Here is an update:

My patient that I was so convinced could be extubated?

Extubated the next day.

Developed airway edema.

Had to be reintubated.

I found this all out when I came to work two days later. So I was wrong. She didn’t fly.

You see? I still have so much to learn.

And learn I shall. After the interview for the psych nursing job, I have come away with a new perspective. I was told that there are two RNs per unit in the psychiatric facility. One RN hands out meds to everyone and one is in charge of the unit. Neither of these roles/tasks have any interest to me so I declined the job.

The hospice nursing interview hasn’t materialized yet.

So I came home and wallowed in depression for about an hour. My husband helped me by rattling off every other conceivable type of nursing that I could try:

Radiology? Too boring.

IV therapy? I suck at phlebotomy.

rehab? Not much demand for nurses there.

oncology? Probably the worst things I hate about the MICU, only magnified.

My husband gave up and I finally went off and sulked by myself. And then I really started to do some serious thinking. What do I really want to do? Two personal idols of mine came to mind: Martha Stewart and Andy Warhol. (Neither have anything to do with nursing, but bear with me). Okay, so in my wildest dreams I would really like to be a wildly successful creative marketing genius nurse. Should I get my MBA? No, another degree would be crazy at this point. So what do I need to do? What would Martha or Andy do? What would Florence do?

And then it hit me. It’s not the job. It’s not the unit. It’s not nursing. It’s me.

I need to learn how to kick ass.

As a nurse.

As a MICU nurse.

I thought about my last post. I really am chicken-shit when it comes to talking to the doctors. Why should I be? They need my perspective. I am at the bedside constantly. I have the information that they need to make their clinical decisions. So what if I every conversation is an interruption? And they interrupt me constantly. The MICU is really just one interuption after another. That’s just the way it is. I need to get over this. Also, I should talk to our attendings more and learn not to be intimidated. They are a wealth of information and they LOVE TO TEACH. I should be taking advantage of this!

Also, I hate asking people for help. For god sake’s, I tried to place a foley catheter in an obese woman BY MYSELF. What was I thinking? I need to get over this. When I need help I will ask the first person I see and I will not hesitate. They can always say no.

And as for feeling disgruntled with my role of “gatekeeper and dictator of information” and as “one who carries out orders?” That is my role for right now. I managed to actually enjoy 10 years of waiting tables. I loved it. I loved the pace, the atmosphere, making things happen under stressful conditions. And yet it never bothered me that I didn’t have any input over what gets placed on the menu. The chef was the decision maker. (Once, very briefly, I entertained the idea of going to chef school until I realized that they work longer hours and get less money for it. )

So I resolved to remember what I love about nursing (the pace, the atmosphere, making things happen under stressful conditions). I went to work the next day with my new attitude. It helps that I now have an iPod nano and so during my 10 minute walk from the parking lot to the MICU I can listen to psyche me up songs from the 90’s like Liz Phair’s “6’2”, the Foo Fighters’ “Monkey Wrench”. And “Waitress in the Sky” by the Replacements.

When I got to the unit and was handed my assignment, I realized that the forces of the universe were somehow aligning as if to confirm my decision. At the risk of sounding like “Agnes of God”, it was almost as if my assignment was handed straight down from God, Himself.

The thing He handed to me was an end stage liver patient. He was denied a transplant because of a cancer history. And he was not in liverland. He was alert and oriented. He had a bad pneumonia and was requiring 100% 02 by non-rebreather mask. The question was whether he wanted to change his status to DNR/DNI. DNR/DNI = legal status of do no rescucitate (using CPR), and do not intubate.

This is the situation that I hear about at every palliative care workshop I have ever attended. This is what they prepare you for. And yet, after almost two years here I have never been faced with this situation.

The patient was faced with imminent death. If he wasn’t intubated it was likely that he would die. If he was intubated it was very possible that he would develop more complications and die on the ventilator. But instead of the family or the physicians calling the shots, this patient was still in a position to make his own decisions. As his oxygen saturation dropped to the low 80’s, I notified the resident. It was time to take the next step. The resident went into the room to have The Conversation.

The patient was still unsure. He had just begun to make peace with the fact that he was dying. But faced with air hunger, pain, and anxiety, and with his family all around him crying, the poor man looked up and said “I don’t know! I just don’t know!”

The physician said, “Then when the time comes, we will intubate you because that is the default. Do you know what default means?” The patient was confused.

(As the physician tried to explain what the word “default” meant to this dying, anxious patient I wondered why physicians have so much trouble explaining things to patients in a language that they can understand. Who wants to learn new vocabulary words on their deathbed?)

The physician left. The family went to the waiting room so the patient could rest some. I realized that it was just me and my dying patient. At every palliative care workshop I have attended, they always make it sound so easy, like DNR/DNI is the obvious choice. Let me tell you, it’s far from easy.

How easy do you think it is when you know you could die in the next hour? Sure, you know you’ve been dying of liver failure for the past five years. It’s a terminal disease. But if intubation could buy you just a little more time would you do it?

I forgot about all my little MICU tasks, (and my other patient who was stable and snowed on the ventilator.) I spent the rest of the afternoon trying to helping this patient, and to make sure that he wasn’t alone. By now his pain was increasing. He had a Fentanyl patch and PRN morphine but it wasn’t cutting it. He was torn between knowing that he wanted to say goodbye to the rest of his family who were on their way from out of state, and knowing that he just wanted enough Morphine to knock him out. I asked the physician to up the dose several times. It still wasn’t working. And as his pain worsened, so did his his oxygen saturation. Finally I told him that I could get him more pain medication but most likely his doctor would need to have him intubated and the time was coming sooner. He told me he didn’t want the breathing tube. He just wanted to go in peace. I went to get the resident so he could clarify this, and the patient was officially made DNR/DNI.

Then we really tried working on his pain. We tried more morphine. We tried dilaudid. We tried Fentanyl. It’s funny, the resident was so hesitant to up the dose. Each time he would go up in piddly little increments. After going to him for dose adjustments three separate times I finally said, “Look. It’s time to stop fooling around here. This man is dying and in agony. I really don’t have much experience with opiate dosing and the dying patient but I know we need more morphine.”

The resident looked at me incredulously. “What do you mean you don’t have any experience with this? You’re a MICU nurse!”

“I know, I know, I’m an anomaly. For some reason, my patients don’t die. I have never had a patient die on me and I have very rarely cared for a DNR/DNI patient.”

He laughed and said, “Well, I’m sticking close to you.”

We finally settled on a Fentanyl drip until we could get a PCA pump placed.

And then my shift was over.

I came back the next day and my patient was gone. I asked the night nurse, “So what time did he pass?”

“Oh, he didn’t pass. We transferred him to the step-down unit.”

Later in the afternoon I snuck a peak at the step-down unit’s roster. Amazingly, he was still alive.

So can you see that I need to learn to kick ass?

(Plus – the son was yelling at me to not “knock out his dad” with Fentanyl because the rest of the family was on their way. But that’s another story.)

The next time I will know how much to ask for.

I told the night nurse about the events that unfolded during the day, and how we danced around with the opiate dosing and she said to me, “You know what? My first job was in a burn unit. I know how much morphine the human body can take.”

I want to have that kind of self assurance and I think the only way to get it is to continue doing what I’m doing.

Even if I have to clean up poo sometimes.