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Moral Distress in the ICU

Moral Distress in the ICU: Can you avoid it?

There is no doubt that working in the ICU can be a source of moral distress. I’ve been spending the last few months doing hospice home care and I’ve been thinking about going back to the hospital for various reasons. The last time I worked as a nurse in the ICU was the summer of 2009. I took a three month contract in the MICU. Not my first choice of employment, but I needed the money, and the work was familiar to me. Read more

Why I’ll Probably Quit Nursing

UPDATE: If you want to read my latest post on quitting nursing, it’s here. The bottom line? Don’t beat yourself up over your decision. And have a game plan before you quit.

There was an old post with this title that I wrote in 2008. For some reason google loves to serve it up when people type in “quit nursing.” That’s always weighed on me a little bit. As if people are looking for career advice and they could find it here on this blog. Read more

Things to remember about nursing

This summer, I came away from my MICU contract with a renewed understanding of why I have this love-hate relationship with nursing. And I’ve summed it up in 6 simple points so when I’m ready to pick up another contract I can remember what to expect, even if months and months of super intense child rearing washes it all out of my head.

So here goes. The love part…

  1. It’s the feeling you get after the shift that is so great. You made it. You got through this grueling, back breaking, nerve wracking day. It’s a feeling of accomplishment.
  2. It’s the social interaction. The camaraderie. There is definitely a bond there among nurses. No matter how different a fellow nurse is from you they know exactly what it is that you go through. And for many of us, you can’t say the same thing about your family, your spouse, or your best friend.
  3. Then there’s just the joy of knowing a difficult job really, really well. Being able to field any curve ball that comes your way in an extremely fast paced environment. Not to mention the fact that people could die if you don’t do the right thing. While that may sound like an enormous amount of pressure, it’s also a great source of pride to know that you can handle that.

And the hate part…

  1. Night shift – Love, love, love the people who work night shift. But I hate the fact that switching from days to nights makes me feel like a human slug.
  2. Lower back pain. No need to elaborate here.
  3. Cleaning up stool. Sorry. it sucks no matter how you slice it. Some will say “Oh it doesn’t bother me at all! You get used to it.” Bullshit. You have 2 ICU patients, each stooling 3-4 times during the night in a 12 hour shift. You do the math. That means you are potentially up to your elbows in shit Q 2 hrs. AND trying to get the rest of your work done.

On Doing What You Love

So I was writing this post about how I’m really lukewarm on being a nurse and I came upon this post by Lisa Sabin Wilson, a wordpress designer who is a former nurse.

Here’s how she felt about nursing:

…I pretty much thought I would be a nurse until the day I retire…Nursing was one of those ok jobs. I didn’t love it. I didn’t hate it. It was . . . fine. I was good at it – – excelled in it, really – and took pride in that fact. But I wasn’t doing what I loved… nor was I loving what I did.

I feel like the future “me” could have written this. In the post I was working on, I was going to spell out why I was so lukewarm on nursing, but you know what? I don’t want to waste your time with that. And I certainly don’t want to discourage anyone from entering the field. There are many ways in which being a nurse is satisfying and meaningful, and the sky’s the limit as far as opportunities go.

But for me being a nurse has sort of been a cop out. It’s like the childish “me” has always wanted to do something creative but then my childish side kind of ran out of time. So I grew up and found a profession. When I first became an RN, I thought. “Finally. I have found a respectable and stable way to earn money. Now I can start painting again in my free time.” Ha. Flash forward to being a full time mom and a part time nurse and suddenly there is no free time. Fortunately I have this blog to fuel my creative side and keep it somewhat balanced for now.

Am I Contributing to the Nursing Shortage?

I got this comment the other day from Trish, and I really have mixed feelings about it:

I just wanted to let you know I like your blog and you have impacted someone’s life (mine), in an unexpected way.

I’m starting college this fall after being out of school many years. I was planning on going into nursing. Deep down I suspected I would suck at being a nurse, especially when I found myself gagging while washing out my pottytraining toddler’s poopy underpants. Your blog, and this post, has pretty much confirmed my suspicions and I’m planning on doing something else now. Thanks for opening my eyes!

On the one hand, I feel bad. We need nurses and I hate to think that I’ve influenced someone to not be a nurse.

On the other hand, everything I write here is my honest and open opinion about the profession, and I write about what being a nurse really entails. And unfortunately, the further I get in this profession, the more I want out of it.

Despite that, I have no regrets as far as choosing this path, and spending the last three years (5 if you include school) being a nurse. It’s been a mind-blowing experience, one in which I’ve learned a lot about life and a lot about my self, and what I’m capable of doing.

To Trish I would say this: Do a little more thinking about what drove you to consider nursing in the first place, because there are many types of nurses that rarely come into contact with poop. (Isn’t it crazy that I’m writing a serious post about poop?) Psych nurses, community health nurses, and case managers are a few types that come to mind. And you can always try being a NICU nurse, because as @thatguynamedtom said, “the poop is so much smaller there.”

One final thought: I used to be a person who was afraid of blood, and for years I wouldn’t even dream of becoming a nurse, for fear of having to actually draw someone’s blood. I later came to find out, however, that this was simply a matter of my own vasovagal response to giving blood. Years later I found myself up to my elbows in blood amongst the GI bleeders in the MICU, and I was as far from syncope as you can get. Instead I found myself pumped up with adrenaline and exhilaration at the chance to be saving someone’s life.

Now there’s a good reason to become a nurse.

Back to the MICU, and back to Liverland

So this MICU shift was very difficult after all, and it wasn’t for the reasons that I suspected. I thought it would be the tasks that got me down, i.e. not enough time to get things done. Surprise, surprise, turns out it was the patients.

Imagine a patient with End Stage Live Disease. She currently has hepatic encephalopathy and suspected GI bleeding. She was recently extubated. They usually put an oral gastric tube in and then yank it out at the same time when the patient is extubated. But then the patient continues to have this hepatic encephalopathy, which is a Catch-22 because then she is unable to swallow her lactulose, (which would help to restore her mental status.)

You attempt placing a nasogastric tube, twice, both times unsuccessfully, both times with the patient screaming at the top of her lungs. So at the end of the day, her baseline mental status hasn’t returned, and you have no way of giving her nutrition or lactulose. But she isn’t sick enough to stay in the ICU so you transfer her to the floor.

Typical situation for this disease, I tell myself, and that’s just the way it is. But I feel so frustrated, and so helpless for two reasons. (1) I CAN’T GIVE THIS PATIENT HER LACTULOSE AND THAT IS THE ONE THING THAT WOULD MAKE HER BETTER and (2) Trying to place this NG tube when she is not mentally stable enough to cooperate is very traumatic to her. And inevitably, the docs will always order a lactulose enema out of desperation. GUESS WHAT? If your patient can’t swallow a cupful of medicine, you can be damn sure she won’t be able to retain a pint of lactulose IN HER BUTT. So that never works.

The weird thing is that even though I hadn’t worked since last August, I had the exact same patient scenario: Liver Failure, recently extubated, mentally, in liver land, and unable to swallow lactulose.

Is it a failure of our healthcare system?
Is it a failure of my nursing skills to place an NG tube?
Is it a failure of our normal routine to yank out the OG tube when extubating?
Is it a failure of medicine in that we have failed to discover a better way of reducing a patient’s ammonia level (which is what lactulose does)?

In the end it doesn’t really matter because it was a failure, and I left that day feeling like I had done nothing for my patient except cause discomfort, and transfer her to lower level of care.

One thing is for sure, I vow never to complain again about working at Chez Recovery. It took a shift back in the MICU to make me realize just how good I had it there.

Follow the Money

At the end of my rant about sloppy physician’s orders, I asked the question, “How do you get beyond that kind of apathy?”

May, whom I have a great deal of admiration for, said,

“i know that clearly looks like apathy, but it could also mean something else. i maybe apathetic about the issue, but i know i still want to take care of sick people most of the time, despite the challenges…”

May, I want to thank you for reminding me that the nurses I work with are very caring and compassionate people, and so apathy may not be the right word to use at all.

Perhaps it’s simply a matter of economics.

So the nurses have voiced their complaints. They have staff meetings, they have a nurse manager who supposedly advocates for them. So why does nothing change? Perhaps it’s just the balance of economic power that exists within the hospital.

Doctors who do expensive procedures bring big gobs of money to the hospital, therefore they have power. Nurses, on the other hand, don’t really bring any money into the hospital and so they have very little power.

It’s a very simple concept: money equals power. You can complain all day long about doctors who are sloppy about writing orders, but what incentive to they have to listen to you? I suppose one incentive is that they might miss out on having a top-notch nursing staff, because they will only attract nurses who will put up with sloppy orders, but does that really matter to a radiologist or an interventional cardiologist?

Maybe not. It doesn’t take much to do my current job. I monitor vital signs, and I tell people to lie flat until their groin site heals. I hand out generic discharge instructions. I occasionally transport a patient to the floor. It’s pretty simple stuff.

That’s not to say that I don’t work with some top-notch nurses in the recovery room. Quite a few of them are excellent. But I think the reason that most of them work there is because it’s a wonderful thing to have a nursing job with no night or weekend requirements.

So what’s my point anyway? Why am I complaining? Why am I so frustrated?

Mark Graban made an interesting point: “It requires Leadership! This isn’t something that Lean can solve if there’s not leadership and a drive to fix problems like this.”

Unfortunately, I have no desire to be some sort of visionary leader who will solve all of the problems in the recovery room. Rather, my instincts are telling me to get as far away from the recovery room as possible. Maybe the answer lies in the fact that my job would be vastly improved if we used a CPOE system. And yes, I have thought about working for a company that sells CPOE programs, because I am truly an evangelist when it comes to using them.

Hmmm. Now there’s something to think about.

Do ICU Nurses Really Have Autonomy?

So today I have an interview at another great hospital in my city, the mental hospital. I’ve spent a lot of time there as a student and was convinced I wanted to do psych nursing. Somewhere along the way I was on monster.com and noticed that Nurse Anesthetists make 100K/year. I also noticed that you need 2 years of critical care experience to even get accepted to a NA program. I thought, hmmm. Well, I certainly wouldn’t want to rule that out, and besides, if I can do critical care, I can do anything, right?

I don’t know if this was such a good idea. Nonetheless, here I am. I know what to do if someone is coding, I know how to titrate pressors, I wean people from ventilators, I can keep a million lab values in my head and spit them back out to you on command but I am weary and unhappy.

This is where greed gets you, I guess. I have officially ruled out the possibility of becoming a nurse anesthetist.

Since contemplating leaving the MICU, I ask myself after every shift, “Are you sure you are making the right decision?” The answer every time lately seems to be a very resounding, YES!

Yesterday I was caring for a 36 year old bariatric patient, very difficult to sedate, had been on the ventilator with ARDS > 1 week. Today the physicians wanted to go the whole nine yards and extubate. They turned her tube feeds off at midnight so she wouldn’t aspirate. Her sedation was cut in half. She did fine on her spontaneous breathing trial so they cut her sedation off completely in hopes of extubating her. I was completely on board with this. If I know what the goal is then I will do anything to try and help achieve it. She was thrashing around in the bed. No many how many times I would boost her up she would slide back down. (Some people just have that kind of anatomy). She was breathing okay, but occasionally setting off the apnea alarm, (you would too if you had all of that sedation on board). The apnea alarm didn’t bother me. I was watching her closely, she was in no distress. She would wake her self up and take a huge breath. I knew that very shortly she would eventually wake up completely and the apnea alarm would go away.

She was satting 97%-100%. I drew a blood gas. It looked identical to the one I drew while the ventilator was doing all the work of her breathing. This girl was ready to fly.

I went to find the physician so we could move to the next step. All I could find was the intern. He consulted with his team and came back and said, “We’re going to have to keep her on the vent and start her sedation again. She needs to have a CT scan. She has had unexplained fevers. and we need to see if there is an abscess.”

“Are you sure?” I said. “I mean, look at her. She is ready to go. And she’s currently afebrile. Her blood pressure is 180/100. It’s not really looking like she’s about to go septic. Once you start getting her sedated again it’s going to take forever to wake her up again. You can extubate her and send her to the CT scan tomorrow.”

AND she had a CT scan 2 days ago, which showed a sinusitis which may have contributed to the fevers.

But I guess at GHOAT we like to be 100%, without a doubt, unequivocally sure. The intern consulted with his team and the decision to keep her intubated was made.

So I gave her hypaque, and attempted to sedate her again. Meanwhile she was continually thrashing around in the bed and now she was pooping all over herself.

After cleaning her up and changing her linens several times (and finally inserting a ‘flexiseal” – flexible plastic tubing which goes into her rectum and collects all of her stool into a bag,) she was transported to the CT scan, and transported back to me.

I checked her blood pressure, it was 80/49. Shit.

The transport tech asked me if we had a MAP goal. (translation: MAP = mean arterial pressure and we use a MAP goal when we are titrating pressors).

At this point I felt like screaming, “No we don’t have a freakin MAP goal because her MAP hasn’t gone below 100 all day long!” (A MAP goal is usually > 60)

But I didn’t scream this because he doesn’t know that, and it’s not his fault.

Instead I said, it’s probably all the sedation boluses she’s been getting. I will turn down her sedation and see if her MAP will go back up to baseline. and of course I will inform the physician of her change in blood pressure.

I turned down her sedation and her blood pressure came right back up to where it was before.

Then the physician ordered to change out her foley because her urine culture was growing something.

Of course it’s growing something, she is laying in stool and probably has been periodically throughout the week. (just to clarify – we do not leave our patients lying in stool purposefully. But think about it. If you are lying in bed, snowed on narcotics, on a ventilator, it is almost inevitable that you will poop all over yourself. And when you are in an intensive care unit, there will be times when the patient next to you is coding, or bleeding out and all of the resources of the unit are taken up by this emergency. You are lying in stool but at that particular moment you are not dying, so you will continue to lie in stool until someone is free to clean you up.)

So my opinion is to get someone closer to being able to control their peeing and pooping themselves. Extubate as soon as possible, don’t fool around, get her sitting up and moving, get her using the bedpan. Please don’t make her lie around in bed sedated on the vent one extra day if you don’t have to.

I don’t know. I think part of my problem is that I’m just too emotional to work there. My instincts were screaming at me that this woman needed to be extubated and that the CT scan was just a CYA type maneuver (or perhaps for educational purposes). I communicated with the doctors, I expressed my opinion. They did not listen to me. And why should they? They have been through many years of medical school and I have not. I have not even been a critical care nurse for very long. They are a team, I am one person. And also, it is their decision to make, not mine. And I guess medical decisions are to be based on scientific data and standards of care rather than instincts and subjective observations (she is buck-wild and ready to reach up and rip that tube out herself!)

I read somewhere that nurses have a very high success rate when predicting whether or not a patient is ready to be extubated.

Is there anything I could have done differently? I went to the intern who in turn went to the resident who in turn went to the fellow. That’s where the final decision came from. I have a feeling that if I went directly to the attending and told him my opinion it may have been taken more seriously.

But isn’t that the just the essence of a bureaucracy? When it takes 5 people to make a decision, and no one can agree so you just sit on it another day. Is that any way to heal ARDS?

But still… there is a tiny little nagging voice in my head that says, “You just don’t have the courage. You don’t have the self-confidence to go up to the attending and interrupt whatever conversation he’s in (because no doctor is ever just standing there doing nothing, it’s always an interruption) and say, “Hey, I really think you should extubate this patient and put the CT scan off until tomorrow.” Because what if you’re wrong? What if they extubate her, and the patient goes back into respiratory failure and then has a difficult intubation (which is quite possible, considering her obesity) and then she dies or is brain dead (I’ve seen this happen on my unit – Did I mention that she’s only 36?).

So when I am telling you this story, I want you to get something from it:

I respect the doctors. I respect their experience and education, and I respect the fact that when they make a decision, a person’s life is on the line. They have to live with that. I can throw my 2 cents in but ultimately, it’s not my decision, nor should it be.

Personally, I just don’t think I’m cut out to work in an environment where doctors write orders, and nurses carry them out. The MICU at first glance, appears to be a place where nurses have autonomy (it was presented to me this way in the beginning because we use “protocols” rather than going to the physician for each and every order) but in the end, we really don’t have much autonomy. It’s false to think that we do.

And some might say, well, what exactly was it was that you thought nurses do?

I dunno. Take care of sick people?

Well, yes, they do (we do, I do) but you still need an order for just about everything you do. In critical care a lot of your day is taken up with collecting data and then making the physician aware of this data, or else weeding out what the physician does and does not need to know.

Kind of like a secretary.

And then you write a bunch of notes. “K=3.2. Dr. Welby made aware. 40 of K given per the protocol, will recheck in 2 hrs.” (duh) or “Pt’s blood pressure in the toilet. Dr. Killjoy made aware and at bedside.”

or, “Pt is continually weeping and states, ‘I want to go home. I’m going to die.’ Dr. Beedlemeyer made aware. No interventions ordered at this time. Will continue to monitor.”

But every once in awhile I’ll have a conversation with a patient or a family member and get a feeling that I have really helped them and then I’ll remember, “Oh yes. This is what nurses do.”

Meanwhile I’m looking into nursing jobs that involve less orders and more conversations, because I think that’s what I am good at.

Hence the psych interview today. Hospice interview (hopefully) next week.