It's amazing to me how annoyed I get when patients are independent. You would think that this would be a good thing- that they can eat, get up to the bathroom, and hold a conversation with you. Good for you, trauma victim, but you need to get out of the ICU already.
It's bothersome when you spend 45 minutes helping meemaw eat her red jello. It takes 45 minutes because she chews like a cow and somehow everything seems come back up and get chewed again. Precious meemaw, but I really don't have time for this. Then she will undoubtably throw it up in 15 minutes and now you are back to square one with a vomit bucket that patients think is blood. Don't freak out, meemaw, remember, it's your jello.
Sweet Lupita can get up to use the bedside commode. So you unhook her leads, saline lock her IV's, put down the bedrails, swing her legs over, help her up, and finally back down on the makeshift toilet (we don't have real bathrooms, our hospital is slightly ghetto...). You leave the room, she sits there for 5 minutes, and you do the whole fiasco backwards. 35 minutes later you start again. She mentions something about overactive bladder. Ah. Perfect.
Meanwhile you are giving saline boluses for low blood pressure and administering blood products on your clearly sicker patient. But Lupita can't wait. At this point, you sequester the help of your neighborly nurses and promise to write them a nice "star" on the board. They are clearly overjoyed at this high honor. Yeah right. But they help you out anyway.
Clark is lonely. And he wants to tell you his life story. He was married, then decided he was gay and then his lover died etc etc etc. He's full of drama. Clark wants you to read his text messages from his new lover, to decide if he's really serious about him or not. Well has he come to visit you in the hospital? That might be a good indicator...
You avoid Clark as best you can, not because you aren't interested in his tumultuous love life (it's clearly interesting), but because you're behind and you have to be efficient. Clark finally appears to be asleep so you sneak in to count up the I&O's (intake and output). You tip toe around the room, obviously holding your breath because Clark has some seriously intune senses. You manage to do your job and it looks like escape is within your grasp when....the apnea alarm goes off. It's very loud and annoying and clearly I can see him breathing so it's a false alarm. Your cover is blown and Clark pops open his eyes to show you the most recent text. Well, it was a good effort. Better luck next time.
Sometimes the root of this annoyance is making sure you give good care to both patients. But mostly it's selfishness. It makes my job harder and I'd rather you just lay there sedated and intubated. No talking, no consciousness. Sounds terrible, but ask any ICU nurse and they will admit the same thing. I'd rather be busy anyday titrating pressors and giving blood and going to stat CT scan than helping you up to pee about one drop then get back in bed to do this all over again. I guess that's why I don't work on the floor.
The Lord has been teaching me patience lately mostly because of this issue. This entry is a comic confession of my sinfulness. I like things to happen quickly and efficiently and I get frustrated when something doesn't go the way it should. But the reality is life is just like that, no matter what job you have or what you are doing. Things don't go as planned and it will go a lot better in the future if you and I realize this now. I am attempting to give up some of this type A control issue and pursue a more relaxed and flexible perspective.
So I bite my tongue and do my job, suppressing the thought in my head that this is a pain in the ass. At least I have good stories right? And there's always Clark there to give me relationship advice. He's actually a good listener with great advice. Who would have thought.
Sunday, April 25, 2010
Monday, April 19, 2010
Code. Blue.
A friend asked me the other day if it bothered me to see people who had devastating injuries and weren't going to make it. I answered not usually. Then he asked if it bothered me that it didn't bother me.
As an individual, it's rather rare to have a patient that codes and dies, unless you are one of those brave people who takes those patients frequently. I haven't quite made it there yet with my whole 11 months of vast knowledge and experience. But it has happened to me. And it is why I work where I do. That might sound strange so let me explain.
Whenever I have a sick patient, my mind focuses on certain things and I work almost completely in tasks. Look at the blood pressure. Titrate the levophed (a pressor that helps keep the blood pressure up by constricting your vessels). Send for the blood. Check the blood. Hang the blood. Talk to the doctor. Receive an order. Implement the order. Etc.
When a patient codes, multiply this approach times ten. The patient is bradycardic to the 40's, blood pressure 65/40. (Hopefully you've already realized what's happening before the pt's BP is 65/40 but sometimes it happens pretty quickly). Call for help. Get the crash cart. Someone else is putting on the defibrillator pads as you break open the med drawer. Tear open the atropine box. Connect the plunger. Give the drug. Flush. Check your heart rate. Still dropping. Heart rythmn is an indistinguishable loose wave. Check a pulse. Not there. Start compressions. Someone is writing down all the times that you give the drugs so that you know when you can give the next one. Etc.
You receive the cooler of blood for massive transfusion protocol and someone checks and hangs the first unit through the Level one infuser (a machine that pumps blood in under pressure so that it goes in very quickly). You hang 8 units and nothing has changed. You've been doing compressions for 25 minutes and nothing has changed. You've given all your epi, atropine, and vasopressin and nothing has worked. The doctor calls the code. Everyone stops. It's done.
Undoubtably, this is a horrible and devastating experience. But I can go home and sleep at night because I know that everyone did all that they could. Death isn't an uncommon or even feared outcome in the ICU. Sometimes patients have been in the unit for weeks and everyone is relieved when the family chooses to withdraw care because there was no quality of life, for anyone.
I have seen the attending doctors come and take a patient back to surgery as a last ditch effort even though usually they just code them in the unit. I can honestly say that they did every single thing they could but the damage was too great. That makes me proud of where I work and also you better send me there if I am in a life-threatening situation.
It's this crazy adrenaline rush as you move from task to task with your mind running a mile a minute. I would liken it to the feeling a marathon runner has at the end of a race. Or a mountain climber when he reaches it to the top. The journey itself wasn't necessarily pleasant but you feel accomplished and purposeful at the end of it. And you know you've done something that's bigger than yourself.
It doesn't happen often, but when it does you have to pull out everything you've learned and use it. You have to put your emotions aside and focus. Because this is the end of the line for this person. It doesn't get more serious than this. And I work here? That still amazes me.
Sometimes I go home all worked up and eat my dinner in about 3 minutes. I can't seem to calm down but it helps to talk to a friend or watch tv to get my mind off of it. If I go out after work, my mind is still processing the events of the day. It does bother me. But it can't while I'm at the bedside because that's my job- to try and save a life.
I've never cried about it. Maybe one day I will. Maybe I should cry. Or maybe it's simply a self-preservation technique so that I will indeed come back the next day. And without fail, I do come back for more. It's the addicting paradox of the ICU. And I love it.
As an individual, it's rather rare to have a patient that codes and dies, unless you are one of those brave people who takes those patients frequently. I haven't quite made it there yet with my whole 11 months of vast knowledge and experience. But it has happened to me. And it is why I work where I do. That might sound strange so let me explain.
Whenever I have a sick patient, my mind focuses on certain things and I work almost completely in tasks. Look at the blood pressure. Titrate the levophed (a pressor that helps keep the blood pressure up by constricting your vessels). Send for the blood. Check the blood. Hang the blood. Talk to the doctor. Receive an order. Implement the order. Etc.
When a patient codes, multiply this approach times ten. The patient is bradycardic to the 40's, blood pressure 65/40. (Hopefully you've already realized what's happening before the pt's BP is 65/40 but sometimes it happens pretty quickly). Call for help. Get the crash cart. Someone else is putting on the defibrillator pads as you break open the med drawer. Tear open the atropine box. Connect the plunger. Give the drug. Flush. Check your heart rate. Still dropping. Heart rythmn is an indistinguishable loose wave. Check a pulse. Not there. Start compressions. Someone is writing down all the times that you give the drugs so that you know when you can give the next one. Etc.
You receive the cooler of blood for massive transfusion protocol and someone checks and hangs the first unit through the Level one infuser (a machine that pumps blood in under pressure so that it goes in very quickly). You hang 8 units and nothing has changed. You've been doing compressions for 25 minutes and nothing has changed. You've given all your epi, atropine, and vasopressin and nothing has worked. The doctor calls the code. Everyone stops. It's done.
Undoubtably, this is a horrible and devastating experience. But I can go home and sleep at night because I know that everyone did all that they could. Death isn't an uncommon or even feared outcome in the ICU. Sometimes patients have been in the unit for weeks and everyone is relieved when the family chooses to withdraw care because there was no quality of life, for anyone.
I have seen the attending doctors come and take a patient back to surgery as a last ditch effort even though usually they just code them in the unit. I can honestly say that they did every single thing they could but the damage was too great. That makes me proud of where I work and also you better send me there if I am in a life-threatening situation.
It's this crazy adrenaline rush as you move from task to task with your mind running a mile a minute. I would liken it to the feeling a marathon runner has at the end of a race. Or a mountain climber when he reaches it to the top. The journey itself wasn't necessarily pleasant but you feel accomplished and purposeful at the end of it. And you know you've done something that's bigger than yourself.
It doesn't happen often, but when it does you have to pull out everything you've learned and use it. You have to put your emotions aside and focus. Because this is the end of the line for this person. It doesn't get more serious than this. And I work here? That still amazes me.
Sometimes I go home all worked up and eat my dinner in about 3 minutes. I can't seem to calm down but it helps to talk to a friend or watch tv to get my mind off of it. If I go out after work, my mind is still processing the events of the day. It does bother me. But it can't while I'm at the bedside because that's my job- to try and save a life.
I've never cried about it. Maybe one day I will. Maybe I should cry. Or maybe it's simply a self-preservation technique so that I will indeed come back the next day. And without fail, I do come back for more. It's the addicting paradox of the ICU. And I love it.
Saturday, April 10, 2010
The scenario goes like this:
Stupid kid goes to the bar with his buddies, has not one, but twelve too many. Starts a ruckus of some kind, probably swinging punches at the guy who unfortunately happened to glance in the direction of this guy's girl while he was looking for the score of the game. Fight breaks out, police jump into action and stupid drunk kid is so out of it that he starts to lose his airway and EMS has to come. Intubated for low GCS (Glascow Coma Scale- determines level of consciousness) and combativeness. Comes to the ICU for...no reason... except that he's a jackass.
...No matter that actually sick people need the beds when you decided to let all those bottled up emotions out at one time. Hope you got it out of your system. Next time try the gym..
Anyways, mom comes in hysterical, crying and pacing while asking questions in incomplete sentences. The doctor tells her that though her son is unconscious right now due to his blood alcohol level, he will wake up and will be extubated (breathing tube removed) with, most likely, no problems. Mom starts to pick up that there's nothing wrong with him and calms down.
The next morning, now just stupid hung over kid, wakes up and flips out, trying to pull out his endotracheal tube. By now he's following commands and is with it enough to pull the tube. The doctor comes to the bedside and the respiratory therapist extubates him.
Here's the great part. Mom comes back to the bedside and the first thing out of her mouth is "I'm gonna whoop your ass!" To your tremendous surprise, parents don't like paying for an unnecessary hospital stay for a diagnosis of immaturity and impulsivity. Mom lectures said stupid kid about how he's coming home with HER this time and "there ain't gonna be no more of this bullcrap" Or almost as likely, the equivalent of this conversation in spanish complete with grandiose hand gestures including pointing and "A Dios mio" every once and while.
After extubation, now stupid whiny kid complains about everything from the temperature in the room to his throat hurting to why can't he sign himself out now and leave.
ME: "Yeah your throat is going to hurt. You had a tube down it for 24 hours. It will go away. Here's some meds"
ME: "You can leave AMA (against medical advice)" (You are thinking to yourself "knock yourself out, sign the paper and get out of my face") You actually say, "It's better that you stay here until the doctors are ready to discharge you. You were very drunk"
SWK (stupid whiny kid): "Like why do I gotta be here? Don't touch me. Ooooooowwwwwwwwwwww.
ME: "Sorry, all I did was lower your bed"
SWK: "Yeah but you did it too fast. Can't you be more considerate?"
And this goes on all day. I didn't go through four years of school to be your babysitter or your personal assistant or someone for you to bitch at. Let's start a new chapter of your life entitled "Actions have Consequences".
I realize this sounds very cynical and sarcastic. It's a coping mechanism and it's pretty funny to me honestly when I think about what some of these crazy people do. But in reality, I do care about their life and I want them to make better choices. Sometimes it's better to lay it all out for them and set them straight. Being super nice doesn't work most of the time. Setting limits does. Not letting patients bully you around does. Otherwise I'll get taken advantage of and they might not ever have someone get in their face about the reality of their life.
Most of these people don't have an education. They've never been taught better or didn't have any good examples to follow. This is what they saw growing up and unfortunately, it's what most of their kids will end up doing. It's a cycle of ignorance and poor choices. So if stupid drunk, hung over, whiny kid wakes up to the fact that the next time he comes in, it might be in a plastic bag, then maybe it was worth it for him to take up that bed overnight.
It's much more tragic when mom doesn't come in and yell at stupid kid but stares at him with apathy. Or she doesn't come at all. But at the end of the day this kid will go home and back to his normal life. Hopefully somewhat wiser and less rambunctious.
"Nurse?" (Because there are only two pronouns in the hospital: Nurse and Doctor, despite the fact that thousands of people work there)
"Yep. What's up?"
"So I can still drink right?...."
Oh dear goodness. Square one. Here we are, standing on it.
Stupid kid goes to the bar with his buddies, has not one, but twelve too many. Starts a ruckus of some kind, probably swinging punches at the guy who unfortunately happened to glance in the direction of this guy's girl while he was looking for the score of the game. Fight breaks out, police jump into action and stupid drunk kid is so out of it that he starts to lose his airway and EMS has to come. Intubated for low GCS (Glascow Coma Scale- determines level of consciousness) and combativeness. Comes to the ICU for...no reason... except that he's a jackass.
...No matter that actually sick people need the beds when you decided to let all those bottled up emotions out at one time. Hope you got it out of your system. Next time try the gym..
Anyways, mom comes in hysterical, crying and pacing while asking questions in incomplete sentences. The doctor tells her that though her son is unconscious right now due to his blood alcohol level, he will wake up and will be extubated (breathing tube removed) with, most likely, no problems. Mom starts to pick up that there's nothing wrong with him and calms down.
The next morning, now just stupid hung over kid, wakes up and flips out, trying to pull out his endotracheal tube. By now he's following commands and is with it enough to pull the tube. The doctor comes to the bedside and the respiratory therapist extubates him.
Here's the great part. Mom comes back to the bedside and the first thing out of her mouth is "I'm gonna whoop your ass!" To your tremendous surprise, parents don't like paying for an unnecessary hospital stay for a diagnosis of immaturity and impulsivity. Mom lectures said stupid kid about how he's coming home with HER this time and "there ain't gonna be no more of this bullcrap" Or almost as likely, the equivalent of this conversation in spanish complete with grandiose hand gestures including pointing and "A Dios mio" every once and while.
After extubation, now stupid whiny kid complains about everything from the temperature in the room to his throat hurting to why can't he sign himself out now and leave.
ME: "Yeah your throat is going to hurt. You had a tube down it for 24 hours. It will go away. Here's some meds"
ME: "You can leave AMA (against medical advice)" (You are thinking to yourself "knock yourself out, sign the paper and get out of my face") You actually say, "It's better that you stay here until the doctors are ready to discharge you. You were very drunk"
SWK (stupid whiny kid): "Like why do I gotta be here? Don't touch me. Ooooooowwwwwwwwwwww.
ME: "Sorry, all I did was lower your bed"
SWK: "Yeah but you did it too fast. Can't you be more considerate?"
And this goes on all day. I didn't go through four years of school to be your babysitter or your personal assistant or someone for you to bitch at. Let's start a new chapter of your life entitled "Actions have Consequences".
I realize this sounds very cynical and sarcastic. It's a coping mechanism and it's pretty funny to me honestly when I think about what some of these crazy people do. But in reality, I do care about their life and I want them to make better choices. Sometimes it's better to lay it all out for them and set them straight. Being super nice doesn't work most of the time. Setting limits does. Not letting patients bully you around does. Otherwise I'll get taken advantage of and they might not ever have someone get in their face about the reality of their life.
Most of these people don't have an education. They've never been taught better or didn't have any good examples to follow. This is what they saw growing up and unfortunately, it's what most of their kids will end up doing. It's a cycle of ignorance and poor choices. So if stupid drunk, hung over, whiny kid wakes up to the fact that the next time he comes in, it might be in a plastic bag, then maybe it was worth it for him to take up that bed overnight.
It's much more tragic when mom doesn't come in and yell at stupid kid but stares at him with apathy. Or she doesn't come at all. But at the end of the day this kid will go home and back to his normal life. Hopefully somewhat wiser and less rambunctious.
"Nurse?" (Because there are only two pronouns in the hospital: Nurse and Doctor, despite the fact that thousands of people work there)
"Yep. What's up?"
"So I can still drink right?...."
Oh dear goodness. Square one. Here we are, standing on it.
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