RC/RN 3

Warning: Traumatically long post ahead. This will teach all of you who asked when the next installment would be. Be careful what you wish for.


I was in the middle of a really bad work run. No matter how positive I tried to stay, it seemed like anything that could go wrong was. Bad days can happen to anyone in any field, but I was a couple of months into the abyss and it was really starting to take its toll on me. And it wasn't just one patient or one situation - it was everything all combined.


We had a teenage gangbanger that had been on the unit for almost nine months. That's a ridiculously long time to be in the ICU. He had finally been stable enough to go a med/surg floor, where he spent many more weeks. To say this kid was a pain in the ass is the understatement of the year. He refused his meds (except the narcotics), he referred to all of us simply as "bitch" and he had an out of control girlfriend who didn't mind chasing you down in other patient's rooms to scream about every single aspect of his care. For a while we had to keep a surgical mask on him because he would spit at anyone who came into his room. When we transferred him to the regular floor we all wanted to throw a party. But when he went home we were, in spite of ourselves, really happy for him. Maybe we were just happy for ourselves. A year is a long time to be in the hospital. For all of us.


He was home less than 24 hours when the rival gang came back to finish him off. Two point blank bullets in the head later he was right back where he started. He died on my shift. On my watch. The shooter was the girlfriend's brother. He made our patient watch while he killed his own sister. And then he shot him. It wasn't hard. Paraplegics don't move so fast.


Then an attending surgeon wrote an order for a procedure that was unclear enough that I checked it out with one of his residents before I carried it out. We both interpreted in the same way and I went ahead. Needless to say, what he wrote was not what he meant and he went off on the both of us. I mean went off. His head didn't swivel and he didn't spew green bile, but it was close. This was followed by a nerve wracking week to see if the patient suffered any ill effects from the procedure. Thank god he didn't, but the resident and I did. I'm sure we both still have pieces of that attending's shoe in our lower intestinal tracts. Leather, I believe. Italian.


We were also being inundated by patients with seriously communicable diseases. A large percentage of our population had Hepatitis C, which you cannot be immunized against. A fair amount were HIV+. And on any given day, at least one of my two patients was an isolation patient. There are many different reasons for this, but the big one is MRSA (Methicillin-resistant Staphylococcus aureus). This is the staph infection that is such a problem in hospitals world-wide, but it is by no means the only problem out there. Lots of these "hospital bugs" were lethal when they got their hooks into someone, so we had to be very careful, both for the patients and ourselves.


Each of the rooms had an isolation cart by the glass door. Before you went into the room you had to put on a mask, gloves, a surgical cap and a lovely yellow paper gown, which tied behind your back. When you came out you would wait until the last possible second to take it all off and throw it into the trash can right inside the door. Then you would scrub violently with soap and hot water, finishing (if you were paranoid) with antibacterial gel. Everything in the room itself was considered contaminated. This whole routine was tolerable if your patient was either a) calm or b) stable. It was when they weren't that problems arose.



I had one gal who was on her call light every couple of minutes. Her anxiety level was perpetually off the scales. Quite simply, she didn't want to be left alone for a minute. She was another long-timer, and somehow I ended up with her a lot. She had a trach, so she couldn't talk. She'd hit her light and when you went to the door she'd motion you in. I'd stand in the doorway and ask if there was anything in particular she wanted. Violent head shaking no. Sixty seconds later, all suited up, I'd go in and she'd write me a note that she wanted pain meds. I'd take off all my gear and go get her the meds. Suit back up and go in. Which med is that? she'd write. I'd tell her. I don't like that one, she wrote. I want another one. Take off all the gear and head out to page the resident and pass this on. Waited for call back and her light would go off again. Stood in the doorway and asked if there was anything in particular she wanted. Told her I was waiting for a call back from the resident. Violent head shaking and beckoning me into the room. Sixty seconds later, all suited up, I'd go in and she'd write me a note saying she'd changed her mind and she really just wanted her anxiety med instead. I'd take off all my gear and go get her anxiety med. Then I'd put it all back on and go in to give it to her. About this time the resident would return my page, but I'd be in the isolation room unable to pick up the phone to tell them that I was about to murder their patient, and could they be a dear and write me some orders for that. We did some variation on this dance every few minutes for twelve hours straight.


People in isolation are also, for some obscure reason, more likely than the "typical" patient to pull out central lines and be shooting blood everywhere while you race to get suited up before they bleed out. Jugulars and subclavians gush like big dogs. It's like some demonic obstacle course where you try to staunch the bleeding while simultaneously dodging it and with your third hand attempting to tie your gown which you left open when you ran into the room in a panic. Add in perpetually cracked and bleeding hands (read: susceptible to infection) from all that washing and it's a situation ripe for worry.


It was during this period of time that I got a particular song stuck in my head. I know I've mentioned this before, but it bears repeating. I could not shake this song. It wouldn't go away. It became my own personal soundtrack.




There was the time we had a weather related power outage that knocked out all our vents. Even though it was pretty quick, it felt like forever before the emergency generator kicked in. I got floated down to our Burn ICU for a day, which will go down as some of the more horrific twelve hours of my life so far. Burns are not my thing. I stood by a teenage girl's bed, flanked by neurosurgeons and her parents as her brain herniated in front of us. It basically swelled so much that it descended into her spinal column. As the numbers climbed on the monitors all I could hear was her mother saying frantically, "Why is that number going up so fast? Is that bad?" And I had a patient who had lost control of his motorcycle (helmet-less, of course) at high speed and basically turned himself into a tattoed omelet. The waiting room was full of his Hell's Angels buddies, and they let us all know in pretty uncertain terms that if he didn't survive they would expect some answers. (Here's your answer: Wear a damned helmet. Don't drive 90 miles an hour. Don't drink a case of beer before you drive. And get the hell out of my face. Now).




I had gotten to the point where I couldn't ever forget about work. I'd come home and lie awake for hours trying to relax enough to sleep. I don't think I ever actually dreamed about a specific patient, but I'd have these weird, fragmented stress dreams. Night after night. One of my friends told me she could always tell when she had gotten me on the phone after a day of work. She said I didn't even sound like myself. I knew exactly what she meant, because I didn't feel like myself either. I've had some wild fantasies in my life, but telling a furious Hell's Angel to fuck off was not one of them. Who was that (stupid) nurse with cojones the size of watermelons? Because it couldn't have really been me. I'm a coward by nature. A coward with a very, very big mouth.


But even all of those things weren't enough to push me totally over the edge. It was going to take something really special for that.


It was going to take the neuro patient from hell.


This poor guy had had a massive head bleed. Unfortunately, he was behind the wheel at the time and proceeded to drive his car off of a small bridge. Normally it would have been a toss-up as to whether he was a neuro patient or a trauma patient, but since the Neuro ICU was at capacity, it was a moot point. He came to us. By the time I took over he was critically unstable. He was intubated. He had a central line and a femoral arterial line. He had two tubes going into the ventricles on either side of his brain. This is called a ventriculostomy and is used for two things - to monitor the intracranial pressure (ICP) and to drain cerobrospinal fluid (CSF) off of the brain. Part of the set-up is the tubing and part is the drainage system, meticulously calibrated to drain off exactly the right amount of CSF. One of these ventrics is bad news. Two is above and beyond the call of bad.


His condition continued to decline. He had at least ten drips going. His ICP was going up and his blood pressure was going down. He was not breathing at all on his own and was totally dependent on the vent. Because he wasn't on the neurosurg floor the docs were having to come to us for all his treatment. So when a bed became available on their unit they jumped on it. Next thing I knew my charge nurse was telling me to call report to the neuro ICU.


I balked. Big time. I was afraid breathing too hard in his room was going to send him over the edge, much less moving him and all of his equipment down a couple of floors. My concerns were duly noted and summarily dismissed. The neuro guys wanted him on their own unit. We had a helicopter flying in with a trauma and we needed the bed. Balking is a lot more satisfying when you get what you want.


So I got him ready to move. Big ICU bed. IV drips on pole (with the tubing attached to his central line in his subclavian). Ventilator (with the endotracheal tube in his airway). Two additional poles that had the ventric set-ups on them (each with tubing that attached into his brain). Arterial monitoring system (with the tubing going into his femoral). A transport monitor so I could keep an eye on his vital signs during the trip. The big red crash suitcase, in case he took a dive during the move. I enlisted the respiratory therapist to help with the vent. I got an aide to help maneuver us to the elevator. And away we went, like a herd of really slow turtles.


We were just off our unit, in our lockdown hallway, when his vent failed. It made a really impressive noise and shut down. I've always thought that nurses had the worst mouths in the hospital, but that RT made me look like a slacker. She cussed non-stop while she bagged him and I pushed the bed at breakneck speed back to where we had started from. We waited while the vent was swapped out for a functional one. Take two.


This time we made it to the elevator without incident. Our teaching hospital was not new and the elevators were on the tight side. By the time we fit in a bed, a vent, three poles and two people, there wasn't an inch left to spare. I was in the back of the elevator, squeezed into the wall. The RT was next to the vent pressed into a corner. I was just congratulating myself on having the transport monitor facing toward me so I could see it when the elevator door started closing.


And snagged one of the ventric tubes and got it caught in the door. The RT and I watched in horror as the line got more and more taut and we both simultaneously flung ourselves at it. She ended up taco shelled across the top of her vent. I ended up crawling up my patient's bed (seriously - sometimes unconscious is good) until my feet were right next to his face. And we still couldn't reach it. One of the anesthesia residents was passing in front of the elevator and, alerted by my professional shriek, stuck her hand in and stopped the doors from closing. Without a word she unsnagged the tubing and put it safely back inside the elevator. Later she told me that she had thought she was having a bad day, but reconsidered after that.


We delivered our patient to the neuro ICU without further incident. As we signed all the safety checks and transfer paperwork I felt very grateful that it was done and I went back to my unit thanking my lucky stars it hadn't been worse. I don't remember anything else about that day until about eight hours later, when the medical director of the neuro unit flew onto our unit madder than hell. Next thing I knew he and my boss were standing in front of me with a look on their faces that I knew well, having watched residents get handed their shorts on a daily basis. I was about to receive another Italian loafer enema.


The medical director was waving a paper chart in the air in front of me and demanding to know why nothing had been charted. Hour after hour of columns for vital signs lay empty. How dare I call myself a critical care nurse, had I gotten my degree from a convenience store, and so on and so on. As he shook it two inches from my face I got a good look at the chart up close. And then I sat back to listen to his rant.


Finally, when he exhausted himself, he asked me in an extremely condescending tone why in the world the last time this patient had his vitals charted was at ten than morning. And I'd be lying if I said I wasn't being a flat out bitch when I replied


I couldn't tell you, because I transferred him to your unit at ten this morning. As a matter of fact, if you'll take a look at the chart, all those neat columns of vitals prior to ten this morning have my signature on them.


He turned a shade of purple that made me think he should up his blood pressure meds and stormed off the unit. Not a single word of apology. And as I watched the door swing slowly shut behind him all I could think was


I've had enough.

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)

RC/RN

There have been some questions lately about my nursing career and I thought now would be just as good a time as any to answer them. How did I start? How long have I been in the ER? And, maybe most provocatively, what is it that I like about nursing and that keeps me in it? I'm going to try to explain the whole tangled mess. Bear with me. This is going to take a while.





The whole time I was in nursing school I knew two things - I wanted to work in the ER and I wanted to be where the helicopters landed.


This is the story of how I got both, just not at the same time.


When you grow up in an urban area you take it for granted that there are hospitals everywhere. World class hospitals. If you get hurt or sick you go to one of them. Simple. In the Midwest it's not that simple. So much of the area is rural and the hospitals, while not exactly hard to come by, are not usually going to be where you find a neurosurgeon or a burn unit. If you get hurt or sick in most of these places they fly you out to where those specialists are.



And that's a Level One Trauma Center. Simply put, this means that there is 24 hour medical coverage from a wide variety of specialists, including a comprehensive trauma team. Not coincidentally, these also tend to be teaching hospitals, almost always associated with major universities. There are various trauma designations. Level One is the gold standard. It's the end of the road, so to speak. It's where nothing is too critical, too catastrophic, too unusual to be treated. It's where the helicopters land.


I knew exactly the hospital I wanted to be at. It was the hospital I had fantasized about since the day I had gotten up the nerve to apply to nursing school. The problem was getting the in the door.


Toward the end of my last semester of school I "shadowed" for a day in the ER at this hospital. Shadowing is a really good idea. You get to follow a nurse around and really see what the unit is like, without the pressure of providing any medical care. You are only there to observe, nothing else. I had a great experience, other than the fact that I felt like Naive Nelly barely ten minutes in. I lost count of how many times I thought (or said) "Oh, my god. Is this for real?" over the course of the six hours I was there. And like a good adrenaline junkie rising to the lure of a caffeinated piece of bait - I was hooked.


This hospital had a program designed to train new grads in different areas of critical care nursing - ER, and Burn, Peds ("peeds"), Neonatal, Medical, Surgical, Neuro and Cardiac Intensive Care Units. The idea was that you would go to the unit that you were the most interested in and commit to a two year contract. In return the hospital would pay a (very) generous sign-on bonus and, for the next twenty four months, train you to within an inch of your life. You would receive every certification you could possibly want or need - all on the hospital's dime. Competition for spots in this program was tight, and they absolutely used that to their advantage .


But here was the problem. My nursing program had a December graduation. And someone had slipped up and all of the ER new grad spots for the year had been filled with the May graduating class. Every other area was, of course, still open. I met with a very nice HR woman who asked me a bunch of questions about what interested me and then suggested I apply for a spot in the Surgical ICU. She explained that this was not only a trauma ICU, but also took care of patients from every surgical specialty, so was quite varied in the patient population. I said I wanted ER. She said I should think about SI (as they called it). She even persuaded me to tour the unit with her, and even though I thought it looked fascinating, I left the interview disgruntled and completely unconvinced.


My best friend in Nursing School, who was a major reason I survived a program designed to stomp the life right out of you, had always wanted to be an ICU nurse. I, of course, wanted to be an ER nurse. We spent hours, in the blissful ignorance that is so prevalent in students, debating the pros and cons of each. We tried in vain, wanting badly to work together when we graduated, to sway the other to our point of view. It never worked. I had badgered her relentlessly to get her to apply at "my" hospital, as I thought of it, but it would have been an unmanageable commute for her. Against my will I was in this alone. And to make it worse they were trying to talk me into trying out for an ICU job - a compulsive, no excitement, anal, chart keeping, med passing, boring ICU job.


I felt a little sick to my stomach walking to the parking lot, the feeling you get when you have built something up so big and realize that it simply isn't going to happen. My brain was bouncing around like a tennis ball - whup whup whup - as I mentally fumbled with a Plan B. As I reached my car I realized that my tennis ball whup whup whup was getting louder, and I looked up to see a helicopter lazily landing on the roof of the building I had just walked out of.


And as the engine cut out and the blades slowed down, I realized exactly what my Plan B was going to be.


To Be Continued...