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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

Surprise! I love being a nurse again.

Having trouble keeping up with my love-hate relationship with nursing? That’s okay, so am I. The good news is that I love it again. I’m almost halfway through my MICU contract and things are going surprisingly well. They didn’t quite start out that way. Here’s a synopsis: Week 1: In the weeds. All the time. Treading water. Hating life. Crossing off the days until this damned contract is over. Week 2: Getting used to it but damn, this job is hard! How does anyone do this for a living? How did I do this for a living? I’ve had it up to here with poop and sputum and agitated patients on the ventilator and I wished I were back working in the recovery room, checking pedal pulses and getting turkey sandwiches for my patients. Week 3: My confidence has officially returned and it’s starting to feel like I never left. I can kind of see why I actually liked this job, although it’s not easy. It’s still very challenging. Week 4: Wait a sec… I kind of love this job! Even after a crazy shift of codes, deaths, bleeding, confusion, and difficult patients, I walk out the door feeling great. It’s probably just the neurotransmitters. I’m high on adrenaline. I drive home with the windows down and the radio blasting, feeling like I really accomplished something. The next day I wake up very tired but still feeling good. I relax more because I feel like I’ve earned it. So now I’m loving it so much I’m thinking about returning as permanent staff. I can make this work. It’s a big pay cut to leave the agency but I love having a work home, and a work family. My MICU coworkers are absolutely the best, and this job is helping me to remember why I chose nursing in the first place. There’s just one teeny weeny little complication. Two, actually. I’m pregnant with twins. So I’m not going to commit to anything just yet. It’s one thing to put one kid in daycare, but three? You get to the point where financially you’re just barely breaking even. So we’ll see. I think the important thing for me is to remember how I feel about being an ICU nurse right now, which is that I love it. After Ben was born I kind of got seduced by that whole social media world and was tempted to migrate away from nursing altogether. But I’m wiser now. And up for the challenge of having 3 kids under the age of 5 for a few years (YIKES!).

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.

Sick as Snot (or Not)

Last year I was talking to this doctor while I was still in nursing school and contemplating working in the MICU.

“Those patients are sick as snot,” she said.

I love that expression. It really paints a picture. I’m here to tell you, though, that it’s not entirely true.

There is one night nurse in particular that subscribes to that belief. She’s a traveler with many years of experience. She?s the one who I referred to earlier that always sprinkles her report with comments like, “This patient is really sick. The resident/intern is just chasing her tail. I don’t know what these doctors are trying to do, but they better do something.”

Now. The first time this happened, I was fresh out of orientation. I listened with my eyes and ears wide open. When she was finished these were my thoughts:

I’m about to take care of a really sick patient (crap).
The doctors don’t know what they’re doing (double crap!!!).
I don’t know what I’m doing (TRIPLE CRAP!!!).

Her overall attitude from the previous night had now set the tone for my day. So I tried to remain calm, get myself organized. One advantage that the day nurse has over the night nurse is this: We participate in AM rounds. This means that we give a nursing report to the team of docs (usually an attending, fellow, resident, intern and sometimes a pharmacist.) We listen to their plan of treatment, and the rationales behind everything. A list of daily goals for the patient is produced. It’s all very collegial and informative and it puts everyone on the same page of music.

So I begin a three day stretch with this patient, and I know what the plan is.

I am not seeing this patient in the same way as the night nurse. Yes, she is very sick. Isn’t everyone ‘very sick’ in the MICU? She is a lung transplant patient. That’s all you need to know to understand how sick she is. Lung transplants are some of the most complicated patients you can care for in the MICU. Two medications make them this way: Tacrolimus and Prednisone. One is an immunosuppressant. So it causes the patient to be immunocompromised. Fill in the blanks for what can go wrong there. The other is a corticosteroid. They can cause hyperglycemia, osteoporosis, and bleeding just to name a few of the lovely side effects. Then there’s the kidney failure associated with tacrolimus, and the ICU psychosis that always seems to hit lung transplant patients the hardest.

At any rate, when you spend three 12 hour days with a patient you are bound to see some changes. I actually saw her improve, at least enough to wake up and interact with her family members.

But now a seed has been planted in my brain. Is this nighttime nurse perhaps somewhat of an alarmist? Do I dare even think that way about someone who has twenty years experience over me? Am I perhaps not enough of an alarmist because I am not freaking out about how sick this patient is? Just some thoughts I had at that particular time.

Fast forward to 4 months later: I am getting report from the same night nurse on a different patient. This time the patient has (I’ll just name the top three diagnoses) chronic pancreatitis, myasthenia gravis, and respiratory failure (which is the main reason she’s in the MICU). But the report sounds identical to the lung transplant patient: “These residents don’t know what they are doing, this woman is so sick! This situation is dangerous!”

It’s amazing what 4 months can do. Because now I have reviewed my patient’s data, gone into the room to assess her, participated in AM rounds, and now the tone of my day is set by my own impressions, not by the night nurse’s.

And my impressions are this: Yes, this woman is extremely sick. No, the doctors can’t quite figure it out why she went in to respiratory failure in the first place. Am I flummoxed? No. I have a job to do. I will be spending the day with this patient. How will it help her if I get all frantic about how sick she is?

So I cared for this patient for three days and I watched her (and helped her I hope) get better. She went from being vented, sedated, and febrile to sitting up in bed, just a little supplemental O2, watching TV with her daughter. No, she’s not cured but at least she’s out of the woods and ready transfer to the floor, one step away from going home.

So I start to wonder, how much does the nurses demeanor/attitude/state of mind affect the patient’s ability to heal? I’ve always been of the belief that you get what you expect. With that in mind you can go to work expecting to have very sick patients that will eventually be healed (or perhaps not) or you can expect to have patients that are very sick and will just lay there hopeless in the MICU while the residents chase their tales. I choose to expect the former.

Then there is the other end of the continuum of experience. On the same three-day stretch I observed another nurse at work who is very fresh out of orientation. She was upset because she had a liver failure patient with multi-organ failure. She was frantic and frustrated. She felt that the docs weren’t listening to her on rounds. She felt like we weren’t doing enough for this patient. I asked her if the patient was being worked up for a transplant.

“No,” she said, “transplant is totally not an option.”
“Is there a family meeting scheduled?”
“Yes, this afternoon.”
“Well then don’t worry about it.”
“What? Don’t worry about it?”
“Yes, don’t worry about it. Your patient is in liver failure. They are going to die. Neither you, not the docs are going to fix anything. The best they can do is have the family meeting and explain this to the family. Just carry out what needs to be done and most importantly make sure she’s comfortable, make sure she’s sedated.”

(And sure enough, that is what happened. Family meeting occurred, family decided to withdraw care, and the patient passed away in peace.)

Now don’t get me wrong. I’m not just sitting there all blase in the nurses station drinking coffee thinking, why bother, all these sickies are going to die anyway. Hey you over there with the fatty liver! Quit yer whining or you’ll be getting another lactulose enema! Far from it. I work my butt off for each and every one of my patients. Maybe I’ve just been told so many times that in the MICU “these patients are the sickest of the sickest” and ‘you will see many deaths here,” to the point where, now that I’m here, it’s not quite the death bed that everyone’s made it out to be. I see people get better. It happens every day.

You want fries with that Atropine?

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.

God – 1, MICU – 0

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.”