Earlier this week I wrote about technology tools for nurses, and how everything we use seems to be so outdated. One thing I wondered: Do nurses even care? So I posed the question on Reddit and got some terrific feedback. Read more
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
There’s been a lot of chatter on twitter as far as whether hospitals are doing enough to protect nurses who come in contact with an Ebola patient. I’ve also seen the sentiment that we shouldn’t be spreading fear, because Ebola isn’t an airborne virus. And the rallying cry that, “Protocols work if we follow them correctly!” There’s no question that these discussions are needed. There seems to be much confusion over what we should be doing. Read more
In 2007 I had an idea to build an aggregator for nursing blogs. At the time I was using an RSS reader to subscribe to blogs, but I felt like there was a better way to keep up with the content. I started trying to build it with a php based RSS tool called Simple Pie. At the same time Guy Kawasaki was putting together Alltop and someone suggested I contact him about creating a nurse category. Read more
I watched someone die this morning.
Ever since I started working in the MICU I’ve been curious about what a death looks like but ashamed to admit to this curiosity. I remember reading some time ago about a serial killer and how he murdered because he was so fascinated by looking into his victims eyes and watching that moment when the light goes out. Because of this I find it difficult to admit to anyone that I am curious about watching a person die.
So on to this patient. He was in the room next to my patient’s room. He was 81 years old with sepsis. He had tons of comorbidities, and a declining state of health over the past year requiring multiple hospitalizations. Now he was in the MICU, not really waking up, getting progressively worse. A family meeting was held and they decided that it would be best not to prolong the inevitable and to let him die in comfort. They had made the difficult decision of changing his status from a full code to a DNR and they decided it would be best to withdraw care.
But not until tomorrow.
I do understand why people choose to delay this withdrawal of care. It’s a great amount of pressure. You are probably feeling guilt and denial. You may have this feeling that by turning off the ventilator you are killing your own family member. You’ve come to the decision that it’s best for your loved one to go in peace?but not just yet. So the healthcare team then feels obligated to keep this person alive until the family is ready to withdraw.
But usually no one thinks about the when the patient is ready.
So last night this patient was trying to die. All night long, little runs of V-tach, blood pressure waxing and waning, agonal breathing. His nurse would watch these goings on and get that momentary sense of urgency and then realize that there were really no measures that she could take. But she was so respectful of the family’s wishes, she was practically willing him to stay alive until the next day when the family would return.
Each little run of V-tach seemed to me like the patient was trying to take charge of his own death. The one thing the docs could do was make ventilator changes so they did that. It seemed to prolong the inevitable. Then right before change of shift, he lost his pressure. His heart rate started to fall. Even though his dopamine drip was increased his heartrate continued to fall.
He was determined. So his nurse was just kind of fussing over him. She kept cycling the pressure cuff and dopplered his pulse (for what?). I sat at the bedside computer and documented for her. I watched the monitor ? heart rate 90s, then 80s then 70s. A couple of other nurses gathered round. We had been expecting this all night.
The agonal breathing became more steady (even though he was still being mechanically ventilated). I watched his face and saw a momentary grimace pass through every thirty seconds or so. It was strange because he was so unreactive before and now his face was showing something…pain, anguish?
As he bradied down to the 40’s ?50’s, I was charting and the nurse next to me said, “Did anyone just feel a chill?” As she said it I realized that a chill had been vibrating through me for the last 10 seconds or so. As I became aware of this sensation, the chill was emanating, pulsating, prickling. Up until then I had been warm all night.
Then his heart stopped. We all entered the room and began cleaning it up, making it presentable for the family that was about to arrive. I checked myself. Did I still feel the chill? Nope. It was 100% gone. I felt kind of an empty feeling in my core, like something had vacated the space.
It was fascinating.
And as I read this I am amazed at my sense of detatchment. I just read Kim’s entry about her patient who died on Easter. (Damn Kim- You always beat me to the punch!) She had the luxury of sitting around with the family and hearing stories about what a great and wonderful life this person had. In the MICU on nightshift, we are often just alone with the dying or comatose patient, not knowing much about who they were or what they were like. We keep them clean, hold their hands, try to provide a peaceful atmosphere. We are just maintaining status quo until the family can make it there. This can go on for days.
Thankfully, we are starting a new committee in the MICU, the “Quality of Death” committee. This will hopefully help us to better educate families (and ourselves) on how to best prepare for a loved one’s imminent death. I can’t think of a better place to start a committee like this.
I know there are a lot of nursing students out there, as well as new nurses. I think it’s important to let you know that things do get better, especially if you have any experience waiting tables. With that in mind, here is a follow-up to the worst day ever.
Over the weekend I had another particularly difficult assignment. One patient was an FTW (failure to wean: unable to be weaned from the ventilator.) He had about a bazillion dressings that needed to be changed and documented on. He also was just awake enough to mouth words and attempt to communicate with me. This always gets me. I have this habit of dropping everything I’m doing in order to try and understand my vented patient as they mouth words to me. I just cannot read lips, no matter how hard I try. For now, the best I can do is ask:
Are you in pain? Are you warm enough? Are you comfortable? Do you need to be cleaned up? Do you want the TV on/off?
That’s about it. I find it pretty hard to do my job while my patient is looking at me, trying to tell me something, and I am powerless to figure out what it is. Can you imagine being say, an accountant, and sitting at your desk trying to crunch numbers while someone is sitting next to you, silently pleading with you, mouthing words you don’t understand? Can you imagine getting any work done at all?
So mentally, I’m in a state of frazzledom.
My other patient was admitted 2 hours ago, which means that she is busy! Lines to be placed, X-rays to be taken, CT scans, cultures, new meds, you name it, they are ordering it! Luckily she is comfortably sedated, and not mouthing words to me.
So I am just barely keeping up. I’m merely treading water but my patients are still alive, dammit! Doesn’t that count for something? It’s toward the end of the day and I’ve almost gotten everything done for one patient, and ready to move onto the next. And patient #1 goes into V-tach. Just like that. This was not part of the plan. And just like that he bounces back into his regular if not somewhat tachy heart rate. So now the docs are at his bedside, coming up with all sorts of new things for me to do. This does not fit into my plan either. The time I allotted for his care is finished and now he is eating into the time of patient #2.
So the treading stops and the drowning begins. But this time, I enlist the help of the charge nurse. Not only do I ask for help, but I tell her that I am drowning. She starts to take care of V-tach-er’s new orders so I can finish up my tasky stuff for patient #2.
The charge nurse tells me that she took care of patient #1 last week and he was so busy that she was unable to leave his bedside the entire shift. Nice to know it’s not just me. In the end, everything is finished on time.
But I go home thinking I am just not getting it.
A good night’s sleep leaves me ready for round 2. I am even hoping that I will have the exact same patient assignment. The devil you know and all.
Part 2: Be careful what you wish for…
In morning report I find out that yes, I do have the same patient assignment and also that the unit is extremely understaffed and everyone will be busy.
So more of the same. Only this time the v-tach-er has turned into a de-sat-er. He keeps dipping down into the low 80?s. I bump him up to 100% and suction. Bump him up and suction. Bump him up and suction. The theory on him today is that he has a mucous plug, and he is to be sent for a thoracic CT to confirm this. So I call the respiratory therapist in to see if she has any ideas. She does. Bag him, lavage him, THEN suction, with a longer suction catheter! Brilliant. I bag, she lavages and suctions, and together we pull up a couple of big gobs of mucous. Yay! Problem solved! We leave him alone for awhile and he is satting 99%.
Moral of the story #1: When you have a patient with a Bivona trach and you are using an inline suction catheter, you may need to switch to a longer catheter that will go deeper. It’s funny, if I read the above statement in a textbook I would never remember it. Instead, I saw it in action and now it will forever be in my arsenal of things to do when my patient desats.
In nursing school I had this one professor who loved to rant about the saline bullet. She would always tell us that there is no evidence that routine lavaging and suctioning with a saline bullet improves outcomes. In my literal-minded nursing student head what I heard was, Saline bullets are evil! Only bad nurses use saline bullets!
So I never used them. Of course now I will. I think what she needed to make clear was that ROUTINE suctioning and lavaging should not be done. Every once in awhile, if the situation calls for it, it can be quite useful.
At any rate, I got through these two shifts quite well. I did, however, confess to the charge nurse that I felt like I was not getting it.
Please, she said. Take a look around. Even the most experienced nurses on this unit have crazy, busy days. It’s just part of the job.
This was kind of an aha moment for me. It’s just like waiting tables. You get in the weeds (waitress speak for “I am totally freaking out of control right now and every single one of my tables wants something!”), and then you get out of the weeds. When you are in the weeds, you can’t see the other side of the weeds. When you are out of the weeds, you can even laugh about being in the weeds. One extremely important difference, though. When a waitress is in the weeds, someone might not get their chicken on time. When a nurse is in the weeds, someone might not get their (you fill in the blank – blood products? Pain meds? Epi? Atropine?) on time.
Moral of the story #2: If you are a nurse and you find yourself in the weeds, ask for help. Your patient’s life may depend on it.
The hospital where I work – we’ll call it: GHOAT, “The Greatest Hospital Of All Time” (or so human resources would have us believe) – is often seen as the last stop for some patients. Other hospitals send their patients to my unit when they have run out of options. As a new grad, I often wonder just what it is that we do that is so different from other hospitals. Do we have some secret technology that we guard and use only for special cases? Do our docs and nurses have some sort of super-natural diagnostic and healing powers? Families seem to have this notion that “If anyone can save my loved one, GHOAT can.” We end up with some disappointed families.
One of the things that we do is to pump unit after unit of blood products into a person who is bleeding out of their GI tract. At GHOAT, GI bleeders go straight to the MICU. And while I might sound cynical, I have to point out that I have also been amazed. One patient that comes to mind had 60 units pumped into him, on three separate occasions (The blood bank hates us!) The third time I really thought it was his time, but he survived. When I was an orientee, I had a patient who managed to start bleeding, get a cordis placed, received numerous blood products, all while I was at lunch and my preceptor was watching my patient.
So GHOAT received one of these GI bleeders the other night. The primary nurse was a friend of mine whom I had gone through orientation with. She had recently confided in me that she was miserable working on this unit, and that she was even questioning whether she was cut out for nursing. She knew this patient was going to be diffcult so she quickly enlisted the help of the entire unit. A table outside the room was turned into a makeshift assembly line, with bags and bags of fluids, flushes, and tubing. The Level One was in position and ready to go. There was nothing left to do but wait. Then we heard the ominous sound of the helicopter landing. Minutes later she was there. It was a young woman with cancer. She had a huge mass in her lower abdomen and was bleeding from somewhere in her lower GI tract. She was lying in a pool of blood. She was awake and alert and I think that’s what made it so difficult. So everyone on the unit began working on her. The teamwork was amazing. Each person there seemed to effortlessly shift into a task. Someone was hanging pressors. Someone was checking blood. Someone was putting in a line. Someone was making runs to the blood bank, someone was manning the level one. Someone was giving oxygen. Someone was doing chest compressions, as she went in and out of conciousness. Someone was getting out the emergency drugs. Someone was holding her hand and telling her that we were taking care of her. Any nurses who were not in the room were making sure all the other patients on the unit were being taken care of. This went on for about two hours until the patient gave up and died. We were pretty despondent. There really was a point where it looked like she was going to survive. The unit was a mess. There was blood everywhere, being tracked around on the floor. The patient was lying in her own personal pool of blood. Her face was swollen from the rapid infusion of fluids. One of the nurses was very upset. “Where was the family? Why did this woman have to die surrounded by strangers? What chance did she have with her cancer?” And of course the answer to all of these questions is that she came to GHOAT, and that’s we do at GHOAT. You want everything done for your family member? Take them to GHOAT.
Since the very beginning of my critical care education, this issue has always loomed large. How much do you do for the dying patient? When is it time to let go and just help the patient die in peace? Everyone in this field has a strong opinion on the matter, one way or the other. I’m starting to learn that you can’t generalize this issue. You have to take it on a case by case basis.
The next night the palliative care nurse paid us a visit. Someone had told her about the recent death and she felt that we could use a tiny bit of counseling. She is no stranger to the MICU and thank God for that. In the MICU there are so many reasons to build up an emotional wall so you can continue to take care of business. I think she helps us to preserve a little piece of the emotionally vulnerable side. The wall is necessary, but you have to leave a little room for escape. So we talked about what a horrible blood bath it was, how it wasn’t right that her family didn’t get to see before she died. How it was so awful to see her face puff up like that. How the whole thing was futile because of her cancer. The palliative nurse’s reply to all of this was completely surprising to me. She said, “You are all heroes.” She pointed out that we joined together and made every effort possible to save this woman. Every person on the unit contributed in some way towards the effort. We did everything we possibly could do. And every step of the way there was a nurse speaking softly into her ear, telling her what was happening, and holding her hand.
So the above title is pretty corny, I know, but when she was saying the whole hero thing, I was mentally conjuring up this Michelangelo painting, where God and the angels were calling for this woman, and the MICU team was working on the ground, fighting to make her live. And my friend, the primary nurse who was thinking of giving up nursing? She did an excellent job. I said to her the next day, “You can’t possibly be thinking that you’re not cut out for nursing.” “No,” she said. “I’m thinking about transferring to the ER.”