Wednesday, January 16, 2008

RC/RN 2


Basically speaking, I picked the hospital I wanted over the exact job I wanted. I applied for the Surgical ICU position, and then spent three weeks jumping through one hoop after another to try to land it. As badly as I had wanted ER before, I now wanted this with an intensity that kind of scared me. I looked at it as invaluable experience, particularly in trauma, and if at some point down the road I could request a transfer to some other (ahem) unit...this was one hell of a stepping stone.


Three interviews, four references and a hotseat Q&A later ("Take a look at all these lab values. Which three are critical and what exactly should you do about them? And in what order? And why?"), I had pretty much figured the one position available had gone to someone else. On Christmas Eve day I got the phone call proving me wrong. It may have been the best Christmas of my life up to that point. To make it even sweeter they let me pick my start date, so I had the prospect of the whole month of January off. After the hell that was nursing school, I was looking forward to a month of normal life.


Now let me make perfectly clear that I've had moments of nervousness in my life. I've had times where I was almost paralyzed with fright. But I've never (in a non-health related instance) felt the fear I felt walking on to that unit for the first time as a graduate nurse. It was head between your knees, waves of nausea, spots in front of your eyes panic. I made a mental bet with myself that I could get through an entire twelve hour shift without killing someone. There was a part of me that was detached enough to be amused by this, figuring it was all beginner's jitters. Luckily, that amused and detached part didn't realize that this particular fear had just become a permanent fixture on my psyche.



And to add to the fun, I still had to take my State Boards a month down the road. No pressure with those, though. No pass, no job. No prob. Boards deserve their very own post in their arbitrary hellishness, but I'll just hit the highlights. Our nursing program was what they call a bi-level program, which meant that at the end of our first year we took LPN boards. You had to pass those to stay in the nursing program. Then, after you graduated you took your RN boards for your license. I thought the pressure of the LPN year was bad enough but it was nothing compared to this. The way the test is given doesn't help. It's a computer generated interactive test. You have to answer enough questions right to get to a high enough level, then you have to answer enough questions right to stay at that level. If you answer a question wrong it bumps you back down a level and then you have to be right a certain number of times in a row to get back to where you had just been. To say it sucks the big one is to damn it with faint praise.


The minimum number of questions you could take was 75. The maximum was 225. It gave you as many questions as you needed to prove competency, but if you hadn't proved it by 225 you failed. I took the test with three friends from my class and we all took 75 questions. We were hoping this would happen, so before I hit submit on question 75 I held my breath and prayed to the patron saint of people who should have stayed in television production. The screen went dark and told me to have a nice day. Fat chance. It was five minutes before my knees stopped shaking enough to walk out of the room. And despite all of my predictions of how I had been so inept that they had failed me with the minimum number of questions, I passed. We all did. Life was good.


My experience on SI was going well, also. I did a twelve week orientation and then took on my own patients. That was another scary day, but the support from the other nurses was phenomenal. My preceptor looked me in the eye, told me I could do it and kicked me out of the nest. And, to my amazement, I flew. Zig-zaggy and shell-shocked, but airborne.


To give an idea of our patient population, here's something one of the hospital administrators told us sometime during my second year there. Our unit had the highest acuity patients in the entire hospital. Our hospital had the highest acuity patients in the entire two state area it was in. This helped explain why I had discovered that adrenaline really does have a taste (metallic, like blood) and why the top of my head permanently felt like it was going to pop off.


We took care of patients immediately after coronary bypass surgery. We handled the liver transplants. We had patients from every surgical specialty in the hospital, including the neurological unit overflow. And then, of course, there were the traumas. Motorcyclists who hit concrete pylons at a hundred miles an hour. People who tried to commit suicide by jumping in front of buses. Point blank gunshot wounds to the head. People who had jumped three floors out of a burning building. Any variation on a vehicular accident you can imagine. If you define "life support" as being on a ventilator (and most people do), at least half of our patients at any given time were on life support.















The patients were a story unto themselves. Murderers. Gangbangers. Child molesters. Wife beaters. I learned more about human nature in that job than I want to think about. The Film Geek still remembers how I would watch the 11 pm news after a day at work to find out exactly why my patient was in the hospital. More than once my skin crawled when I found out what had happened immediately before they came to our fine establishment. And to think that I had been in a small enclosed space with them alone. A lot of those people were seriously jacked up.



Take your garden variety gangbanger, for example. Used to be if they wanted to kill someone they'd shoot them in the head. Several times if necessary. Well, it seems that that isn't good enough anymore. Too fast. Relatively painless. The current thinking is to shoot them point blank in the abdomen. Why, you ask? I'm going to tell you. Consider yourselves warned. Because, gentle readers, if you shoot someone in the gut you're going to involve their intestines. It's a given. And what that means is that they will then have fecal matter scattered all through their abdomen. Which means that, in spite of the best medical care possible, and at ungodly expense, they will probably develop a horrendous infection and, after a colostomy and months in the hospital on a vent will die from sepsis. Slowly and horribly rotting from the inside out. As one fine upstanding citizen explained to me, "It's funny, bitch. He's got shit all on his insides and a bag on his stomach. Don't you think that's some funny shit?" and then cackled at his own wordplay. Shit. Get it? Right.


The best illustration of the unit I can give is this ICU monitor. All of our patients were on the monitor 24/7. One of the first things I always did was to familiarize the family with the monitor, since it seems to be second nature to watch it constantly and it makes more sense when you know what you're looking at. I told them what everything meant and what normal limits were. This way when it alarmed (which was often) they wouldn't panic every time.


Let's take a stroll through the monitor.

The first green number (78) is the heart rate. The pattern is the heart rhythm. This comes from the electrodes on the patients chest.


The red line (129/58) is (obviously) the blood pressure. But...the red color indicates it's an arterial blood pressure, not a cuff pressure. Arterial lines are basically like IV's, just in an artery instead of a vein and you don't put anything in these lines. If someone is on a vent you need frequent arterial blood gasses which hurt like a son of a bitch, so they put these lines in for monitoring. Other than the fact that you can bleed to death in about three minutes if one gets dislodged, they're pretty handy.


The yellow number (9) is a Central Venous Pressure, which is an invasive monitoring of the pressure in the right atrium of the heart. Basically, there's a probe physically in the heart.


The light blue ICP line (19) is Intracranial pressure. Basically, there's a probe physically in the brain.


The purple 100 is the percentage of oxygen the patient is getting throughout their body.


And the dark blue 12 is how many times a minute they're breathing.


We always had two patients at a time. We charted vital signs every hour and did a full body assessment every four hours. Most of our patients had at least one triple IV line and quite a few had two. Each patient was receiving a minimum of three kinds of IV meds, not counting fluids. It was not uncommon to have a patient getting fifteen IV meds, with half of them being incompatible with the others and having to be spaced perfectly. If a patient was on a vent there was a whole other set of vitals to chart and the vent itself to monitor. Patients on vents were always restrained to keep them from pulling out their airway and sedated to within an inch of their lives. These both had to be charted and scrupulously monitored. We drew all of our own blood for labs. We did almost all of the surgical dressings. We were given perimeters on a lot of the drugs we gave and we decided the dosage. The worst thing was when you had to "travel", which meant taking your patient (and their vent and their drips and the crash suitcase) to CT or MRI. And, because most of our patients were unconscious, we had to physically reposition them every two hours around the clock. We didn't sit a lot. I wore a pedometer to work one day out of curiosity to see if I reached the 10,000 steps a day that the Heart Association recommends. At the end of the day (which had been uncharacteristically slow) I was at 17,000 steps. I never wore it again.


The medical teams rounded every morning and wrote orders. We spent the day carrying out these orders. By the time we were thinking of being caught up they rounded again and wrote different orders. There was real animosity between the day and night shifts, so if you left even the tiniest thing undone you'd hear about it. The days flew by. It was not unusual to look at the clock in horror at all the things you still had to do in the half hour left of your shift and realize that you had neither eaten nor peed in twelve hours.


But I wouldn't trade the experience for anything. I saw some of the most incredible things imaginable. We were cutting edge and it was electrifying. Our unit had a little bit of an ego issue, frankly. We weren't allowed to call a code, since we were one of the units responding to codes on other floors, and it would look bad. But our little "code" for a code was to call Anesthesia (usually for an emergent intubation). If you heard "Anesthesia Stat SICU" overhead, you knew that all hell was breaking loose. And between us, hell breaking loose was a daily happening.


In an unexpected way I got a lot of ER experience, too. ER would basically plug up as much of the bleeding as they could and race them up to us as fast as possible, leaving a current of blood behind them. Not only did the helicopters land there, but often we ourselves took the people off of them and straight to our unit.


It was the most intense experience of my entire life, but I was burning out big time toward my two year anniversary. I had gotten all the adrenaline inducing adventures I could have ever wanted - and then some. I had literally been up to my ankles in blood and brains. I had seen so many people die that I was almost immune to it. I'd seen one too many grieving parents for my taste. Three twelve hour shifts a week were slowly turning me into someone I didn't know anymore. I had basically come to the conclusion that you could sum up every shift this way: for twelve hours a patient would actively try to die on me and I would do my best to prevent it. The final kicker was that my boss wouldn't let any of us transfer to other units, but by that point I didn't think I wanted to anyway. I had hit trauma overload.


And all it was going to take was one more thing to push me completely over the edge.


To Be Continued...
(and good lord am I sorry this is so long)

25 comments:

Corey~living and loving said...

All I can muster is a big fat "W
OW!!!!!!" I couldn't imagine that kind of pressure.

Stacie said...

Ahh, the monitors. I know them all too well, although the colors are slightly different. You are right when you say they are mesmorizing--especially in the beginning. Now I just go by the lovely tones they emit! If it isn't the right tone, then I don't look anymore. I suppose most of your patients weren't around long enough to get to that point?

That place sounds incredible. I am not sure I would be able to handle all the pressure or all of that death. I can see how it would burn you out. You must be incredibly strong to stay in that environment for as long as you did!

Waiting anxiously for the next installment of RC/RN...

Mya said...

Exciting stuff RC! Great to have the monitors translated - I often wonder when I'm watching House!

The point-blank abdomen shooting things is...well, just evil. You get to see and hear all things in a job like yours, I suppose, the best...and the worst. I've said it before, and I'll say it again - I don't know how you do it! Respect!

Mya x

Thalia's Child said...

ooh! My heart rate is all elevated now! Fantastic post, and I didn't even notice the length until you apologized (of course, my posts are always long, so maybe that's why.)

Dumdad said...

Fascinating (even if ghastly at times) and educational.

Potty Mummy said...

Wow. I already had respect for you guys, but now... Thanks for the education (I may print off that bit about the monitors!)

PixelPi said...

We very rarely transcribe death reports in the ED, because we get them to SIUC/MICU from the trauma bay the wheels on the gurney haven't stopped til it hits the elevator doors. Nobody dies in the ED if we can help it. As callous as it sounds, death in the ED is sort of NIMBY. You want them to die on someone else's unit.

I don't know how you handled SICU as long as you did. My brother-in-law was in SICU for 3 months (artificial coma with ARDS and peritonitis), and frankly, that place scared the heck out of me.

Please send your phone number STAT so that when I hit a pylon at 100 mph, Mr. Pi can call you to come fix it.

laurie said...

thank god for you and other intelligent, caring, capable adrenaline junkies who want to do this job.

that's all i can say.

looking forward to tomorrow, and your tipping point...

Jen said...

Arrrgh! Friggin' blogger, ate my comment. And it was a nice comment, too.

To recap: You are awesome for doing what you do, as are all the people who work in jobs that deal with us, the usually ignorant public.

Oh, and I knew about the abdoment thing, too. Sometimes working in news and covering ugly stories, you learn a bit more than you really want to. It's why I quit.

auntie barbie said...

Yours is truly a labor of love, and I admire you and others like you who do this kind of work.
How do you not become emotionally attached to your patients and their families?

Eileen said...

This post was amazing to me on so many levels. WOW! Talk about stress, 24/7. How do you leave it at work, when you go home. It must be so difficult to unwind/let go when your shift is over. What pressure!

Thank God for people like you, who are willing to give so much of yourself to take care of other people. I can see why burn out is a serious problem, it is just a never ending series of major medical issues. Seems like you get one person stable and in comes another, and another.

It takes a very strong, compassionate person to do what you do. I am in awe of you.

Looking forward to the next installment. Completely compelling.

XOXOXO

Jo Beaufoix said...

RC, blimey, you are amazing. I mean, I knew what you did was hard, but this has really opened my eyes. There really are some evil people out there aren't there. And then there are people like you.
Can't wait till the next installment.
Fantastic.

Lisa said...

On the edge of my seat...

Diana said...

I'm having flash backs! I actually loved the ICU but our hospital was not a level 1 trauma center but had its emphasis on medical issues (our helicopters flew in crashing non-GSW sepsis patients and malaria and that sort of thing), so our ICU patients as a rule lived (so much nicer than death after death, isn't it?).

I love that you spent time educating your families on the monitors (and, I'm guessing the drips and drugs and tubes and all the rest of the controlled horror that is the ICU to the outsider).

More! More!

Kaycie said...

Sweetheart, I have tears in my eyes. I don't know how you did it. I had two people in ICU after bypass surgeries the week of my birthday. One died, one didn't. Just being on the periphery of it was way, way too much for me.

I am looking forward to the rest of the story (I feel like Paul Harvey).

-Ann said...

Don't apologise - it's a fascinating story, well-told. Plus, I've got a special place in my heart for nurses. Not only is my mom a nurse, my dad's had two heart surgeries (a valve repair with a double bypass since they were in the neighbourhood and then, 3 months later a valve replacement because the repair didn't take). The decision of where to have his second surgery was based on the nursing staff - the hospital he went to had 1-to-1 ICU care.

aims said...

Just sitting here thinking of all the lives you have saved - good ones and bad.

Can't think of anything to say - it's overwhelming.

ped crossing said...

My goodness, RC. I don't know how you did it. Does the ER seem calm in comparison?

There is a reason I am uber-nice to my nurses.

Anxiously awaiting the next installment.

Amy said...

It's interesting to read about your perspective. I've spent far too much time in hospitals as one of those family members watching the monitor. I always thought the ICU and ER nurses were the most willing to talk and treat me and my family as human beings. Nursing is not a job I could happily do. Hats off to you.

Akelamalu said...

OH MY GOOD GOD! And I thank him for people like you Correspondent! You and your colleagues deserve a place in heaven.

Swearing Mother said...

Just brilliant.

my two cents said...

Yes, you are amazing!

Sweet Irene said...

That's one heck of a story, RC, and to think that this happens in hospitals around the world every day. That's something we can not even imagine. You look at a nurse and you have no idea what sort of knowledge and nerves she's got to have. It is good that you are writing this all down for us. You must be a very courageous person and full of confidence about your work, otherwise you wouldn't be able to do your job so well. Good for you!

wakeupandsmellthecoffee said...

How can people say bad things about nurses? You are a hero in my book. And I can't wait to read more.

ciara said...

wow...so intriguing and i'm worn out just reading everything you've gone through. woohoo a part 3 :)