Last Three Weeks of Critical Care

This is hard to write about it because the last three weeks were times of real discouragement for me in school. The whole time I was in school I felt uplifted in support by clinical faculty, care teams and friends. The last three weeks felt like a desert. I had a terrible midterm evaluation, a clinical instructor who made it obvious that she didn't care for me, and had a lot of sleepless nights worrying about everything; school, family, missed friendships, and second guessing whether I made the right decision to go into nursing school in the first place. There is this "myth" out there that nurses eat their young. For 3 weeks, the emotional toll this took on me made me rethink a lot of the optimism I had about becoming a nurse, how I could help people, working in a constantly changing environment and adapt to multiple personalities and temperaments.

Week three I went back to Tele (cardiac care) for two days and prepped on two patients. The first was a deaf patient with pneumonia and the other was a late Friday afternoon admit, whose records were still being assembled while I prepped on him. I made as many notes as I could gather assuming I would finish all my history gathering the following day as I assessed and care for him. Since things change so fast in tele...we always risked full preps on people who might be discharged the next day. This always happens with me, regardless of the acuity level of the patient, and as I arrived on the unit the next day, the care nurse told me that she was orienting a new nurse and to essentially stay out of the way. Nice.

My 2nd and 3rd patients were interesting. One needed an adenoscan. Went with him to see what that was all about and decided that if I ever needed one of those, I would not consent to one. Essentially, adenosine chemically induces the effects of running a marathon while you lie still. My patient freaked out. As I tried to reassure him, he looked at me like I pulled fast one on him. The first patient I was supposed to care for, but ended up deferring to the new orientee was just a little too active for the care nurse so she asked me to restrain him. As I zipped up his vest, he looked at me and said "no, SN not you!" Feeling like 'one of them', I cried in the shower that night. Seeking refuge with a little sweet old lady who need ortho HTN vitals done, I rounded out the day talking to her about books we both loved. After renal diet teaching and discussing the importance of medication compliance with my young dialysis patient, I went home to update all the care plans..four pounds of paper later...zzzzzz.

Week 4 was in ICU: My patient was in respiratory failure. My nurse was a tazmanian devil and really sharp. We had a loaded unit with two suicide attempts. My patient's family reminded me a lot of my own. They were there all the time. Dad was really struggling with breathing and as we tried SAT and SBT trials to wean him off his vent, I witnessed the most rapid respiratory failure I had only read about in books. Being Sunday, all I could do was pray hard that we could keep him calm while the RT fetched the BiPAP machine. Holding this guy's hand, it felt oddly familar. That weekend wiped me out.

Weekend 5 was full prep with two patients. One had a decub that wiped out his heel at a SNF. Seeing someone with DP pulses and missing his heel tissue was another one I thought I'd only see in the books, but SNF neglect still happens. Boatloads of meds. I enjoyed getting this guy up in a cardiac chair with PT and giving him my farewell speech. We both knew he was going to lose his lower leg two days later in surgery - I tried to equate this with the problems my own father had following his hospitalization and I demanded this patient keep his gym membership and never give up. Everything about recovery is in attitude. He had several rough months in a SNF - he could make it. Shaving away the last remnants of his beard, he laughed at the amount of cream I put on his face...we had to laugh. There was so much to cry about.

As I left that night. I was sad and tired. Spent and frustrated. Second guessing everything. This was the hardest part of school for me. The biggest learning curve and the most difficult to navigate. My CI gave me my final review and I passed. For some reason, I was numb. My clinical group all made it. But we all had that same worn torn look of fatigue.

Are you still here???? Yep! Wouldn't miss it!

My partner & I arm wrestled for a CRRT trauma crush patient last Friday. I had first choice the weekend before so she took him. The next highest acuity patient was in the room down the hall according to the shift charge, so I grabbed the chart and started to prep. While prepping on my patient, I noticed the neuro doc stopping by to meet with the family. The code status was downgraded from full code to DNR. My patient 'Pebbles' had a brain aneurysm that ruptured and she was not doing well after surgery. I finished my prep at midnight and went to bed. The next morning I arrived to find that she had died two hours after I left the hospital. Picking a new patient, I got report, started reprep and began to take care of a patient with a brain mass, status post surgery, ventricularostomy and ICP monitor. I learned about calibrating his arterial line and ICP line, how to monitor intercranial pressure and doing frequent neurological assessments. My patient was affable, talked a lot and was very alert and oriented to his situation. I hung several IVPB medications and took care of his needs for the day. I was able to take out his arterial line, foley catheter and get him out of bed several times to assess how intercranial pressure would be affected with increasing levels of activity. Learning about brain compromised patients is fascinating and exhausting at the same time. I finished his care plan and helped with other patients on the unit. My partner's patient had a Swann Ganz line and an expert on the line taught us about it as we looked at his monitors.

In the midst of caring for this patient, my care nurse had a patient who also had a stoke, whose family withheld treatment. In that regard, we were providing comfort measures to him. His lungs were filling with fluid, so I was able to help suction and clear his airway to ease his breathing and offer reassurance. By the next day he was gone. Two patients in one weekend. ICU is fast and furious in one respect and slow and intense in the next. The contrast in the ICU was black and white. Such differences with each patient.

On Sunday my happy patient was downgraded and I re-prepped (again) on a new admission from a motorcycle accident who had broken his femur and ribs. He had a chest tube and his leg was pointing in several different directions in a Bucks traction device (something invented in the Civil War - much like a weight and pulley system) that stabilizes the bones and joint while the patient waits for his surgeon to fix his leg. I was able to do some patient teaching on pain management using a PCA device which is a button system the patient uses to deliver his own analgesics. Assessing his breathing was interesting. When someone has a pnemothorax (collapsed lung) due to trauma, their breathing sounds like hiccups..short inspirations which are cutoff midway. I made a bath blanket splint which he could use when he felt the urge to cough and help ease the pain from his broken ribs. We talked about his surgery and a few of his friends came to check on him.

That afternoon I went to the OR with my patient and watched his surgeon prep him and open his leg at the thigh. What resembled a car (up on a jack), ended up being huge rods, nails, pins, and drilling sounds with hydraulics set against the sound of Enya playing on the surgeon's IPOD. I saw more blood with this procedure than I saw with my previous OR rotation ( thorocotomy, total neck and ventriculostomy)...the blood was all over. Everything was done with X-ray for placement so we all had to wear to protective aprons in addition to our OR gear.

In the middle of my patient's surgery, one of the OR nurses came in to grab me to help with a trauma coming in (a self inflicted gunshot victim who had severed his popliteal artery which was being held closed with an EMT's finger ETA 8 minutes)...while the room was being prepped, I sterile gloved and waited with my heart racing as to what was going to show up. (Apparently, not realizing while cleaning his gun, a bullet was lodged in the chamber, it fired into his leg...owwwie)

As they wheeled in the man, his clothing was being cut off, I grabbed all the gurney materials, clothing and bags and sorted through the bloody mess to get the patient belongings into a separate bag. Throwing the gurney back into the hallway I re-gloved and went in to assist the prep. The patients legs needed to prepped and elevated for sterile wash and possible vein grafting. I had one leg and another nurse had the other. It felt like each leg weighed about 100 pounds each. 10 minutes later, the surgeon was there, draped and cutting into the leg to secure the leg to repair the artery. The anesthesiologist was the same one I had observed with my OR rotation and I was amazed at how fast he was able to get this trauma patient under and intubated.

With the muscles in my arms still shaking from holding the gunshot victim's leg up for so long, I walked back to the other OR to check on my patient who was coming out of OR and going back to ICU. I escorted him back to the unit and with my care nurse, completed the PACU assessments in the ICU, which involves assessing all his vitals every 15 minutes, getting blood samples and cleaning him up after surgery. My patient had been intoxicated when he was injured. Earlier in the day we talked about drinking and driving. My patient verbalized how fortunate he was to be alive and that his friend (riding on the rear) had not been seriously hurt. You wonder if it is a wake up call or a pattern of risk taking that will eventually catch up to the patient. We are there to treat and teach.

As my patient woke up, he looked at me and said, "Are you still here?" "Yep!" Wouldn't miss it!

Welcome to Neuro Trauma Intensive Care... Roll with it baby

Web photo courtesy: (Hartford Hospital Images)

Excited about the prospect of critical care for the weeks leading up to it, the 4 days prior to prep were nerve wracking to say the least. We finished last semester after being in a comfort zone with theory instructors and clinical faculty that I came to depend on. You go into this learning curve which I liken to a roller coaster; already defensive, the next loop might be the one you totally barf on- because so much time, resources, blood, sweat and tears is invested into the venture of this type of learning. It can be disappointing to be treated like you haven't worked hard enough, long enough or know enough to be successful.

I went to prep as early as permitted on Friday (just knowing how slow prep can be for me). I tried to pick the most complicated patient based on the recommendations of the ICU RN in the unit at the time. Little did I realize how fast some of these patients turn over either to a step down unit, transfer to med-surg, home or sadly, to the morgue. So, I wanted someone with airway problems, perhaps some brain issues and maybe some renal stuff..so that it would be complicated enough. Sure enough, my patient had a brain bleed, he had a craniotomy and a ventriculostomy (both of these surgeries were procedures I had seen on OR rotation, so I was excited about taking care of a patient post op in the ICU. This patient had airway issues too, with failed mechanical ventilation, a relatively new tracheostomy (something I already had experience with)...and renal compromise because I saw they were doing a 24H urine collect on him and I knew he'd be around for the weekend....it was that or I was looking at taking care of a patient with a hip fracture. Been there. Done that. So, I thought I had a good one.

Knowing how much of his care was multi system, I went to my old friend (Lewis textbook) and started looking up care plans for inter cranial bleeds/increased intercranial pressure..management of trach patient and (oh, my patient was also in DTs for ETOH withdrawal, so I had resources there). What amounted to be a NANDA compliant, medication compliant (I had 7 pages of medications I had to reconcile) and also look up this patient's labs and diagnostic studies, ended up amounting to an 11 hour prep including time in the neuro ICU making sure I had all the information from his chart that weighed about 15 pounds...head home...and 8 hours at home all night. With my own brain function ceasing at midnight, I collapsed into bed, a complete insomniac, because I was trying to remember the sequence on the crash carts. Imagining I would surely be working a code (the imagination runneth). In addition I was looking at neuro trauma information on the web from allnurses.com and trying to be sure I brushed up on things in case the docs caught us off guard. We hadn't worked 12 shifts yet and this was going to be a new first this weekend. So after drifting off at 1:30, I remember I hadn't done a patho-map (the one thing I've NEVER been good at doing well)...so I went to concept mapping (saw "uncontrolled HTN")..wrote on it that it was draft and I would do a real one the next night after I met and assessed my patient. (Note: We can't show up to clinical unless we have something...I had to get up at 5 AM to be at clinical by 6:30 AM). I dropped off to sleep at 2:45 AM and the alarm nudged me at 4:45. I shot out of bed like a cannon ball, showered, gathered up my stuff and headed out the door to find an open coffee shop. With 3 shots in my cup, I got to the hospital early, met our new group in the lobby and met the first of our two new CIs (clinical instructors). We went to our assigned units. My buddy and I headed up to Neuro Trauma, to get report from the night shift and meet our care team.

My care murse (male nurse) was a staff III nurse. We had a great day. He was very experienced, had a wealth of knowledge and allowed me to ask a lot of questions. I was able to work with my patient a lot and he gave me the space to also work with the patient's family. One thing I immediately noticed was how much my patient had improved in the 24 hours since I prepped on him. His ICP monitor was out, his NG tube was out and his trach was being weaned. I was able to take out his foley catheter, get his head shaved completely..because believe me, it looks kinda ridiculous to have half your head shaved and the other lookin like Bozo the Clown. He now had a nice Daughtry-esque appearance that made him more comfortable in bed. I did my neuro assessments and head to toe assessment and watched how my care nurse charted on the new flow sheets. I gave a lot of meds, changed EKG pads (because how else could my patient be smiling and in asystole at the time) and then watched how everyone else around me adjusted to life in the ICU. It was impressive. My buddy pulled an ICP, inserted a NG and did all kinds of cool stuff on her patient who was coming off a dirt bike trauma. The hours passed and I think I got home around 8:30 PM. I had been up since 4:45 AM.

I left the shift utterly exhausted and went home to hand sketch my pathomap with colored pencils and a sketch book pad...I updated notes on my care plans pertaining to my patient, logged med reactions, made sure the lab results were updated and did my self-evalution..After all that, I went to bed at 1:30, only to get 4 hours sleep and then rush back for day 2.

Rushing to the hospital, I made it in time for report. Different care nurse. Different clinical faculty. My patient looked great. We were able to repeat a lot of day 1, activities, plus shave his face and get him bathed. My second CI dropped by to look at my paperwork and asked me a couple questions about brain hemotomas and ACE inhibitors. Not knowing too much off the top of my head (at hour 5 of 12), I went to conference with the answers and decided I liked this style of teaching and interaction. She wanted to get to know us better and allowed us to say a little bit ourselves to her. She also passed around a bag of chocolate. We went to skills lab and reviewed a few things about different types of med pumps, and looked over the crash cart again for a quick brush up. I actually left this shift totally spent ,but relieved that I survived. I liked the high acuity level, respected the nature of people's perspectives and differences of opinion and learned a lot. Most importantly, I gained my patient's trust.

On the way out the door, I stopped by the floor where my patient was moved (as he had been downgraded - meaning he was improved enough to be off ICU) to say goodbye. It was sweet to wish him well and say goodbye, plus it was rewarding to hear a little gratitude from the patient and his wife for the 24 hours we spent together. Nursing is an intimate relationship that starts and ends quickly between a nurse and patient, but leaves an indelible mark on both.

Expect anything and roll with it. I guess I just want to be a nurse.

Week 10 - MCA II Finale - real cute boy

Picture: Courtesy of the Web: National Association Down Syndrome - Adult Center)

We rounded out our medical surgical rotation with a nice little final exam on ICP and other complications from neuro trauma and the like (truly you don't want this) and we had a wrap up in the other classes with presentations and potlucks. I'd collapse in bed at night ...wishing for the end of term.

Clinical found me in the Med Tower with a leukocytosis patient with very loose stools. Nursing students somehow always manage to end up with these patients. I haven't had one until my last rotation day. I guess I was saving the best for last.

As I completed his assessment he asked for a hug and told me that he was a 'real cute boy.' How could I disagree? My patient was a middle aged adult with Down Syndrome. I practically pulled the rug out from under Trudy to get this patient. I have a real fondness for my friends with DS. Giving him a hug and holding his hand, I let him listen to his own lung/heart and bowel sounds. He had ticklish feet and the assessment felt like a fun little game, rather than a chore. Even when feeling like garbage, my patient was happy, albeit in a sore, dehydrated and slightly elevated temp sort of way. He didn't have a care in the world.

My last hours in MCA II were spent watching Bonanza with him and cleaning up some of his 'loose ends' ~ For some reason, I managed to go an entire 10 weeks without a single splash down until the final day. As Trude fetched me some linens and pads (probably relieved that it was me dealing with this for a change) I was intrigued with the notion that I didn't mind how unglamourous it can be (sometimes, it is dirty work)..but there we were -chatting up a storm about Hoss, Little Joe and Pa.

He giggled and laughed about everything and nothing at all. The 7-up tasted good. The rash hurt, the wash cloth felt good. The incentive spirometer was an exercise in futility. I think I needed it more than he did. I charted and tried to figure out what I could do about the perianal rash that was developing due to the two day advent of acid laden loose stools. After a nice paint job with barrier cream, we talked about friends and how everyone had nice eyes, pretty hair (especially care nurse Jaime). We talked about eating slow (I should really take my own advice) and not eating so much. He wiggled his toes, sat up in bed and wanted more 7-up. I remember thinking that the idea of 7-up sounded so good....

I think it was rather cathartic to end the term on this happy note...a pretty rank and dirty splash down...strip bed, paint job, one med, a couple hugs, ticklish feet and a real cute boy.

Bless your heart buttons...

Back to oncology this weekend. I had picked two patients on Friday- that one of the AM RNs said would be around for the weekend. One had INR issues and the other was supposed to have a chest tube inserted so she assured me they wouldn't be discharged. I prepped on both and discovered they both shared virtually the same diagnosis...malignant cancer of the lung. One had a stage IV pleural effusion that needed to be drained. The other was coming off chemo with a persistent fever of unknown etiology and needed to be stabilized before his next round of chemo.

After prepping on my patients, I knew I was going to learn a lot this weekend because one was a retired health care professional in a specialty that involved his own diagnosis, and the other was an independent retiree who reminded me of my dad. Nothing was keeping "my guys" down. They had loving, well educated spouses who had been married to them for over 40 years. One of the spouses was a retired ICU nurse and the other was a fireman's wife.

These men both enjoyed long fulfilling careers in their fields. They were fighters through and through. The medical guy knew exactly how things were going to go for him and he taught me a couple things I'll never forget about respiratory assessments particularly. For example, he suggested that the best way to ausculate the lung fields is from the back side and if you ask the patient to say the letter E with each field through all the points of ausculation..and it gets to a point where the E sounds like an A...that's the point of effusion in the lungs and you can mark it with a pen. Since he had a chest tube inserted, I got him out of bed and tried this technique. My care nurse and I were both amazed that the E does sound like A..and we didn't need an X-ray to know where the effusion was in his lungs.

It is difficult to explain what it means at the end of the weekend when you are either discharging your patient home to an uncertain future of months or days or whether you leave them not knowing if they will be back next week because of an infection or recurrence of their symptoms. I always try to say goodbye to my patients because the time spent changing their dressings, assisting with personal care, medicating them, injecting them or teaching them something important about their care, is a time when a bond of trust is established. I feel the same way about the families who stay with them. When I left Sunday night, I knew my 'teacher' wouldn't be there the next day. He made eye contact with me, wished me well with nursing school and we bade our farewells...he might be back soon because his diagnosis is terminal, but knowing him, he will prefer to be at home when that time comes. It's the kind of person he revealed himself to be and I was certainly humbled by the inherent dignity our patients possess when they are the most vulnerable to us as nurses. I was able to medicate him, obtain cultures, humidify his oxygen and change his chest tube dressings. The best thing I did for him however, was switch out the remote control on his television set. He went a whole week waiting for one. Mostly, nursing is about listening. I haven't always been a great listener...because I like to talk. I am learning to be a better listener.

One LOL (little old lady) was on my unit this weekend with an acute bout of pancreatitis. I could read the body language of her son, who was irritated to be summoned to the hospital and it made me mad because he wanted nothing to do with her. As I took out her IV, she rubbed my arm and said "Bless your heart buttons." She was a dear. As a total stranger pulled up in the Lexus SUV to pick her up to take her back to the board and care home; they wanted us to scratch off the prescriptions we transcribed and phoned to the pharmacy, because they didn't want to pay for them. I knew the sweet LOL wouldn't be getting half the medications the doctor ordered for her because they owner of the board and care wouldn't pick them up at the pharmacy. As she waved good bye to me...I wished in my heart that her son would care enough and that she would never realize that he didn't. Bless her heart...sweet little button.

Easy does it

Couple things happened this weekend. I went back to surgery and had a nice run of abdominal cases with penrose drains and minor complications (peritonitis and bile leakage.) I have done a lot of dressing changes, so this weekend I perfected my skills at changing abdominal dressings and charting the character of bodily fluids draining out of incisions and drains. I also admitted my first post op trauma patient who had a dirt bike accident. Between these three, I had a three day run of staying busy and honing some skills. I dc'd my first foley and Trude inserted her first, so it was all good.

I didn't expect to wake up with a call from the school that my son had a accident at school. With DH following the ambulance team into the ED at the local hospital, Trude and I weren't far behind, all decked out for clinical . We saw the team in the ED (slow day) picking him up for radiology (Trude's first reaction upon hearing that he sustained a pelvic fracture, said, "We have a care plan for that"...yep. Irony reigns eternal.

Finishing up clinical early we trudged out with two weeks to go before start clinical for critical care. I would prefer not to have a parallel experience in the family while this is going on...so be careful people...easy does it.

Nursing outside the box

I am a changed person. I've seen the light. Call it an epiphany of sorts.

We've had a lot of lectures in health assessment about this topic and the focus this week in Medical-Surgical Care of the Adult II was OBEEEEEESITY (say that in the movie trailer guy deep slow voice), and all the resultant complications , I've pretty much lost my appetite. Trude will tell you I haven't eaten in a week. To top that off, after my theory instructor had a big story about a Pickwickian patient she had once that she found hard to forget and she shared quite a story with the class. Guess what kind of patient I had this week after my ARF patient when up to the ICU 15 minutes into shift? Yep, a very sweet P.W. patient with long lasting COPD and a health history that beats "Roots".

In any event, I had to pull a rabbit out of my hat this weekend when it came to nursing interventions for this woman. I absolutely fell in love with her. She had one of those big girl beds and I knew that for any kind of real nursing care, I was going in and under like 20,000 leagues under the sea..remember the arm story that Talitha told. We can do bowel management and that makes us good plumbers but really...the most important assessments are the spiritual and sexual assessments we do as nurses (I digress). Those of you who were present for April Fools Day lecture will understnad that line.

So, I decided to really take my time with her and just talk. She has a lot of neglect issues. I asked her the question (don't ask me why) "if she had one wish what would it be" and she said "I'd really like a hot guy with 6 pack abs and a tight ass to come in my room and talk to me"...

Missing my husband, I told her without missing a beat, that I could arrange this for her and asked DH if he would stop by Sunday night and see my patient. (not quite a 6 pack, but he is quite charming, very handsome and has his Zoolander moments.)

With flowers and a chocolate egg, he spent about 90 minutes with my patient, visiting with her, massaging her hands and talking to her about nutrition and friendship and her family.

I loaded her up all weekends with meds and assessments, but this by far was the best care I gave all semester. Trude doesn't think he's hot. But my patient fell asleep with a smile on her face.

This story is true. The opinions expressed do not necessarily reflect the opinions of my school or it's affiliates