree, payors are dictating our care. It's gross, it's complex, and it's unfortunate. While case management is important and necessary in our current system, turns out it's not for me. Gets my hackles up too much.

Death of a homeless woman

Three weeks in ICU, she was. No one could ever find any family. The cops even came and took pictures, sent them off somewhere far away. It was a dead end.

This GI bleed was the one that killed her. After her blood pressure dropped and she started seizing on the floor, she wound up in the ICU. She got continuous EEG and her blood pressure supported with medications requiring constant monitoring and frequent adjustment. Someone checked her blood sugar and urine output every hour.

Sarah was homeless. She couldn't get this kind of attention if she begged for it. She got a ventilator for three weeks, got liters of fluid drained off her swollen abdomen. They used a needle at first, but then the fluid just kept coming and coming, leaking out the tiny puncture hole from its endless source.

We turned her, cleaned her, talked to her. K. washed and braided her hair when the EEG monitoring was finally discontinued. Eventually, I stopped talking so much to her. What was there to say?

It was agreed by all that there was no hope for a meaningful recovery. The day she died, Sam stopped all her drips and took her FIO2 down to 21%-- room air. The ventilator kept giving her breaths, but it didn't matter. She couldn't live without the support. Sam had to take his other patient to CT scan, so as charge nurse I kept an eye on her.

There was no family to take care of this time. I talked to her again, told her it was okay and she would not have to worry anymore. She would not hurt or have to be afraid. Sam returned from his field trip, and we were there, quiet, when she went. I turned off the vent, we looked out the window. It was the kind of day she might have spent at the bus stop or outside a drug store, soaking up the sun.

You are the project

I work steadily on your belly, applying paste under the sterile plastic wrap anywhere I think there might be a tiny leak. The suction catheter tucked inside gurgles away. We are so close now: all day, with each turn the fluid has poured from one place or another. We have changed your linens a million times over. Now we have a plan.

"The skin can fail just like any other organ," our wound care clinical nurse specialist reminded me as we finished up an hour long creative problem solving session at your bedside. I had just shown her your new pressure ulcer.

"It's our fault," I had said.

She eyed me skeptically. Outside, she reminded me about you:

You are 86. You've been living in a skilled nursing facility (SNF), i.e. a nursing home, for about six months already. You've been receiving nutrition solely by IV (total parenteral nutrition, TPN for short) all that time because your body is unable to absorb any nutrients from your gut. They think you have Crohn's disease but no one is too sure. TPN by itself puts you at increased risk for infection. For one thing, there's all that sugar flowing through your central venous catheter 24 hours a day. Bugs love that. Plus, you miss out on all the immune system activity that is normally stimulated by activity of the gut.

You've been spending most of your time in bed since well before your admission to our hospital. A chronically ill 86 year old who is spending more that 50% of his time in bed is unlikely to live more than about two more months.

Then there's the giant abdominal wound you have, thanks to the surgeons who thought an exploratory laparotomy was a good idea when the nursing home staff brought you to our ER with low blood pressure, a firm belly, and increased lactate level in your blood. You've been to the OR 4 times so far, and you will go back again. They have removed your entire colon. The first ileostomy never worked, so they took that down and now you have that cavity, there on your right, about two inches deep that wells up continuously with warm, pinkish fluid. On the left is the newer ostomy. It looks like it might be a keeper.

In our institution, any surgical patient over 80 is an automatic nursing referral to a dietitian, and for good reason. Surgery is a major insult to an already weakened being. The reserve is low.

We turn you religiously, painstakingly positioning your every part. We float your heels, check your many lines, tubes, and wires to ensure they're not pressing into your skin. Still, you break down in areas where we can't completely eliminate pressure. Your skin also has stretched, blistered, and split open from the liters of fluid we poured in to keep your blood pressure up. It didn't stay long in your blood vessels without much protein to hold it in, creeping instead into the spaces between cells and blowing you up like a balloon. Once open, your skin erodes quickly and steadily.

The constant pouring of liquid from your abdominal wounds doesn't help, either. Skin hates to be wet, this is why TV ads pitch high tech diapers to moms and dads.

Back at your bedside, I put down the paste. I have been working intently, so focused. I look up at you from my project, and you are still there, eyes open. I see the tears that come out and roll down your right cheek sometimes. I bolus you with extra pain medication, hover close to you and stare into your eyes, wondering what they are saying. I don't know how to apologize. I can't. I try anyway.

What was this surgery for, anyway? They thought you really wanted a few more great months in the nursing home?

During rounds, I stand firm when the surgery team wants to decrease your pain medication so you might be more awake. I describe your tears, your deer-in-the-headlights look. They relent. I describe my interactions with your family members, offer to facilitate a meeting to discuss "the plan." They agree in words but don't commit to anything concrete. They tweak your antibiotics based on your latest cultures, and move on.

I return to my project.

Bellyache

In the morning before he went to work, she reported that her belly hurt.

When he got home that afternoon, she was on the floor, unresponsive.

At the hospital, they rushed her into the OR for an exploratory laparotomy, where they didn't find anything of note. There was a lot of swelling, though, so they left her abdomen open and just closed the skin on top. 5 big black X shapes made of thick suture held her together.

When we arrived the next morning, she was getting worse. Her lactate level was high, a sign that cells are trying to make do without oxygen. We picked up where the night crew left off. While I started the vasopressin drip, my newly graduated RN orientee manned the double spike tubing, hanging bag after bag of fluid to squeeze in with a pressure bag.

Her belly was looking bigger and bigger, her blood pressure not coming up. We implored the surgical team to return to the bedside once again. As the chief resident arrived she began to drop her heart rate.

He grabbed a pair of scissors and cut the big black Xs. The contents of her abdomen erupted, welling up as liquid poured down her sides and soaked the bed. The smell was warm and not quite right. With his sterile gloves he poked around a bit. We all watched the monitor for signs that perhaps she liked this relief of pressure.

There was no improvement.

While her loved ones waited outside the curtain, we placed the sterile plastic wrap over her open belly and covered her with blankets.

Serial blood gases indicated she was increasingly acidotic and her lactate level now into the teens. We kept pouring in the fluids, blood products, and powerful medications. Boxes from amps of sodium bicarbonate were littered all over. The fluids were leaking rapidly out of her vessels, and she began to puff up dramatically now, like some strange alien creature distantly related to the Michelin Man.

The family was large and loud. Her husband developed chest pain and shortness of breath, and was wheeled off to the ED for evaluation. One daughter became terribly angry upon realizing that her mother was lying on a wet bed. I explained over and over that we couldn't move her mother right now because she would likely die immediately as a result. It was painfully clear that everyone wasn't prepared for that yet.

She was far too sick for transport to the OR. Lactate now >15, the highest value our equipment accurately measures. Her belly was welling up higher and higher, like a great mountain in the center of the room. A niece developed an asthma (panic?) attack, and was next to leave for the ER. About this time a grandchild returned wheeling Grandpa, who had left against medical advice when they tried to admit him for the chest pain.

Things were getting worse by the minute. The room was packed, the wailing nearly continuous. One daughter, who had been designated medical power of attorney by the patient, agreed to refrain from shocks and chest compressions (CPR). She was nearly beside herself, declaring that her siblings were second guessing every choice she made. She felt she had to leave it up to her father whether to continue aggressive support. There was yelling back and forth across the bed between various members of the family.

"Dad, you've got to let her go! You're just prolonging things now."

"Shut up and leave Dad alone. It's his decision!"

"I need to get out of here, I can't take this," he said.

"Dad, you can't! You have to stay here with her. You cannot leave her."

About this time, a very pregnant granddaughter turned to me and asked, "Is there somewhere I can throw up?"

I ushered her into the tiny bathroom where she sank down beside the toilet. "We need more nurses for this family!" I exclaimed as I scrambled to care for my patient. The pregnant one was escorted out, not a moment too soon.

"How will I ever live without her?" her husband cried in anguish, the chaplain by his side.

"Daddy, we'll take care of you," the angry one said.

He started to leave. "I need to get out of here, take a smoke," he said.

I was watching the monitor closely as he said this. I knew it was time to get my amps of epinephrine and atropine in my hand and ready to go. I stopped him with a hand on the shoulder. "It looks like she might go at any minute now. We have tried everything we know to stop this process, but we are out of options. Do you want to stay? It is okay either way."

He shuffled back to her side. I called the ICU resident to come, and when her heart rate suddenly plummeted, I pushed the atropine. She didn't respond to that, but some epinephrine gave her a heart rate and pressure for about 4 minutes. Then she went nearly asystolic-- flat line. I pushed another amp of epi and got the same result. All their eyes were fixed on the monitor.

"She may keep responding temporarily like this for a while, but we can't fix the underlying problem," explained my colleague who had joined us at the bedside. As I prepared to push the 3rd epi, her husband said, "Stop. No more."

It was hard to zip the body bag closed, her belly was so big.



When those patients finally “die,” it becomes apparent just how fuzzy the line between alive and dead is. If a patient has a heart rate on the monitor of 30 with a pressure of about 21/18, are they still alive? You won’t be able to feel pulses with that, though there is technically a pulse pressure. Do you wait for the last physical beat of the heart? That comes before the last electrical activity of the heart. If you see 25 complexes a minute but the blood pressure is 4, when shall we stop calling it pulseless electrical activity and start calling it dead? How about 12 and a BP of zero, or shall we say less than six per minute? We must pick a time. If we didn’t have a monitor, we’d call them dead when we couldn’t feel a pulse. But since we do, families, nurses, physicians all stare up at it and keep pushing drugs, waiting for it to show us what we already know.

why sometimes i don't say much

I haven't been posting lately. It's not that I don't want to. Well, sometimes I don't. It's too hard. What does one say? Sometimes there are no words left to describe the atrocity when it's all said and done. Sometimes I have lots to say, but the stories are so outrageous, so painful, so heartwrenchingly unique, and I fear the monster that is the HIPAA police. Sometimes they are in the national news.

Don't get me wrong-- it's not that I actually believe that what we do is so special and different. But, I worry that just once someone will see themselves, or someone they know, in the story and it will really be them. Sure, I know I could change more details, but sometimes I can't stand not being true to the story. That is where I am as a writer, I think. I somehow feel that I'm not telling the whole tale, the real truth, if I alter too many things.

So that's why.

Things I can't live without/wish I had

So I've been tagged by PixelRN. Without futher ado, here is my list.

The four things I cannot live without:

1. The coolest pharmacist in the world. T. is our unit pharmacist, and she rocks it like no other. She is buzzing around all the time, keeping track of all those little things nurses and physicians sometimes lose in the midst of everything. Her incredible knowledge base and fantastic cooperative attitude make our patients safer and my work a more joyful place.

2. Dr D. This is the kind of attending who spends hours in family meetings her first day on service. When D. is on, families and patients are not regarded as an afterthought, somehow disconnected from the task of maintaining physiological stability at all costs. Not only are her people skills fantastic, but clinically she is top-tier. I'm not sure exactly when she does it since she is always on the unit, but sometime she is busy reading up on the latest ideas. D. listens to patients, families, nurses, and respiratory therapists. She listens, period.

3. Skin prep. It sometimes keeps my patients from literally falling to pieces, and keeps those central line dressings intact just a few more hours when the patient is an oozy mess. I am a huge fan.

4. The therapy and security dogs. When I see them coming, I run for my Milk Bone stash in the break room!

5. An expert respiratory therapist. More than once I have been majorly rescued by a super-RT. Their specialized knowledge is invaluable, and when we work together we are amazing!

Okay, so that was five. Too bad.

Now, what do I covet? Honestly, many many things. If I must pick one, it shall be this:

A culture change, so that we might stop regarding death as the ultimate enemy and put pain and suffering in that place instead. How things, then, might be different.


I'm really glad PixelRN tagged me. As I started putting down all the things I cannot live without, I realized just how many things I love about my work enough to share them with others. The list is a lot longer than five!

Now, I shall tag PaedsRN at Cricoid Pressure and TC at donorcycle.

What happens at my work

You know what happens at my work?

People occasionally get feeding tubes in the wrong place, like a lung.

People who can't speak for themselves sometimes have decisions made by someone who was not their first choice.

Mothers and fathers and wives and sons cry, sob these heart-wrenching sobs that permeate to the core of every individual within earshot.

People get out of bed for the first time in months.

Ribs are broken by resuscitative efforts.

Skin splits and peels, gives way to the intolerable tension created by the fluid leaking out of vessels and in between the cells.

Egos sometimes determine the ventilator settings.

We leave exhausted, and we leave some people feeling better.

Wow!

If you didn't catch today's Here and Now on NPR, click right over to check out Robin Young's feature on the nursing shortage. Mary Jane Williams, an Associate Professor of Nursing at the University of Harford, and Suzanne Gordon, author of Nursing Against the Odds and coauthor of From Silence to Voice: What Nurses Know and Must Communicate to the Public, were guests on the program. In addition to discussing the shortage of practicing nurses and the projected increasing demand in the coming decades, they also highlighted the dire shortage of nursing faculty. They explored the bizarrely inaccurate media portrayals of nursing, noting how these influence the actual public image of the profession, and they reflected on how this relates to our current nursing shortage. They highlighted the tireless work by Sandy Summers and company over at the Center for Nursing Advocacy. Perhaps most importantly, they discussed the real nature of nursing work and it's primary importance to patient health and safety. Highly unusual, I'm afraid. Thanks, Robin!

A must read

Wow! Barbara Ehrenreich has done it again! The same woman who brought us the phenomenal book Nickel and Dimed has busted out with Pathologies of Hope, in the February notebook section of Harper's Magazine.

Barbara starts the piece with this: "I hate hope," and proceeds to blast "positive psychology" and it's overly enthusiastic followers. I'm so glad to hear someone pointing out that pushing people to "be positive" can be terribly destructive, especially when they are fragile, vulnerable, and under stress or in crisis. Maybe if we could as a culture swing back in this direction, fewer people would have to tolerate being told that they could surely get well/be successful/etc. if they would just be more hopeful. This kind of thinking is not reality based, and I have seen it be a source of great stress for more than just a few patients.

Right on, sister!

a little of this, a little of that

Where to start? Why haven't I posted in awhile? Well, because there's too much to say, and not enough all at the same time. Maybe we'll just start with some simple updates. There has been some exciting news lately!

First, just before Christmas, I was in a patient's room when another nurse came to the door and said, "There's someone here to see you."

"Who is it?" I said, but she had already walked away. As I finished up and washed my hands, I figured it was probably one of the therapy dogs, since they know to look for me and beg for me to get out my secret stash of Milk Bones.

But walking to the charge desk, instead I found Gina. Gina! You remember Gina, who teetered on the edge while waiting for new lungs and finally received them. There she was breathing nothing but good old room air, walking unassisted with her family. She looked so different! No longer the cachectic woman I once knew, this Gina was round and puffy, the poster face for steroids.

"I'm doing really well," she said. "I came to thank you all. We're moving out of our apartment here in town and heading home for good next week."

She and her husband were all smiles. We were too.

Then, just the other day I ran into the medical student who I had worked with when I cared for Rosa, the woman from Mexico. The student had continued to follow Rosa after she was transferred out of ICU. Turns out, Rosa became just one of those people who squeaks through without dying or becoming disabled and slides quietly out the hospital door into a nation full of opportunity. She was healthy enough to leave the hospital independently, so this attentive student found her some clothes and shoes. Rosa's husband hired someone to safely transport her deep into middle America. The student helped her get outside to the right place at the right time, and off she went.

Now, on to the reason I'm not writing too much these days. I'm not exactly sure what it is, but I think it has to do with the fact that these stories, these dramas, are so infinitely complex, so thick with loss, joy, and unknowns, that they are hard to package up neatly. Even when I give myself permission not to do the whole thing justice, it is still really hard. So sometimes I just go about my work, processing things internally but not forcing that next layer of sorting out that might be required to write coherently.

Sometimes, when you are tired through and through, there is honestly nothing left for such luxuries. When you work in a profession where hard, good work is rewarded with more responsibility but often no more money or power, that can feel very defeating. This is coming from someone who now has the joy of being charge nurse.

Now, don't get me wrong. Sometimes being charge is really cool. If it's a really weird day and we're actually adequately staffed, the charge nurse stays out of ratio (i.e. does not take a patient assignment). Instead, he or she is the helper bee, scurrying around looking for fires to put out, people to help. You're the go-to guru for any problems, whether they be clinical issues, interpersonal issues, material/supply issues, safety issues, etc. It's all fair game. So, when the unit is humming along, nice and busy but staffed adequately with enthusiastic, energetic, smart nurses (like so many of my colleagues are), that job is really fun! I get to run around and do whatever is needed, problem solve all kinds of wacky stuff and learn a lot in the process. I get to make sure everyone gets to eat lunch, which I think is hugely important! Having people who get to take a thirty minute lunch break during an intense twelve hour shift of monitoring and responding to the needs of unstable patients is an obvious plus for safety, right?!?

But what about those days when things aren't so cute? We're short a nurse (or two, or three) so I've got an assignment that I can just barely manage. I can see my colleagues struggling too, and there's not too much I can really do for them or our patients, besides run faster and faster. We have to do the best we can. What's really frustrating about these scenarios is that we have basically zero control of what is happening. We can say to the nurse house supervisor, "This is not safe. This is scary. We are uncomfortable with this." Or, "We're stretched to the limit right now. We're okay, but we cannot safely take another admission into the unit with our current staffing." But, all we can do is say it. We have no actual power in these negotiations. And anyway, we're so busy, we hardly have time to pull our heads up above water and look at the total picture of our surroundings.

It's kind of frustrating when you realize that you get stuck in this bad position precisely because you do good work. Serving as a decision maker and resource for the unit is great. But being forced to put aside your good judgment (perhaps the very thing that earned you this post), battle hard and often unsuccessfully for your staff and your patients, and make no additional money is pretty crappy, don't ya think? No wonder so many intelligent, motivated nurses choose to pursue advanced practice. It's not necessarily because bedside professional nursing does not satisfy their need for challenge, investigation, and reward. Rather, perhaps it's because they are uncomfortable taking on increasing responsibility along with minimal control over things in which they are quite expert, minimal recognition of their contributions by other disciplines, and stagnant financial compensation. There will be no easy fix for this nursing shortage.

By the way, you might be interested to know that the National Labor Relations Board recently ruled in it's "Kentucky River" decision that permanent charge nurses in a Michigan hospital are considered "supervisors" and are thus ineligible for union protections. This potentially leaves these nurses in a very bad spot. You can learn more about this in the January issue of American Nurse Today, the journal of the American Nurses Association.

Heavy load

Christine was somewhere in her fifties. She was one of my first giant patients, weighing close to five hundred pounds. Everyone complained about her; she used her call light to ask for help with things a normal sized human would be able to do alone. But she was polite, gracious, and attempted to maintain some independence within her physical limitations. She was in for a congestive heart failure exacerbation. Naturally, she had diabetes and joint problems as well.

During her two week stay, I found myself caring for her a lot. Man, did I learn some things from Christine.

One day, she wanted to talk about her weight. Specifically, how she got this way.

"My mom died when I was pretty young. My father would use food as a way to have power and control over us. When we didn't behave how he wanted us to, he would send us to bed with no dinner. This happened a lot. I remember creeping downstairs in the middle of the night to get a piece of bread for me and my sister to share. I would ball it up in my hand, take it up to our room, and we would pick off tiny pieces, making it last as long as we could. Afterward, we would still be hungry, but I would feel a little better because I was taking care of us. Our father would tell us that these restrictions would help us to stay thin and beautiful.

"When I got older and began to have control over what and when I ate, I chose to assert my independence and freedom through food. I cooked big, elaborate meals for my sister, and later for my two children and now ex-husband."

Listening to Christine made me remember a study I ran across one time that found that a startlingly large percentage of obese women have a history of abuse in their past. There is a significant amount of evidence that points to a link between childhood abuse and obesity in adulthood.

Christine was one of many patients who taught me early in my nursing career that there is always a story, and there's a lot more to it than we usually think. Every human is at the center of a giant web that only he or she knows. When I can remember this, it helps me to talk less and listen more.

Rapid Infuser

The numbers:

1 fourteen hour shift
10 units of packed red blood cells
10 units of fresh frozen plasma
10 units of cryoprecipitate
3 units of platelets
2 hours in interventional radiology
10 liters of crystalloid fluids
3 pressors, maxed
2 daughters
1 sister
4 people who had to change their scrubs
1-5 registered nurses, depending on the moment
0-3 physicians, depending on the moment

Last week, I learned to use the rapid infuser. I had been wanting to for a while, so that when an emergency came up I would be quick on the draw. That day, the emergency just would not quit, so I learned as we went. Now, I'm a pro. If you're wondering, the rapid infuser is a device that warms fluids or blood products and delivers them, using pressure, very rapidly. It's for when your patient needs that volume and/or blood about twenty minutes ago. It is how you keep up when your patient is bleeding out-- treading water while trying to identify, pinpoint the location, and hopefully fix the problem.

After all those blood products, the hemoglobin was 4.6. The intervention to stop her bleeding, while apparently successful initially, had not been effective. It was a very, very hard day. One thing I do know is that, if she could have been resuscitated, she would have been. We did the right things, we did them fast, and we did them well. I was mildly impressed with my own work that day; I didn't know I could handle something like that yet. I was far, far, far from alone and utterly awed by the seamless cooperation of my colleagues that day, but I also contributed more than ever before. So, now it's time to raise the bar a little more.

Sheila's family let her die before anyone had to start cracking ribs, and that felt like a real blessing. Periodically, I leaned close and explained where she was, what was happening, and who was there with her. I reminded her she would not be alone through this, no matter what. And she wasn't.

The Preceptor

Well, they've got me teaching other people now. How scary is that? It's been just over a year now in ICU, and just over two as a nurse. I'm finally starting to hit my stride, and wham! they throw me off with this new business! I could really sympathize the other day when one of my colleagues remarked, "I just want to come to work, do my job, and be left alone." It is not that we don't want new nurses to be guided, supported, encouraged, and actively taught, but it sometimes seems like a heavy burden to be that guide, supporter, encourager, and teacher.

You can really see the nursing shortage's effects in our unit where the nursing staff turns over quickly and the percentage of new grads is high. In a world full of travel assignments with housing allowances, sign-on and contract completion bonuses, there are lots of incentives to move around, even within the same city. Our unit management would really like to stop using travelers, so they pushed to hire more core staff. Well, who do you think is applying for those jobs? New grads! They all want to clamor their way into the ICU, many with that syndrome where people think they're too special to do floor nursing. The new grads don't have the experience to make them eligible for those non-traditional positions with more cushy offerings, and there are simply not enough experienced applicants. So we end up with a whole pile of them.

So okay, that's fine, I suppose. In a way, precepting has been good for me. It has helped me to realize how much I do know, and how far I have come in my development as a nurse. I am amazed by my efficiency, speed, and attention to detail. However, I am keenly aware of my lack of experience with so many things, and understand that time is the only way to learn a lot of this stuff. On that note, it is interesting how much nurses learn on the job. I learned a lot during my challenging BSN program at a highly regarded university, but the way the knowledge just keeps piling on, stacking up in layers and layers and building bridges all over the place is really amazing. From working so closely with the residents at our teaching hospital, I can see that a similar phenomenon happens for physicians. However, physicians have a formal residency time that differs dramatically from that of nurses. Maybe we need to rethink that. I don't know.

The balance of letting your orientee have enough freedom to learn on his own, yet remain well within safe practice, is not an easy one to achieve. Ever mindful of the limits of my own knowledge and experience, my obsession with efficiency, detail, and routine is my way of keeping my own practice safe. When I have to relinquish those few elements of control in order to let someone else feel things out, things can feel pretty sketchy sometimes. After all, I don't really know how much I can count on myself yet! I haven't been tested that much, I don't think. To hear about one recent test, check out Rapid Infuser.

New lungs!

Guess what? Gina got a new set of lungs! And they're still working! Wow!

A good old-fashioned foot-washing

Remember Tomas? In that post, I forgot to tell about the best thing I did for him. I thought of it last week, as I washed and bandaged the feet and necrotic toes of a most pitiful patient.

Besides the scratches everywhere, Tomas had one visible wound from his journey: a large, open blister on the bottom of his foot. His feet were still pretty dirty following an initial cleaning the night before. He was sore and stiff, so I sat at the foot of his bed and washed his feet very carefully. I cleansed the wound and applied a bandage, then put on some socks (non-skid, of course!) so that, when ready, he could safely traverse the floors of the hospital.

This was how I came to hear the details of his story, his motivation for travel, his feelings about the experience. By turning my attention to his feet, I was honoring him in his entirety. In particular, caring for visible wounds on the feet can have meaning, I think. In this case, it was about acknowledging the losses and suffering inherent in his journey, and readying him to travel again.

Over and over, I am honored to wash my patients' feet.

Who am I writing for, anyway?

Oh yeah, me! My own sanity, that is.

So, I've noticed that I'm not very consistent. Sometimes, I'm really good about defining everything, making this blog great for the non-healthcare provider. But sometimes, I can't figure quite how to work it nicely into the writing, and I'm not savvy enough to know how to set it up ultra-cool so you can click on a word and go to a definition. So sometimes, I end up writing for an audience that's more like my colleagues. When it happens, I let it, because it feels good to write like that, too. So the inconsistency will continue indefinitely. Sorry for any inconvenience.

Absence

Ana was 36. She had type I diabetes and chronic renal failure, but she was still pretty vibrant. A huge family loved-- loves-- her. She had a large spontaneous bleed in her head, and wound up in our ICU.

My first day with them comes one day after a trip to the OR where they tried to evacuate the blood that was taking up all that space. Her neurological exam remains unchanged-- pupils fixed and dilated, etc. The bleed was so big, and the resulting secondary brain injury massive. As I care for her and her Spanish speaking family, I do my best with a limited vocabulary to talk about things like brain death and carbon dioxide levels.

At 6:50 pm, we finally begin the apnea test. Based on her latest pCO2, we've calculated that she'll need about seven to eight minutes without breathing to reach a level greater than 60. If this is how it goes, she can be declared brain dead by two physicians.

We sit (myself and three respiratory therapists) watching her intently for any sign of spontaneous breath, punctuated by glances at the monitor and at the ventilator screen which is handily counting the time, second by second, since it was placed on standby. She does not become unstable or do anything weird during the test. Her vitals stay steady. In fact, she does nothing at all.

At eight minutes, K draws a third and final blood gas. I document on my bedside computer: no breaths. The night shift comes out to take over. During report, the phone rings. It's the blood gas lab with results: pCO2 70, pH 7.23. I page the attending neurosurgeon. By 8pm I am out of there, thirty minutes late.

Her family is outside and they don't yet know the results. I want to see it through and be with them when they learn it, but I'm tired, and I have to come back tomorrow. At home, I shower, eat (thanks to my husband) and then sleep. I wake in the middle of the night with a cat curled tightly against me.

In the morning, she's lying dead in the bed, long extubated. Her family just couldn't do the organ donation thing-- it was so hard for them to believe she was already dead when she was still receiving 10 breaths a minute from the ventilator. They surround her, taking turns filling the tiny room. They want-- need-- to stay and be with her. The ER is calling, hoping to give report on my new patient. I explain that there's still someone in the bed-- they'll just have to call back.

We gently remind the family that we'll have to move her from this room soon. They nod, but stay settled close at her side. Eventually, we realize they're staying to see it through completely. I ask her husband, "Do you want to stay until we move her from here?"

"I think so," he responds.

"We have to bring a special stretcher in. Do you want to stay for that?"

"Yes, we do."

T and L go to the morgue and get the cart. When they return her relatives are saying more goodbyes, this time really the final ones. They slip out of the room as we bring the cart in, and they stand outside while we move her. We close the curtain so they don't see us put her in the bag and zip it up.

They thank us. As she is wheeled out of the unit, they follow, moving cohesively like a flock of birds down the hall behind her.

L tells me later that they followed all the way to the heavy double doors between the new and old parts of the hospital. There, they stopped and stood, watching the doors swing shut, completely experiencing the separation.

Pulmonary Hypertension

Gina is 43. She's been with us for around eight weeks. Gina can hardly go to the bathroom or eat without seriously desaturating-- like from a normal oxygen sat of 95% right down to 68%, in just a few seconds. Recovery is slow each time, made up of many quiet slow deep breaths from the nonrebreather mask that gives her as close to 100% oxygen as we can. These days, when she's going to engage in any activity at all, we just crank her on up to 100%. She desats anyway.

She spent her first month with us on Flolan, a powerful drug given IV that relaxes the pulmonary blood vessels and affects blood clotting to help improve blood flow in the lungs. Not only does this help with oxygenation, but it reduces the burden on the right side of her heart, which must pump against all that resistance day in and day out. The drug has a very short half-life: just a few minutes. The infusion must not ever be interrupted. We must always have a back up pump and tubing ready to go, as well as a second (or third) IV access in case her peripheral falls out or her newly inserted PICC line decides to explode spontaneously. If her Flolan pump alarms, everyone comes running. Naturally, Gina proves to be a nervous type. Who wouldn't?

We titrate her dose up slowly and steadily, horrific side effects our only limitation. It is difficult to tell whether she's getting much benefit from the Flolan: her oxygen requirements are still super high, and her severe shortness of breath with any activity almost completely disabling. However, presuming that she would be worse off without the drug, and with very few things to offer, the decision is made to transition her to Remodulin. This is a drug that works very similarly, but is given subcutaneously via a tiny needle, much like insulin pumps some diabetics use. It has a longer half life (measured in hours instead of minutes) which means it is a lot safer, especially for home use. There is less risk of infection than with a central IV, and less risk of death from pump malfunction or operator error.

Home use is what Gina is looking at, if we can get her oxygen requirement down to a more reasonable level. Really, what she needs is a new set of lungs.

One morning, I am sitting by her bed after one of our frequent pump checks (she does most of it while we RNs watch, because she needs to learn to manage it all by herself). We’re looking at a brochure the transplant coordinator has brought by. It talks all about life before, during, and after in excruciating detail.

Right now, she’s stuck in the before-before zone. She’s three hours from home because we’re the only place around for this therapy. Sometimes, we talk about her kids. She hates that she is going to miss her daughter’s first day of school. She worries about them even more when her husband is here and they're staying with relatives, but she feels so much better when he sleeps on the fold-out chair next to her.

Gina is in limbo. Will she get new lungs? When will they show up? Will she be ready? What will the surgery be like? Will her body accept these foreigners? Will she ever be able to live without a mask on her face? Will she ever make it home again? She tells me she was never claustrophobic before, but now, with the mask always covering her, little things like a closed curtain can be too much to take.

She's "stable" on the Remodulin now, though she has seen minimal functional improvement. It is time for her to leave the ICU and go to a floor. We just can't justify her staying with us any longer. At this point for Gina, it's mostly about the waiting, and small tweaks to therapy that may help a little here and there.

It’s time for her to face another unknown, the first in a long line. As she’s wheeling away in her new bed, I dash across the unit for a quick hug. Then, she’s gone.

Burned out?

How can I go from energetic, enthusiastic--albeit realistic-- to grouchy, tired, and jaded so damn fast? Yesterday at work I had last pick of assignments, and I got the bad pair. Well, not the only bad pair, but the worst one. The guy who has been there forever (we're talking five months and around 20 trips to the OR), belly still open, who along with his family is exceptionally needy (and who could blame them?). Then, two doors down, we had the 70-something gal with stage IV cancer (recently diagnosed after the breast cancer came through her skin) who is on a ventilator. Seems that "everyone" knew she would not be weanable, and the pulmonary team tried to share this with her and her family pre-intubation, but then the gallant oncologists swept in and announced their chemo could surely work wonders, a few chest tubes would "fix" those pleural effusions, and she'd be a breathing champ again. The ventilator would be a temporary thing, and before long she would be sailing out in a wheelchair.

After many a trial, her spontaneous tidal volumes remain around 120-150mL, which means she has to breathe about fifty times a minute to get a decent minute volume. Those chest tubes continuously drain large amount of serous fluid, which come from endless springs within her cancer-ridden lungs. Is she supposed to wander around with those things sticking out of her and bubbling away for the rest of her *long* life?

To top off the whacked-out-ness of the situation, the oncology team is starting to think realistically about her inability to wean from the vent. What do they say?

"Time to talk to the family."

"We should really talk to her family before we do more chemo as planned today."

Hello?!? This woman is totally awake and completely alert and oriented. She writes us complex notes all day long. I reminded our pulmonary attending of this and he said, "Okay, well does she have a living will or power of attorney?"

"Maybe, but it doesn't matter right now because she can tell us what to do!" I reminded him.

People seem to think that just because a patient is on a ventilator, they are incapacitated. This is not true! I reiterate this during rounds and the resident says he'll come back and talk to her.

A few hours later, he and the fellow enter her room. They explain her situation briefly, including the fact that she may need a tracheostomy if she is going to stay on the vent much longer. They say, "What do you think?"

I count about three seconds before they turn to me and say, "She's overwhelmed. She's not processing. We'll come back another time."

"She hasn't even had time to get her Sharpie in hand!" I exclaim. "Give the woman a few minutes!"

It is hard to be patient in the hospital, when there is so much to do. Patients to be admitted, lines to be placed and changed, families to be updated, films to review. But sometimes you must be patient, stand at the bedside, and wait the necessary time for the patient to find her voice.

For me, it is morally distressing on many levels to care for an elderly patient with advanced cancer who is being mechanically ventilated. From the questions they ask me, it is obvious that she and her family do not have a sense of the big picture of her total health. I try to give it to them piece by piece, but if it doesn't jive with what the various teams of physicians are saying, that only serves to confuse them more. Even framing it as, "Here are some questions you might want to ask... Here are some things to be thinking about... etc" seems like banging one's head against a brick wall.

Yesterday at work, several people commented that I was not my usual cheerful self. Usually when I announce that I'm feeling grouchy, my colleagues say things like, "You're never grouchy," "Impossible," etc. Not yesterday. I hope it's just a passing thing, but the fact is these things weigh heavily on a person.

Probably what makes it the hardest is that only about forty percent of our nursing staff seems to recognize that we must share these burdens together. The other sixty percent just does everything they can to stay away. This doesn't feel very cooperative or facilitate feelings of happy, we can do it team-ness!

This isn't my best writing today, this is just a tired, frustrated nurse who wonders sometimes how to keep going at all, much less with a good attitude. Part of this may be coming from the fact that I'm currently reading Suzanne Gordon's awesome book, "Nursing Against the Odds." The book illuminates so many complex issues in our health care system and examines them specifically as they relate to nursing. While at times it is uplifting and inspiring, it sometimes reads like a laundry list of (seemingly) unfixable problems that are enough to make any nurse crawl under a rock and not come out! Anyhow, I highly recommend the book and hopefully will have some forthcoming more thoughtful posts born out of this good reading.

Oh, baby

We step off the elevator. I'm too tired to take the stairs this morning. As I walk toward the unit, I turn to my patient's husband and ask, "How are you today?"

"I'm okay," he says.
"Did you sleep?" I ask.
"Some," he responds.
"How is the baby doing?"
"She's stable, they say."

We walk in silence, alone in the long hallway.

"I hope my wife is better today," he says, turning to look at me.

"Me, too."

We enter the unit and part ways as I head for the report room. I watch him walk with the bent posture of someone straining under so much weight he can hardly stand up. All day, he goes back and forth between his wife in our unit and their only child in the NICU.

His wife alternates between sedation and agitation. When she is awake, she is trying always to ask about the baby, over and over. We tell her what we know, but we can't tell her what she needs to hear because it isn't true. The continuous dialysis machine clicks and whirrs.

He may lose them both at any moment. He is a big, lumbering man, but he looks so small and alone in the recliner, even when family comes around. Sometimes, he begins to snore and I move so quietly, I am almost like a whisper.

the damn border... again

Hope you're not too sick of border issues... I know I am.

Rosa is 39. She comes from way down south, down in Mexico is what I'm talking about. Her goal: to reach her husband in a nameless city, far away in the American Midwest. The report is familiar: 39 y/o female, found down in the desert. Diagnosis: dehydration, rhabdomyolysis. Walking for 8 days, out of water for 3, down for two.

She shares her story with me, lying in one of our ICU beds, eating a red popsicle.

"I was getting very weak,” she tells me. “The guide had told us it was a twelve hour walk, but it had been days and we had no water or food. I couldn’t go on. Finally I lay down under a tree. I told my son, ‘I am going to die. You must go on without me.’ I was sure that I was going to die there. But instead he went for help. I woke up with people around me.”

The day I cared for her, she was doing so much better. Her kidneys were making urine, and her wildly aberrant lab values were slowly resolving. Her tongue still showed deep furrows, a sign of marked dehydration. I pushed popsicles, jello, water and juice as the IV fluids flowed.

The social worker, medical student and I worked hard to help her contact her family. When we finally reached them, they said, “We’re coming for you, don’t worry.” Her son came in and her eyes showed the first spark of joy. A hospital representative came by and showed her an estimated bill, with a discount-- 11,000 dollars and some change. Her eyes widened and she said nothing.

"I had no idea what I was getting into," she told me as I drew more blood.

Why do I keep writing about these people? The stories start to sound the same, I know. But each one is different, each one an amazing brush with disaster. They are a small sample, and there are so many more we don't ever see. Some of the dead are never found. Some sons don't find help in time. Pregnancies are lost con frecuencia. Some people are dialysis dependent for the rest of their lives. Many are dropped off by the migra in a drug and crime-ridden border town far, far from the home they left, often temporarily, in search of better things.

I realize now that I also write because I wonder what happened next. These are not the sort of patients who come back or write in a year to give us an update. If they make it out reasonably healthy, I know that most of them eventually find their families and friends. They find work and proceed living off the radar screen in the deep undercurrent of our society, contributing more as a group to our economy than they ever take, even though the 11,000 dollar hospital bill remains unpaid.

Limited Access

when the ache grew to be unbearable,
the accordion player finally went to the dentist
crossed the border to his hometown
where the dental care is cheap-- relatively speaking

afterward,
the fungus that was lurking, now unleashed,
began to migrate through his head
visiting the sinuses
invading his left orbit

now we care for him in the ICU
post craniotomy
head bloodied and bandaged
his eye and sinuses gone

we infuse high doses of ampho-terrible
after premedicating for the shakes,
hoping to squelch the fungus the surgeons could not reach

today, the rest of the band came
they asked, "?cuantos pueden entrar?"
i said, "as many as we have room for."
so they filed in,
stood all around the bed
and sang
it was like a hymn, i think
soft and low, in
five-part harmony
then they prayed
and left him
sleeping so soundly, getting his best rest yet.

Nogales, Sonora/Nogales, Arizona

We sit in long lines of cars, waiting. Doors locked and windows up, A/C blasting, we inch toward the large gate which the people on foot cannot pass. As we lurch forward one car length, I dig for loose pesos and roll my window down to hand them to the man with no legs. He sits in a wheelchair between the lanes of traffic. B. hands me a perfect mango from our friend's farm and I pass it to him-- we can't bring it in anyway. For the next ten minutes, I avoid eye contact with the ten or so other humans who come to my window, offering duros (I hate duros!), candy, or trinkets for sale. Some, like this young man, come with nothing-- only hungry eyes. He takes note of the two kayaks on our roof. We are rich, rich, rich. I steel myself and shake my head firmly "no". I say out loud, for my own benefit, "this is not the way to help." Yet I watch the young man in my mirror as he moves on down the line, and I think how his story is likely quite similar to Jose's and Tomas'. I think, what does he have to do, land in the ICU for me to take action on his behalf?

It is perfectly reasonable to think that he spent his entire life savings to get here, perhaps got turned back once, now he's stuck in a no-man's land, far from home, with no money. Those pesos passed from car windows may add up to a ticket home, or supplies for another try at the original plan. I think about this as we creep across the bridge, the large metal fence visible off to both sides. I wonder if they all resent the man in the wheelchair-- he's clearly doing the best. Maybe they have an arrangement, I think. Perhaps they share, pool their earnings. Or maybe they rob him later.

We slide through the big yellow gate. We're still ten cars back from the camera, scanners, and Customs and Border Protection official who will wave us through back to our comfortable world. I breathe a sigh of relief that I don't have to choose who to help anymore, and think of their faces all the way home.

border blues

This time, he is twenty-two. The report:

"Illegal alien", Mexican national
ejected in a motor vehicle crash
four humans dead on the scene

Jose's body is incredibly swollen-- you have to pry his eyes open to check his pupils. His body is in severe shock. His intracranial pressure is too high-- so high, his low blood pressure can't overcome it to get oxygen rich blood to his brain. There are many signs now that his brain is no longer working.

Details emerge, gathered from fellow travelers and emergency reports. There were eleven people in the van. They were newly arrived in our country, and all here illegally. He has four children back in Mexico. He was coming to fund dreams, dreams like school that require uniforms and books. We have no idea how to find and contact his family. He is going to die soon. The search begins in earnest when organ donation services come for a screening. Finally, some progress is made. Our phone starts to ring, people asking questions in Spanish. Where do we start?

They won't be able to come see him. They live too far away. Buses don't travel fast enough, and they cannot buy plane tickets. We will ship his body back to Mexico. The sadness along our border grows and grows, and some days I can actually feel the divide between us growing wider too.

The next day, I ride into the desert, on a mission to deliver water to areas where migrants are known to have died of dehydration. Where we go, it is remote, lonely. But it is not that far from the swimming pools and golf courses, or from the grocery stores brimming with affordable, spotless produce picked by migrants.

As I fill the barrels, I breathe in and out, in and out, and think of Jose. I hope, pray, plead silently that today one traveler in need will happen by, rest in the tiny patch of shade, and, when ready, tread on with thirst slaked. Today, I place the water in honor of Jose.

Renewal

Well, wouldn't you know I got back to work and found the most wonderful thank you note from a family in my mailbox, transforming my attitude significantly before I even made it out of the report room. The timing was excellent! It really did give me just enough of a boost to get back out there and go to it again, and I found that I still have the energy to continue to work and learn here, for now.

Everyone always talks about "moral distress," and how much of it nurses experience. This is no joke. It can be astounding how often we are in work situations where there is great conflict about what is the right/best thing to do for this human being. We are frequently facing situations where people's preferences and wishes are being disregarded, blatantly or insidiously. We are tangled up somewhere in the web of patients, families, and physicians, insurance companies, and politicians, implementing the decisions made by many parties. Sometimes our place is a strange one.

rethinking

Well, I've had some time away from my work because of happy life events. Today I was to be back again, but I'm home sick with a bad cold-- yuck. It will be interesting to get back and see how it is, because I've been doing a lot of thinking. Rethinking, actually, I suppose, about priorities (as discussed in my last post), stress, and where to direct my energies so that my days are satisfying and spent effectively contributing to the community well-being. After all, that's why I became a nurse, more or less.

What has surfaced is that it might be time for me to leave the ICU. Already? It has not even yet been a year. It has not quite even been two years as an RN, spent in acute care hospital. Now, I've known for a long time I would probably end up in hospice or palliative care, but I had a sense that it would take some time. I wanted to sink in, learn, learn, learn, cement much of the amorphous blob of information circulating inside my head into knowledge-- usable, accessible knowledge. I wanted to become an expert clinician, that was my plan!

Of course, I still do. But I'm opening my perspective to acknowledge that I don't have to do that in an inpatient, acute care setting where I'm participating in some pretty horrible things, such as endless flogging of people ready to die, and inexcusable use of resources that are, ultimately, community-owned. Add to that trying to learn while having no choice but to attempt to work collaboratively with physicians who are uncooperative, poor communicators, aggressive, and frequently obnoxious. Please note this description applies to a minority, as discussed in previous posts, but nonetheless their influence on the work environment and my stress level belies their small number.

I'm also pretty tired of feeling crushed under the weight of regulatory agencies (not that I'm delirious enough to think I'll ever escape those as a nurse), growing documentation (same applies), and crushing responsibility paired with minimal autonomy. So, I'm thinking... is it time for hospice, either home care or inpatient? Or, should I move in the direction of community nursing, such as health department or nonprofit clinic? I am particularly interested in a local clinic which has a service for HIV/AIDS patients and also a service for homeless patients.

Right now, I'm thinking, thinking. Maybe I'll stay here awhile, maybe not.

paradox part two

George is 56. His skin looks gray and he appears much older. He has been in the ICU for about three weeks now.

George is homeless. The report includes a history of alcohol abuse, cocaine use, and hepatitis. He has not had any visitors.

He has had either his own registered nurse, or shared an RN with one other patient every day since he came to ICU after arriving in the emergency room with shortness of breath and a roaring pneumonia. In the emergency room, he dropped his oxygen saturation and blood pressure because he became septic (overwhelming bloodstream infection that originated with his still-roaring pneumonia). He had to be intubated (get a breathing tube and go on a mechanical ventilator) and put on high doses of vasopressors (medications to raise his blood pressure). The RN titrates these IV medications to keep his blood pressure high enough to feed the brain, heart, kidneys, liver, and gut, sometimes minute by minute. He gets intensive respiratory therapy. Pulmonary intensive care physicians see him a minimum of twice a day, and that's on the good days. He has undergone many procedures and tests, some of which cost several thousand dollars a pop.

George's toes are now black-- completely black and crusty. They appear dead, deprived of oxygen rich blood during the times when his vasopressors were jacked up so high all his tiny blood vessels clamped shut. He gets an undoubtedly pricey consult from the vascular surgery service, where they come, examine the toes, and predict their future. They offer no intervention and tell us, "They might not fall off, and we might not have to amputate them."

Yay! But wait, George doesn't just need feet, he needs them to be functional. If he ever gets out of here, he'll need to traverse the streets in search of basic necessities again. He'll need to get from a cold place to a warm one in the winter, or to a desperately needed drink of water in the southwestern summer.

George also has no medical insurance. Should he live, he'll be so debilitated he'll need extensive rehab and care to even think about independence again. I can't help but wonder how things might be different if we, as a community, had invested the amount we've spent on George in the last three weeks in him before he got sick. But, we're all about the rescue, right?

A million times, we've driven past him sitting in the median at a stoplight or trolling the side of the road for aluminum cans-- hungry, dirty, tired, alone, and in need of neighborly aid. But, the moment he falls critically ill, we run to the rescue and flog the hell out of him even when his body tells us, "please, please stop." If we manage to save him, we'll turn him out on his own again, complaining all the while about people who drain our health care system.

I don't know, but I bet George would have rathered have a little help at a different time.

Yesterday, George was awake, still clinging to life. I went into his room and put my hand on his forehead. "I'm sorry, George," I said. "We want what's best for you, and we want peace for you. I'm really sorry this is such a bad time."

He was disoriented, moving his head from side to side, not understanding.

Sometime, as a society, we're going to have to reprioritize.

paradox

Tomas came from Nicaragua. He has three children, the oldest of which is sixteen. He and his wife need more money to pay for her school, and it is not to be found anywhere around. So, he rode north, hidden in the bottom of a truck, to the Mexico-U.S. border. Then, he paid $1500-- an unimaginable amount of money-- to a "coyote," or human smuggler, and started off into the desert.

He told me this in our ICU last Tuesday, where he landed after a March cold snap brought snowdrifts, wind and rain to the desert. The brief report was:

36 y/o male, found down in a snowdrift
walking in the desert for 8 days
Diagnosis: diabetic ketoacidosis, rhabdomyolysis


"We walked for eight days," he said.
"Did you run out of food?"
"Yes."
"How about water?"
"Yes, we were out of that, too."
I asked him his destination. "I have family in Chicago and Houston," he said. I waited for more information, but he just looked at me.
"How were you going to get to them?"
"The coyote. He told me it wasn't far, he would get me there. That was part of the $1500."

Tomas was a relatively stable patient for the ICU, breathing effectively on his own and his heart properly delivering oxygen-rich blood to his whole body. The report said he was found in a snowdrift and brought to our hospital by helicopter. He says he remembers feeling terrible, and several members of his walking group being sick. There was a man who had a bad nosebleed and was also vomiting blood. It was very cold. He shut his eyes and went to sleep, and when he woke there was no one around. He started walking and found a highway. This was lucky because there are not many out in the desert southwest.

I took the best care I could of this man. He was receiving intensive care in a state of the art hospital. This was the same man who had to risk and nearly lose his life just to try to foot the bill for his children's school. Tears appeared in his eyes when he told me about his kids.

"This is the first time I've ever left them," he said quietly, staring at the bedspread.

His diabetic ketoacidosis was quickly resolved, and he turned out to have no damage to his organs from the rhabdomyolysis. As usual in our country, we were glad to give him a helicopter ride to the hospital, perk him back up, and then kick him out all on his own, with no resources. I apologized for the bad welcome to our nation, worked all day with the social worker on our unit to contact family in Nicaragua, and tried to get good calories in him. We had some epic international dialing sessions, trying to reach the right humans.

It's all about the rescue in our culture.... we invite, practically beg people to come here as undocumented workers with our daily practices and our standard of living, then force them to risk their lives and health getting here. We treat them as outcasts, and complain about them taking jobs we wouldn't want anyway-- at least not for that pay. We save them from death in the desert, or a gunshot wound from a border drug smuggler, then we congratulate ourselves and cast them off again to be forgotten along with the homeless and impoverished who already live here.

Last weekend, four humans were found dead in the desert. Likely cause: hypothermia, exposure. They may have been part of Tomas' group. Humans, trying to survive, feed, clothe, house, and educate their families. Dreaming, hoping, risking. It is not rare for us to have someone found down in the heat of summer, kidneys toasted thanks to rhabdo, and they get shipped back to Mexico just as bad off as before, only now they're dialysis dependent. In some places, it is a three day walk through the desert, at minimum. We are forcing our brothers and sisters to take these risks.

Tomas was one of the lucky ones. I was lucky to be his nurse, and be reminded that there are thousands of other humans on this same journey every day. I hope the compassion and interest I showed him were enough to sustain him until he could reach some semblance of home.

waiting

Being with someone who's dying (and being permitted to do so in peace) is kind of like waiting for a baby to be born. You all stand in awe of this thing that's happening, that you can kind of follow but can't quite predict, and you have to let the human who is doing the thing (whichever one it is) just do it. You watch and you wait, anticipating a very real relief of one type or another. You try to help them along as best you can. Your power is limited. Your presence is powerful.

One of the strangest things I encounter as a nurse is how one minute I'm taking care of a person, and the next it is just the body of the person. I keep thinking sometime I'll feel it go, but I don't. They just are and then they aren't. When I first have that sense, I immediately feel sad, even when it was a good death. There is something about being in the room with another living human one moment and not the next that invokes a sadness, perhaps a loneliness, within.

Tonight when Mr. L. was dying, for some reason I kept looking at him and imagining him as a newborn, transitioning into the first few moments of life. Then I would imagine all the joyful, sad, and in between times he had racked up in the 82 years between then and now. And there he was in transition again, with us at his side. Then he went.

indignant nurse

Today, I feel indignant. I am tired of having my intelligence, my knowledge base, and my capabilities insulted. I acknowledge that I am inexperienced-- I am 25, and I have been a registered nurse less than 2 years, with less than one year in critical care. I acknowledge that I am not a physician. I do not want to be a physician. This does not mean I am merely a robot, capable only of carrying out others' plans. I am a well educated, competent professional who collaborates daily with respiratory therapists, pharmacists, physicians, social workers, physical, occupational, and speech therapists, and other professionals to provide complete, holistic care of critically ill humans at various stages of life. Sometimes my big achievement of the day is protecting my patient from some other professional who doesn't know his or her story as well as I do, as the primary caregiver in the hospital setting. So that is my first beef today. I'm sick of nurses having their input and suggestions ignored or shot down by physicians who only like ideas that originate with them.

Also, the fact that I am an ICU nurse does not make me superior to other RNs. Nurses and physicians alike perpetuate this myth-- that's right, it is a myth. It weakens the profession as a whole when critical care nurses behave as though we are some special breed, and that all the common assumptions about nurses do apply to everyone except us. The fact is, they don't apply to any nurses. It is the job of all of us to undermine and eliminate all the inaccurate stereotypes floating around and being highlighted not only by popular media but also by our behavior in work and non-work settings every day.

I am so tired of these issues plaguing my work on a daily basis, following me around and keeping me from focusing on the important patient care to be done. I'm not asking for someone to fix it for me, I'm just shouting out to the world that I get really tired of it sometimes!

waking up after four months in ICU

I'm still pretty new to the MICU, and others tend to steal the sicker patients. They're the 1:1 assignments, which people prefer because even though they are busy, there is one to worry about instead of two. Many times when you have a "pair", as we call 1:2 assignments, you run your butt off in similar fashion to a floor nurse. They can still be quite critically ill. Oftentimes I don't care for a particular human until he or she is through the worst period of instability. Suddenly that same patient is always up for grabs.

Why is this? Well, I think it is because their needs often grow at this point. By this time, they have tracheostomies, long term feeding tubes and central venous access devices, and are so horribly deconditioned that they can't even begin to reposition themselves on their own. However, if they are lucky and their brain has not been significantly damaged by hypoxia (lack of oxygen to tissues), hypotension (low blood pressure resulting in insufficient delivery to the brain), bleeding within the brain, or drug effects, they are now awake and aware of themselves and their surroundings. If their lungs are functioning well enough, they may be off the ventilator and begin to use a speaking valve on their tracheostomy. At this point they can finally start asking the questions that have been brewing since we first began to lighten the sedation.

They have no idea what they look like, why they are so weak, why they can't speak (either at all, or in their normal fashion), how they are getting fed, and what all those weird bags and tubes are. Yesterday a woman pointed in the direction of her tracheostomy and said through her speaking valve, "What happened to my breathing?" This was a long answer.

For these patients, the needs that grow are often not meetable by working with equipment, medications, pharmacists, or physicians. They are needs that can only be addressed by spending time with the patient, looking him or her in the eye, listening, and telling the truth about what has happened and what may be to come. This is not an easy job and it can be exhausting, but it is essential to humane and complete care. Sometimes I wish critical care nurses (and critical care physicians) took it as seriously as they did the physiologically teetering patient. I hope I always do.

Falling down

today the topic is caregivers-- and their overwhelming sense of responsibility. nurses frequently fall into the category of feeling entirely responsible and, thus, to blame, when a human under their care is injured or harmed. this is very often the case when someone falls. falls are never going to go away, no matter how careful we are and how good the care is that we give our patients, and our friends and family.

when someone falls, as a nurse you simply can't help but feel as though you let them fall, even if you didn't do that at all. once, in about my third month as an RN, i was getting report on my busy medical-surgical unit. i remember some odd noises just barely floating through my filter as i focused on report and tuned out the myriad of other sounds. before i even fully processed these sounds, there was a large clunk and a thud coming from the patient room by our workstation. i leapt up, pushed open the door, and found... you guessed it: the 60 something post-operative patient i had just received report on was slumped against the wall, entirely tangled in her IV pole. so, after completing a brief assessment, picking her up, dusting her off, reassessing her (with special attention to neurological and musculoskeletal concerns), addressing the need that led her to get up unassisted in the first place, finishing report on the rest of my acutely ill patients, notifying the resident on her surgical team, and attending to other morning start of shift business, i began my day completing an incident report.

the idea behind these reports is that, by recording all the details immediately after the event, we then have access to the entire event and can look back and say "what could we change or manipulate here that might lead to a different outcome?" many times we look at the facts and can say, "hey, we did everything we could to create a safe environment," but even then as nurses we still feel the weight of that fall squarely upon our shoulders.

we look you in the eye and say, "i'm so sorry i was not here to help you when you needed it," and we feel as though we have failed you, even though we are well aware that we are not psychic nor can we see through walls in every direction at all times. no matter how we might try to anticipate needs, we can't always get it right.

it is hard to be human and yet responsible for the safety and well being of others so directly and in so many ways. it takes a great deal of courage to stand up to this challenge, and to accept it with good humor, enthusiasm, and compassion on a daily basis. it can be hard, as a nurse, to complete that incident report, click submit and have it float off into the void. you have to have faith that someone, somewhere is being paid to pull them all together, to really examine them, and then to spread the knowledge gleaned. meanwhile, you keep on doing your best to keep people infection and injury-free.

pain management hurts

1.17.06
so this is my first post. i am finally compelled to write and share, perhaps mostly for my own sanity. however, it would be nice if this goes out into the void and at least a few people read it. i believe there are so many misconceptions about nursing, what nurses do, and the incredible challenges we face every day we work.

i am still seething with anger, weighed down by the frustration that comes with knowing you have let a patient down. i wish sometimes that i could "order" a physician to sit in a patient's room for one hour and watch his or her face as we go through the maneuvers, the basics of nursing care-- human care, that is, for that is what nursing is-- care of the whole and complete human. how, then, after just one hour (never mind twelve) watching a 76 year old man grimace and cry around his endotracheal tube, could a physician actually say, "we'll treat his pain later." the medical care of a critically ill human is complex, challenging, and often an inexact game of trial and error. sometimes we cannot meet all their needs, and i know this. but to leave a fellow creature miserable and in pain for hour after hour is just intolerable. there is no excuse, no reason, no explanation to offer, no matter how badly you want to extubate him.

one of the challenges of practicing in a teaching hospital is working with inexperienced residents who are making executive decisions while certain attending physicians “manage” the care of the patient in absentia. even when they do show up, they don’t do much listening, and do not usually offer insight or advice to the team as a whole. yet, intermingled with these morons is another breed of attentive, wise teachers who guide and lead the new physicians toward the best care for their patients, and who incorporate the expertise of nurses into the medical care they provide. they demonstrate good listening skills (the core of good patient care in both medicine and nursing) and effective communication techniques. were it not for these physicians i think my job would make me so sick i would be unable to continue.

yesterday morning, i stood in the med room and cried. i hated to do it but i figured, why fight it? the facts were that my patient, intubated and mechanically ventilated, with a shattered pelvis and severe abdominal injures, could not speak for himself, couldn’t even cry properly. i cried for him, but also out of the pure anger and frustration i still carry now, the next morning, that when i went to bat for him a physician grabbed the bat out of my hands and threw it on the ground. this is my pledge, to my patients now and in the future: i will be diligent in my batting practice. maybe none of my patients will see this, but it feels good to put it out in the world anyway. i have been a nurse less than two years, and in the ICU only about six months. i will improve at this. i hope somewhere a physician is wholeheartedly making the same pledge today.

yesterday was Martin Luther King day. i woke up to his voice on the radio, thinking about his model of compassion and love toward others, to treating all humans as our brothers and sisters. the fact that this is inherent in my work is one reason i love being a nurse. i went in to work with all this in mind, and, as i said before, we failed this man.

there is something horribly wrong with a medical education system that gives lip service to pain management but clearly not much more at times, given the practice these new physicians demonstrate. we think we have come so far, but there is soooo much farther to go. the same is true of nursing. i cannot begin to count the number of times, in my short practice as an RN, that i have heard another nurse discredit a patient’s report of pain, determine that a patient is “drug seeking”, or some other nonsense. Wake up, people, and get with the program!