15 years ago in my CCU, long before I arrived, a young girl of 12 was admitted with “sudden death.” She was revived before coming to our unit, but was ultimately declared brain dead. She became an organ donor. I don’t know the specifics of her situation.

All I know is that for the last 15 years, her father has delivered a dozen peach-pink roses to the nurses in CCU on the anniversary of his daughter’s death.

The roses showed up yesterday. They’re beautiful.

About a year after starting in ICU, I was expected to take care of post-op open heart patients. I took a class, and I’d already been helping out with them after surgery, but had never been the primary RN. If I’d had my way, I never would have taken them. I was fairly comfortable with being in ICU by that point, but still not really mentally ready to take on the responsibility of recovering fresh open heart patients. The more experienced nurses did that kind of thing! I’d only been at this for a year! Didn’t matter, I had to do it anyway.

My first fresh open heart patient was one that I had admitted on a Saturday. He’d had an emergency cardiac cath and it was determined that he needed some bypass grafting. He was sent to my ICU for monitoring, but it was clear by Sunday that he could have gone to a stepdown unit. He was really very stable, walking around his room and such. But we didn’t need the bed for another patient, and figured he’d be back in a day or so after surgery anyway, so I took care of him all weekend. During that time, I’d say I developed a pretty good rapport with the patient and his wife.

The cardiac surgeon who saw the patient, Dr. A, was fairly new to this particular physician practice that had been established about 10 years prior. As he already had cases scheduled for Monday, he put the patient on the surgery schedule for one of his partners, Dr. Z, to do first thing Monday morning. All day Sunday I did pre-op teaching and answered questions.

Monday came, and I was very nervous about taking “my first heart.” I had a preceptor with me, of course, so at least I knew I wouldn’t do anything wrong. As I walked in at 7:30am, my patient was being wheeled off to surgery. The family was very emotional and it was a touching send-off. I had another patient at that time, so I busied myself with taking care of them, thinking that I had til about noon until “the heart” came back.

I was wrong. The heart came back at 8am.

Apparently, Dr. A didn’t inform Dr. Z that he had a surgery that morning. When Dr. Z found out, he was very angry. Dr. Z had had Monday morning office hours since the dawn of time, but no one thought that it was odd that there was a surgery scheduled for him. So the patient arrived to the OR that morning, had begun to be prepped, but no surgeon showed up. Dr. Z was the kind of doctor who, when consulting on a patient who needed open heart surgery, gave the patient a whole big informative speech on what that entailed, why the surgery was necessary, alternatives to the surgery, etc. Never have I come across another cardiac surgeon so involved in teaching and preparing patients.

To say that Dr. Z was angry with the situation wholly pales to the anger of the patient and family. Dr. A was able to come by and apologize for the mix-up, but that did very little to allay the family’s intense anger. I could understand their feelings – they were sending their husband/father/brother off to have his chest sawed open and his heart stopped – would it be too much to ask for a surgeon to show up at the appointed time?? It wasn’t like the surgeon was sick, or an emergency had come up… It’s just that no one showed up to do what could be the most stressful surgery in someone’s life. Questioning the competency of a hospital that could do such a thing would surely cross one’s mind….

And boy did it cross theirs. Although I had taken care of the patient all weekend, although I had a good rapport with them before surgery, even I was not immune to the many comments that were hurled at anyone who dared enter the room. That family made it VERY clear that they were mad at anyone and everyone who worked for that hospital, even down to glaring at the housekeeper. At one point, I had to go in the room to test my patient’s blood sugar, and I still count that as one of the hardest things I have ever had to do.

As soon as I walked into the room, 6 sets of eyes watched my every move. I meekly told the patient that I would be checking his blood sugar, and as soon as the words came out, I heard one of the family members tell another that he wondered if they could sue for such incompetence. Another wondered aloud if it was too late to change hospitals, since we “clearly did not have our act together here.” I know they were just expressing deep frustration, but it made me feel about 3 inches tall. Today I’m quite confident that I would be able to handle the situation and would certainly talk to the family and patient, but back then – I was pretty much still a new nurse, only having graduated a year and a half prior. I was quite easily cowed by confrontational family members. I didn’t want to make the situation worse, so I said nothing. At one point, I looked at my patient and he looked back at me with a mixture of sadness, anger, frustration and maybe even a little embarrassment for his family’s behavior in his eyes. They were definitely the ones raising hackles – the patient hadn’t said very much at all.

Lunchtime came and went and Dr. Z came to see the patient. The family had only somewhat calmed down, but after talking to the doctor decided to go ahead with the surgery that day. I don’t know what it was that Dr. Z said, but it seemed to go a long way. The tension in the room was cut in half and I was actually able to look some of them in the eye without being glared into a blubbering mass of shame.

The patient went to surgery and came back about 4 hours later. I was still incredibly nervous about this being my first open heart patient, and my nerves were also still a little extra-frayed by the morning’s events. Nevertheless, my preceptor was absolutely wonderful and we got the patient settled quickly. After that, it was time to call the family into the room to explain all of the various tubes, wires, and machines that were connected to the patient. I love teaching, so I knew this would be my favorite part under normal circumstances, but this time I was dreading it. My preceptor asked if I wanted her to do it, but I said I would go ahead and talk to them as long as she stayed in the room. I called for them and nervously waited for everyone to file into the room. I gave them a few minutes to look the patient over and then told them that his surgery went very well, he was very stable at that point, and everything was going as well as it could.

The remaining tension and anger almost visibly drained from their faces and I was able to get through my little teaching session not feeling as though I was standing in front of a firing squad. After all of their questions had been answered, everyone but the patient’s wife left the room. She came up to my preceptor and I and apologized for all of the harsh words and comments from earlier in the day. I was immensely relieved by this – I mean, who wants to go home feeling as though they were practically hated by their patient and family?

I had a few days off after that, so I never saw the patient again. And although I took several more hearts at that job, I have never had the desire to do them at my current job and have thus far been able to go about my career without having to do that particular task.

Oh yeah – and did I mention that Joint Commission was there that day, surveying the hospital? And that they were in our unit, witnessing the entire show? Could it have possibly been more stressful?

We had a patient for 6 months. Yep, 6 months. As one doctor said, “If you can’t fix whatever’s wrong with a 6 month stay in ICU, you aren’t likely to ever fix it.” Indeed. This patient knocked on death’s door several times, and even entered once or twice, only to be brought back to earth for more bedrest and bedsores.

We were really confused as to why the family would want to keep him alive in this state – they’d brought in pictures of him and he was really a very vibrant and almost regal man. Now he sits in a bed every day, breathing through a hole in his neck, being fed through a tube in his stomach. His bed was pretty nifty – it would transform into a chair position at the touch of a few buttons. We’d try to put him in this position for a few hours every day.

He’d stopped trying to communicate with us months ago. Well, he was already unable to talk because of the trach and ventilator, but he wouldn’t even look at us. He wouldn’t respond to his family either. I had the feeling that he was really in there, but was just mad. At life, at us, at his family. At his situation. But the medical system is what it is, and when he became “unresponsive,” many tests were done – CT’s, MRI’s. He was put on antidepressants, but after a couple of months was taken off because there was absolutely no change in his affect.

We carried on taking care of him. We talked to him, turned him, cleaned him – all with no response. His eyes would open, but he wouldn’t look at anyone, didn’t seem to focus on anything in particular. It was like the human-ness had just dissipated from his body. He almost became just a body that we took care of. His family would visit every day, for several hours, inquiring about his condition, asking countless questions. They’d try so hard to get to him, but he never responded. Doctors would come and go, day in and day out, and they’d try to get him to respond. He’d only rarely open his eyes. When he did, it was just to stare off into some faraway place.

This went on for months. Gradually, his labs improved. His condition overall improved and somewhat stabilized. His bedsores started healing. It soon became clear that the only thing holding him back was, well, him. We tried to tell him this, but as usual, we were only met with a blank stare, if he even bothered to open his eyes at all. I still felt that he was “in” there.

Last week, he was sitting in the bed, which was in chair position, and one of his doctors stopped by. She suggested getting him up into a chair that had wheels and she wanted me to take him outside. It was a sunny, lovely day, but I admit – I was quite sure it would be lost on him. He hadn’t been outside, breathing fresh air, for over 6 months. I was very resistant to the idea – it’s a lot of work, and I didn’t even think it would help.

But the doctor went in to talk to him and his wife, and although his face never changed when she asked if he wanted to go outside, his wife got used to the idea immediately. From getting to know her over months, I knew she wouldn’t let it go until I followed the “doctor’s orders.” Great.

I rounded up some nurses and got him into the chair. We disconnected his monitoring equipment (with the doctor’s OK) and loaded up an oxygen tank. Then we went outside.

As I said, it was a lovely day. We pushed him a few yards from the hospital, to a safe place in the shade. There was a light breeze. There were squirrels and birds. My patient had no response to this change in environment. None whatsoever. I wasn’t surprised in the least. His wife and I started talking about being outside excitedly. We started pointing out birds and trees. I felt absoutely stupid, trying to get this man who seemed so mentally and emotionally detached, who had been through some unimaginable stuff, excited about being outside.

His wife and I started talking to each other, just the usual small talk, when I looked down and noticed that my patient’s eyes were open. Well, that’s a step in the right direction at least. His wife decided to run with it – she started speaking to him in their language. Just then, a really wonderful breeze blew by, a bird sang – and he opened his eyes a little wider. He seemed to start focusing. He started moving his eyes – he was looking around! His wife was really excited, and started talking to him in that same language – he eventually looked at her, and then reached his hand out to grab hers. I doubt that I could fully explain in words the look on her face when he did that. It was the first time in months that he had communicated in any way to her.

We stayed there, outside in the sun and breeze, for awhile longer. My patient’s wife continued to talk to him in words that I could not understand. Unbelievably, to my great and utter shock, he started talking back. By this point in his hospital stay, we had been capping his trach for a few hours at a time. We would tell him repeatedly that he could talk, but he never tried – until that day. All he could manage was a whisper, and his wife was beside herself. I asked her what he’d said and she replied, “He said he wants to go home.” He managed to whisper that same phrase several more times, never uttering anything else.

After about 15 minutes, I noticed that he was starting to get a bit droopy, so we wheeled him back in and put him to bed. He fell asleep almost immediately.

After 6 months of caring for this patient, I had almost ceased to see him as human. I figured that he was so depressed he’d never snap out of it. And for all we knew, he may have had some brain damage from all those times that his blood pressure was too low – something that wasn’t showing up on all the scans. After 15 minutes of simply having him outside, he became human again. It was the greatest thing I’d seen in a long time.

My patient was in his 90′s, and his family wanted everything done. He was intubated when his breathing became ineffective. We, as nurses, thought that this was awful. We weren’t prolonging life; we were prolonging death.

My patient spoke only Russian. His daughter spoke mostly Russian, but understood just a little English. After he had been intubated for about 2 weeks, it was time to do a tracheostomy. It was on this day that I took care of him for the very first time.

The consent was signed, the checklist completed, he was ready to go. The OR nurses came up to get him, along with an anesthesiologist who bagged him on the way down.

10 minutes later, they called to tell us that they were coming back. What??? Trachs usually take about an hour. I wondered what went wrong – did his sats drop?? His blood pressure? His sats had been very borderline that day, necessitating us to go up to 100% O2 on the vent. He was a full code, so I was getting a tiny bit nervous about his condition, but what else could we do? He was on the most vent support he could be on. He wasn’t on pressors, but his BP was okay.

Anyway, they brought him back a few minutes later, explaining that his anatomy was “weird” and that the surgeon would not be able to perform the operation. To say that I was livid would be an understatement. In that short amount of time, they could not have done anything invasive to determine that his anatomy was weird, so I concluded that the surgeon could have easily determined this while the patient was still in his room, you know, when he was first consulted. The time it took to get the consent signed, the checklist done, the other paperwork assembled… all wasted.

Anyway. I didn’t have a lot of time to ruminate about that, because after he got back, his blood pressure became very marginal. He wasn’t on pressors, but I really wanted to avoid having to start them. As the day went on, his blood pressure got lower and lower. His daughter was there to see him, and we had a heck of a time explaining to her why the procedure wasn’t done that day. Fortunately, her husband (We’ll call him “Viktor”) was bilingual. He was also about 8 hours away, so I ended up explaining everything to him on the phone, and he explained it to her (we’ll call her “Lia”). Great.

Finally, my patient’s BP was too low not to start pressors. This poor man already looked half dead, and I knew that the end was very near for him. At this point, I normally would have taken the Person Making Decisions aside to explain the situation. Unfortunately in this case, I did not speak the same language as she. I at least wanted to make him a no code – if his heart stopped, I didn’t want to have to code him. I explained this to Viktor, and he asked me point blank, “What do you REALLY think? If this was your father, what would you do?” I replied that I would never have let it get this far, I would never have intubated him, and if I had arrived to find him in this condition, I would extubate and let him go. Hey, he asked.

We went back and forth like this for awhile, me talking to Vik on a phone 8 hours away, and he would call his wife on her cell and talk to her, then call me back with what Lia had said. It wasn’t the best system, but it was working for the time being. We finally agreed to make the patient a no code, but Vik wanted to go further than that – he wanted to convince his wife to stop the madness, as it were, and just let the poor man go.

What ensued was telephonic chaos.

I can’t take the husband’s word for what his wife is saying to carry out such a decision. I just can’t. It isn’t right. Therefore, I needed an interpreter. Our hospital does not happen to have Russian-speaking in-house interpreters (bummer!) but we can use a language line – a phone with two handsets that we use to call a 3rd party number who will translate. I’ve never had to use this before, and I’ve never wanted to. It’s bad enough to serve up distressing news through a 3rd person translating, but over the phone? I know I’d be right there, but the dynamics are really very odd, if you think about it. But I had no choice. I had to get it from HER.

I got the translator on the phone, and I told Lia through her that her father was not doing well at all, and that his BP was getting dangerously low. I had to explain to her that using pressors would be a short-term solution, and that in all honestly, I thought he would die sooner than later. She finally agreed to make him a no code, but did NOT want to extubate and let him go. (Yes, Mia, I’m trying to avoid the word “withdraw” :))

It was really hard doing it this way. She had the receiver up to her ear, and was talking to the translator, but was looking down and crying softly. She never looked at me. As hard as it was, though, it worked fairly well. I got my message across, although I found that I missed using body language and facial expressions to convey what I meant. Maybe she wouldn’t have looked at me if it was just the two of us regardless, but suffice it to say – it was different.

Figuring I just took a step in the right direction, I called Vik back and updated him. He was disappointed that his wife did not tell me to extubate him, as they had agreed upon. He said he wanted to talk to Lia some more. While they were on the phone, a shift change had occurred, and as luck would have it, a Russian speaking student was nearby. Holy Toledo!!

At that point, things went from merely complicated to downright complex.

Vik called me back and told me that Lia had decided to take her father off of the ventilator. For real this time. I asked him if she understood that he would in all likelihood die very quickly. He said that she did.

I thought I could use the student instead of the language line to verify this, but I soon learned that this was a very misguided thought. Being a student, and therefore being somewhat naive (hey, I was there, too), she was not accustomed to telling daughters that their fathers were going to die, and couldn’t we just let that happen peacefully, without ventilators and tubes and wires? I think the student managed to get the point across, but as she did so, I could tell that she was getting a tiny bit emotional, leading me to wonder if she was saying EXACTLY what I was telling her to say. I had no way of knowing if she was “softening the blow,” so to speak. Those words are very hard to say.

So, still feeling skittish about the whole thing, I really wanted an objective person involved. I could tell that Lia was extremely sad and torn and just wanted to do the right thing. So I called the language line back, and had to go through the whole thing over again, asking her if she understood that extubating him would be the end, and that I needed to hear that from her. I felt so incredibly…. stupid. I felt so bad for making her say it AGAIN. Note to self: do not use naive and inexperienced student to translate for such a weighty issue EVER AGAIN. She was so sad, and I felt like the bad guy. Lia’s only request was that I wait for some of her family to arrive before doing it. I agreed.

I then called one of the doctors on the case, and although he knows and trusts me (I think), he understandably wanted to hear from the daugher (as I did) before giving the order. I think I successfully convinced him to just trust me on this one, and to get the specifics from Viktor.

Soon, some of Lia’s family came and they were also blessedly bilingual. I had to go over the whole thing with them, as they were previously led to believe that they might have weeks with the patient, not hours, certainly not minutes! By this time, my poor little patient had no blood pressure that was measurable, but was still breathing and had a pulse. I patiently went over everything again, and said that I was really quite sure that there was absolutely no chance of meaningful recovery. In the past, having this same conversation, I have always had little fringes of doubt when saying this. This time I meant it 100%. I explained that I would give him as much morphine as was necessary to ease his breathing, and then I told her that she was absolutely doing the right thing. She actually seemed to take a lot of comfort in that, for which I was grateful.

So wouldn’t you know it, the time to extubate happened RIGHT at my shift change. I’d been with this woman and her father for 12 hours, and we’d been through quite a lot in that time. To hand the whole situation over to another nurse seemed cruel, and that nurse made sure I knew it :) So I stayed for the extubation. I helped extubate him, and I gave him adequate morphine. Usually, at this point I exit the room so the family can be with the patient, and that’s what I did this time. After a few minutes, I went back in with some more morphine (more to ease their discomfort than his) and they were surrounding his bed, stroking his forehead, whispering things to him. He had been completely unconscious all day, and he remained so, but I told them that it was possible he could hear them. This time I stayed with them at his bedside instead of exiting. After the monitor flat-lined, I turned it off and told them that he was gone. Lia then turned to me and gave me a hug and just sobbed.

I am not a typically touchy feely person, especially with people who are practically strangers, but at that moment I was so relieved. I had been very focused on advocating for the patient, and it’s difficult to do that and help the family come to terms with a painful situation as well. So when she did that, I felt as though I had been successful on both fronts. It was completely worth staying after my shift to be there for that.

This is a very very long post. It details the first 5 hours of a 12 hour shift. Things were especially frustrating on this day.

I had two patients, both of which I had had the day before. Patient 1 is a 300lb. woman in her 40′s with multiple medical problems. By this point, she was on a ventilator in a coma, had a history of spiking temps to 107, was on 70% oxygen with 10 of PEEP (5 is normal) and sats in the low 90′s. We were basically keeping her alive until her grandmother could get there that evening. Patient 2 was a man in his 50′s with an infected toe. He came to us in CCU because his BP in the ER went to 70 one time, which made the docs worry about sepsis. Every vital sign that he had taken in CCU was normal and stable. Prior to admission the day before, he had been independent at home and had a job.

7:45AM: I have 10 medications due for my comatose patient at 8am. Yesterday, I had problems getting one of those meds from pharmacy. Today I check early – it’s not there! I go to the computer and re-order the medication. I mount my patient’s EKG strips and organize my day.

8AM: I check for the med – not there. Okay. I hang/administer the other 9 meds. This takes me 1/2 hour, as the pills need to be crushed and dissolved, other drugs need to be drawn up and pushed slowly, etc. It also takes longer because the stopcock on the patient’s NG tube is cracked and leaking. Got another one and changed it out. Also, the tape on patient’s nose keeping the NG tube in has come off from sweat. I change that after struggling with the old tape – the nurse who put it on didn’t fold over the edges of the tape, so it was all stuck together. I have to be careful tugging at the tape so I don’t pull the tube out of the patient’s nose.

8:30AM: I check for the 10th drug. Not there. I call pharmacy and ask where my drug is… they say that it’s a once a day drug. Yes, I know this. It’s due once a day at 8am. I tell them that this is the 2nd day in a row that the medication has not been available for me when it was due. They say they’ll make a note of it, and they’ll mix it up right now. This is fine, except that the purpose of re-ordering the med in the computer was supposed to take the place of this phone call.

8:35AM: I get the call that nuclear medicine is ready for patient 2. I get the gurney to get the patient on it to go down for this test, after I’ve paged the doc (twice) to get orders for him to go unmonitored (he’s very stable). I do this because I know that the flex nurse that must go with monitored patients is very busy and it will take much longer to arrange for her to come.

8:40AM: Transporter (in record time) is waiting here for my 2nd patient, who has decided that he has to use the urinal right now. I beg the transporter to stay and wait a few minutes – transporters in our hospital are very very busy and in demand. They usually won’t wait more than a minute or so. If you aren’t ready, they leave and you have to call again. This can take up to 30 more minutes. I don’t want my patient to be late for his test, so I tell her it will only be 3 minutes, hoping that he can pee fast.

8:41AM: I check for patient 1′s med in the tube delivery system – I find that the delivery system is not working right now. Great.

8:42AM: I check on patient 2. Still peeing. Transporter still waiting.

8:43AM: I check on patient 2. Done peeing. I quickly unhook him from the EKG leads, BP cuff, O2 sat probe and IV and ask him to move over to the gurney. I am trying to be fast.

8:45AM: I tell the transporter that patient 2 is ready for his test. She asks where the transport sheet is (yes, another sheet to fill out). I hurriedly fill one out and tell a coworker that I am going to the pharmacy to get my medication for patient 1.

8:53AM: I return, distribute 3 other meds to other nurses that the pharmacist has asked me to bring over, then hang my 8AM med one hour late. This means that my 9AM med will be late, which means that my whole morning’s IV meds will be off. Get patient 2′s breakfast off the cart and put it in his room before someone takes the cart back to the kitchen with it still inside.

9:00AM: Patient 1 has an insulin shot due. I check the fridge for insulin – we usually have several bottles of each type of insulin open because people take them into the rooms, someone else needs the insulin and since it isn’t there, assumes that the bottle is empty and opens another bottle. Yesterday, there were two 1/2 filled open bottles of Aspart insulin either on the counter or in the fridge. It can take a week or so to deplete insulin bottles. Right now, there is no Aspart to be found. Re-order Aspart from pharmacy. Patient’s blood sugar is over 300. Oh yeah, tube system still down. Damn. Check with other nurses to see if they’ve used Aspart recently. None have.

9:05AM: Second trip to pharmacy today. Why do I go myself? Well, it’s true that the pharmacy can call transporters. Transporters, as I said, are very busy and it can take 30 minutes for them to bring something over from pharmacy. I’m already feeling behind and don’t want to wait that long, as I might get distracted with other things and forget altogether.

9:07AM: I get to pharmacy. I tell the person helping me that I ordered Aspart insulin and am here to pick it up. She gives me a quizzical look (like I said, we usually have several bottles of each type of insulin around) and asks if I checked the insulin bin in the fridge. This is where I start to lose it a little bit. Yes, I say in a controlled voice. Of course I checked. There isn’t any there.

9:10AM: I give my insulin. Patient 1′s temperature is about 103, and I check the cooling blanket that she’s laying on. Did I mention that she weighs 300 pounds? The blanket is warm. There is no cool/cold water circulating. It might be because the nurse before me didn’t clamp the blanket before putting it under the patient. The patient’s weight will have pushed all the water out and seeing as how she weighs 300 pounds, it’s not going to refill until I take it out.

9:15AM: Patient 2 is back. I get him back into bed and hook him back up to everything (EKG monitor, O2 sat probe, BP cuff, IV) myself, and take his temperature. Get him set up for breakfast. Patient reminds me that he is lactose intolerant, and there is milk on his tray, despite the fact that I entered in TWO places that the patient is lactose intolerant yesterday when I admitted him. Get him juice instead. Give his meds, give his insulin.

9:35AM: I manage to find 2 other nurses to help me roll the patient over so that I can take the blanket out. One of these nurses can’t lift more than 25 pounds due to a recent injury. She’s the one that takes the blanket out. Now free to fill up, we watch it. Nothing. No filling.

9:37AM: Order new blanket and new cooling machine, just in case.

9:40AM: Give rest of 9AM meds. Think back to yesterday when patient 1′s potassium level was low. Realize that I just gave 80mg of Lasix and no one had ordered a chem panel for this patient this morning. Order it myself, draw it up and send it to lab. This takes several more minutes than I had anticipated because the blood flow through the catheter is very sluggish. Thank GOD tube system is now working and I won’t have to have it hand-delivered. I get another nurse to lift up the fat folds on patient 1 so that I can put anti-fungal powder there so she won’t get yeast infections. There is no way that I can lift her pendulous belly, arms, and breasts myself with one arm and put the powder on with the other … I will surely hurt myself. I’m not being mean, I’m being realistic. The little, tiny hole on the top of the powder bottle won’t let any powder through. I stick a needle in it – it’s not clogged. Still, every time I squeeze, only a few faint puffs come out. I get a pair of hemastats and jam them into the hole. Ahhhhh. Much better. Powder everywhere!

10:00AM: Time for patient 2′s pain med. He’s been asking for it for an hour, but it wasn’t due until now. Had no time to call the doc and ask for more frequent dosing. Patient 2 was not in that much distress; he said his toe only hurt when he moved it. I give the med.

10:15AM: MD decides he wants a cat scan of patient 1′s head. I tell him that when we had her laid flat to get the cooling blanket out, she turned a bit purple. He wants me to show him. I put the head of her bed flat again, she turns a not-as-dark shade of bluish. He tells me to get the scan. (You have to be completely flat for several minutes to get a head CT.)

10:30AM: Put in order for CT of the head. Get potassium results back – ACK! K+ level is 2.8. Very low. Start replacing potassium via IV. Check on patient 2, as he has put his light on. He wants the dressing on his toe changed. I take off the band-aid and put another one on it. He asks why I did not clean out the 1cm x 1/2 cm wound. It had been draining, yes, but I didn’t feel as though I had time to sit there and irrigate it. I feel guilty, like I’m neglecting him or something, so I say I’ll be right back.

10:45AM: Return with towels, irrigant, dressings. Take off band aid, irrigate wound with saline, dry it gently with sterile gauze, apply dressing.

11:00AM: I call the CT scanner for patient 1 to set up a time for her scan. They say that they have a patient on the table, but I can start getting her ready and that I should call them before she leaves the unit. I am used to dealing with PM scanner techs, and we have an understanding that when they say get the patient ready, I am going to start assembling several people: 2 Respiratory Therapists (RT’s) – one to bag the patient on the way over, and the other to take the vent to the scanner and get it set up. I need to call the flex nurse (“flex”) to accompany the patient, as she is critically ill and needs monitoring. I cannot go myself because I have another patient. I get a portable monitor and the flex nurse shows up. The flex and I transfer all of the monitoring boxes from the bedside monitor to the portable. I stop the patient’s tube feeding and flush the tube. We disconnect other various tubes and wires.

We call transporter to come and help push the bed – they say that they’re on the way. The RT’s were eating lunch, but came up anyway to take this patient to CT. I call the CT scanner and say that the patient will be over just as soon as transport gets there.

The tech says that there is still a patient on the table. How much longer, I ask? I have coordinated 3 other people (with a 4th on the way) because you said to get her ready. The tech says it’ll be another 25 minutes. 25 MINUTES??? I have to tell 4 other people that they have to wait another 25 minutes, especially when 2 have left their lunches to come as soon as possible? It seems like an eternity. I tell the tech that the other tech said to get the patient ready and call. She said no, the other tech said to get the patient ready and call to see if we could come then. I am livid. LIVID! She KNOWS how difficult it is to arrange to take a critically ill patient to CT. I hang up on her.

11:20AM: I tell the flex nurse that the tech wants him at 11:45AM. The flex tells me that’s probably how long it will take transporter to get here. (ha ha) I intuit that that will not be the case. I go to the other side of the unit to get a dressing change kit and see a transporter walk up (really on the ball today, those transporters) and ask the secretary who paged them. I see that there’s a patient on this side that needs to go to another unit, but the nurse says she isn’t ready; she doesn’t know who called. I ignore the situation thinking it will buy me time. Yes, I’m not proud of it, but I was prepared to blame the delay on the transporter rather than tell the RT’s that they had to wait another 20 minutes, when they could have finished their lunch. I knew the flex would take the patient early, where the patient would sit out in the hall being bagged. I just didn’t feel right about it; I felt better having the patient wait in our unit.

11:30AM: I sit down for 3 minutes and catch up writing my vitals.

11:33AM: The flex nurse re-pages transport. I did not tell her that they had already been here. She specifies this time which room to come to.

11:38AM: Transport shows up. The patient is ready to leave. I call the scanner to let them know that the patient is coming NOW. I am feeling sheepish since the last time I talked to her, I hung up on her in frustration. They don’t answer. I let it go – there’s nothing I can do now. The patient will just have to wait in the hall, being bagged and monitored, until the patient on the table is done.

11:40AM: Sit down to chart my assessments (yes, at some point I did manage to listen to lung and heart sounds, etc. on both patients).

11:45AM: Patient 2 puts light on. His urinal needs to be emptied. I go to empty it and he says that he spilled some on his sheets. I realize that it must not be an easy feat using a urinal in bed (it hurt his toe too much to stand to use it), but if 100′s of other patients can do it without spilling, why can’t he? I admit that this is going through my head and probably shows on my face. I empty the urinal, noting how much was in it, then go get new sheets. I pull the curtain and tell him to roll over. A little more, sir. Ok, a bit more, please. (GOD! TURN ON YOUR SIDE!). Ok, now turn the other way, there will be a bump where the linen is folded over. Great. I start to walk out and the patient calls to me. I turn around and his hands are up. I look at him, realizing the second before he announces it that he wants to wash his hands. I think soap and water will be messy in bed, so I go and find some of those antiseptic towelettes that come on the patient’s food trays.

I find one and take it to him, opening it for him, and he says, “What is this?” I say it’s antiseptic, to wash his hands with and hand it to him. He reluctantly takes it and looks at me like I have 3 heads. I say What? He says in his best “Well, duh” voice: “I need to wash down there, too.”

(Side rant:) Ok, forgive me, but in 7 years of nursing (ugh – actually it’s almost 8!), I have had very very few male patients ask to wash themselves down there after peeing. That’s just how it’s been. Females almost always want to, but males.. not so much. I do realize that he spilled some. I still have patient 1 on my mind, wondering if she’s about ready to code in the scanner while being flat, thinking of all the meds I have to chart, the assessments I have to chart, and yes, I was thinking that I wished the aide was there, but she wasn’t.

This was probably somewhat reflected on my face. It was sort of the last straw that was precisely placed on a pile of a whole bunch of other last straws. There was just someting about the way he looked, the tone of his voice… I felt like a handmaiden. Even so, I turned and went to get him some washcloths. I went into the room, straight to the sink and held my foot down on the pedal until the water that came out was very warm. I put soap in two washclothes, plain water on the other two, and had a dry towel. When I went to give these items to him, he was looking straight at me (NOW the aide is in the room, preparing to test his blood sugar) and said,

“Have I done something to make you so cold and uncaring towards me? All of my other nurses [He'd had ONE other nurse, overnight, and yes - she's probably a pillow-fluffer] have shown me such caring, but you are so cold.”

This statement was met with stunned silence on my part. I had answered his light every time within minutes of him putting it on, instead of waiting for the aide to get it, like many other nurses do. In between coordinating all of the SNAFU’s with patient 1, I had gotten him his pain med on time, gotten him to his test on time, gotten his meds into him on time, and changed his dressing, which is NOT something that needed to be done right then, especially in light of my other patient, who’s temp was up, who’s cooling blanket was on the fritz, and who’s sats weren’t the greatest on (now) 100% O2 with 10 of peep. I had brought him several warm blankets when he was cold. I made sure his breakfast was there when he got back. I did all of this between dealing with Patient 1, AND patient 1′s family, who understandably had a lot of questions.

I finally managed to stammer that I was sorry he felt that way, but that my other patient was very busy, and….

And then is when I plopped his damn washcloths down and walked out. I never went back in.

I told the charge nurse (through tears) that I needed to switch assignments and told her what he had said. It HURT. Right after that, I went into the bathroom and cried for 10 minutes. When I came back out, I found that my coworker was totally willing to swap one of her patients for mine, and we did just that.

I was very grateful.

12:15PM: Patient 1 is back from the scanner. Although the head of her bed is up, she is purple. Very, very purple, with bloodshot eyes that are bulging out of their sockets. Still comatose, she’d had her eyes open for days. Every hour or so, I’d put artificial tear drops in to keep them moist.

We got her hooked back up to the vent and had to switch monitors back, and plug in all of the other stuff. By then, I’d gotten a new cooling blanket and machine and got that back on her (not under her; not enough nurses around at that time to help me roll her.) Gave her Tylenol and had the aide do her blood sugar. Covered that with the insulin that strangely cloned itself in the last 3 hours – there were now 3 open bottles of Aspart insulin on the counter, 2 of which were half empty. I hope they had a nice time wherever they were when I needed them before. Hung more potassium, hung antibiotics.

1:00PM: I have finished charting now. My charge nurse tells me that I have to transfer the patient that I have just swapped for to the telemetry floor.
I get his belonging sheet checked off and get him in a wheelchair (small miracle that one of those were available) and get him to the other unit after calling report. Not before giving him his 1PM meds, of course.

1:30PM: I have just one patient now. I go into her room and find that her cooling blanket stopped being cool. And there’s a funny red button on the cooling machine that’s blinking.

1:35PM: I call central supply to see if they have another machine. They say that one’s in biomed (no kidding), and that they do have one more. They bring it to me in record time (thank you) and this 3rd machine works great the rest of the day.

2:00PM: I go to lunch.

The rest of the day was fairly uneventful; certainly nothing like the morning. Interspersed with what I described here, I had to take phone calls and patient 1 needed to be suctioned frequently, sometimes several times an hour. Patient 2 was in the unit all day, having to go on an insulin drip for his high blood sugar. I asked the nurse to pull his curtain a little so I wouldn’t have to look at him through the glass door. I catch him staring at me anyway, because he can still see out into the unit. I resisted the urge to glare at him, and tried my best to ignore him.

The other day, a woman walked onto the unit. This is not a rare occurrence, of course. She was dressed in street clothes and was a complete stranger to me. She was talking to a dietician that was walking by, and the dietician came up to me and indicated that the woman needed to ask a question. I assumed that she was there to see a patient and right off the bat asked her what patient she wanted to see. “Well… I’m the patient,” she replied.

I love when patients come back to the unit to visit, especially if they had been there for a long time. As soon as she said her name, I recognized her and remembered what room she’d been in. How funny that even though I had taken care of her a few times, and helped other nurses who were taking care of her, I didn’t recognize her, even though she has a slight deformity of her eye.

Or maybe it’s not that surprising that I didn’t recognize her. The whole time I knew her, she was wearing a standard-issue hospital gown, just like everyone else. She had multiple tubes and lines and her face was covered in tape from being intubated. It’s odd to see someone that you’ve had a certain mental picture of suddenly standing before you, wearing street clothes and cracking jokes. She looked like a person, not a patient.

She was very shy and kept saying that she didn’t remember any of us, didn’t remember her time in the unit at all. This is quite common; even when patients seem alert and oriented to us at the time, sometimes when they come back they say that they don’t remember it at all. This mostly happens with patients who had been sedated on ventilators, or very ill.

I think it took a lot of courage to come and visit a place where people may or may not recognize you, a place that you know you spent a lot of time but remember nothing of. I was very happy to see that she looked so good. I remember wondering, when she was a patient, if she was going to make it out of the hospital alive.

Which reminds me – many months ago, 2 people walked onto the unit and I recognized one immediately – he was the husband of the person that had spent almost a month in our unit. The 2nd person, of course, was that patient. If he hadn’t walked in with her, I wouldn’t have recognized her in a million years. (For one thing, she was very short – you don’t get a good idea of how tall someone is while they’re in the bed!)

I love when patients come back to visit. Sometimes we never know what’s become of them unless one of us remembers to ask one of the docs.

Those aren’t words you want to hear over the loudspeaker of your place of employment.

The alarm sounded, but although it’s usually cleared within a few moments, this time it just kept going. Ding. Ding. Ding. What the heck was going on? The rumors filtered down over a matter of minutes. A doctor who had been on the Floor In Question came down to ICU with stories of patients being evacuated. Huh? If patients are being evacuated, why are you down HERE telling us about it instead of up there? We thought he was full of it, trying to pull our collective legs.

But then we heard the announcement, and it cemented everything he’d said. We were having an Internal Disaster. “This is not a drill.” Soon, we heard our charge nurse’s Vocera chime in: “Please have all evacuation litters and chairs ready to go when the transporters come for them.”

!!!!

This was real! A real, live emergency! An honest-to-goodness-break-out-the-red-safety-binder-and-look-up-what-to-do-in-an-internal-disaster emergency! Not being one to miss such excitement, I asked my charge nurse if I could go and help out. I’ve never been in a situation like that, and I wanted to see what was going on. She said that would be okay – so I went and asked 2 fellow nurses to watch my patients while I was gone and they agreed.

Off I went to the stairwell. On my way there, I encountered other employees going the opposite direction – out. They didn’t look panicked and weren’t in a hurry, but it was a little disconcerting. If they weren’t up there helping out, why would they need me? But I went anyway, and ran into Someone In Charge. I asked if I could help out and she directed me where to go. (Yes! I get to go!) When I got to that floor, they had already evacuated it laterally across the hall. I discovered that patients were being moved on litters and evac chairs down 2 flights of stairs. There were beds and people wrapped in blankets everywhere. There was no panic, no distress among patients. They were just sitting there calmly waiting their turn to be carried down the stairs.

It was decided to evacuate another part of the floor as well, so I went to help with that. When everyone had been carried off, I went back to where I started. I saw that a nurse was helping a very elderly lady go from a wheelchair to an evac chair. Since the lady looked unsteady, I supported her until she got settled. Right as I was turning around to see if someone could carry her down the stairs, the nurse I’d been helping said, “Ready?” As in… “Are you going to help me carry her down now?” I looked around, but saw no one else that wasn’t already doing something, and I felt like I was holding things up, so… I helped her carry that woman down 2 flights of stairs.

I am very sore. Very very sore. My back feels just fine, but my arms and shoulders hurt. I’m positive that I did not sustain an actual injury (in fact, no one had), but those muscles had not been used for such an activity, ever. The patient wasn’t heavy by any means, but navigating around tight corners was a little harrowing. We set her down in the hallway of the unit we were evacuating people to and someone hurried over to “check her in.” People were going around with lists of names and checking them off when the patient was accounted for.

After that, another nurse and I went back to CCU to get portable monitors so that we could hook up the patients that had been on heart monitors. When we returned to the floor, we found that everyone had been accounted for. Care plans were being printed off and matched to each patient. Patients had been told to keep their own charts, and as I walked down the hallway, I noticed little old ladies in chairs clutching their charts as though they were life preservers. I guess they took instruction well :-)

We went patient to patient, assessing those with heart conditions for chest pain from the excitement and assessing those with respiratory problems for their oxygen levels. There were lots of portable oxygen tanks around, and there were people constantly looking at how full each tank being used was.

Someone from the kitchen brought up cases of bottled water, which I was SO thankful for. Eventually, the Floor In Question was secured, but not deemed habitable just yet. So we faced the task of moving patients around to empty beds on other units, and opening up overflow units to accomodate the rest. Housekeeping was called to clean beds that had been left behind, and they came out in full force. I’ve never seen so many Environmental Servicers at one time, in one place. Beds were cleaned and re-sheeted faster than we could move them.

Finally things started to really settle down. The patients on surrounding floors that had been evacuated went back to their rooms. The others were placed in overflow units. I went back to my unit 2 hours after I had left it and tried to focus on my patients. There was a debriefing session that afternoon where we were told exactly what happened. We went over the things that went well, and there was time to go over what we learned for next time. The Voceras were invaluable. You could get hold of anyone, anywhere – no phones necessary. One thing I’d like to share with other healthcare workers out there that may be faced with a similar situation, though: Although there were patients that could walk, some had a really hard time navigating the staircase in all the commotion. They kind of held up those that were carrying patients down. It might be best to go ahead and carry everyone to avoid this problem. It all seemed to go fast to me, but maybe the slower patients were already evacuated by the time I arrived.

I am so proud of my hospital. There was absolutely no panic, just efficient and expediant work. No one sustained injuries, and no patients had untoward effects. Although some patients were sent to the ER, it was for the closer monitoring that they could provide (CCU had NO beds available to do this). Although we have drills to practice this sort of thing, we never actually haul the patients out of their beds and down the stairs during those times, so this was a true test. It could have been a lot worse, but luckily, it wasn’t.

As you may know, for over a year I had the position in my unit of “break nurse.” By law, ICU nurses can only have 2 patients at any one time, and so a position was created to cover nurses for their breaks or other time away from the unit. The worst part was that it was 5 days a week. Most nurses work 4 days a week, some work three 12 hour shifts. And I know that the majority of adults who have jobs go to them 5 days a week. Personally, I was on a one-way road to burnout doing that schedule and have recently changed to the coveted three 12′s.

Being there 5 days a week, I started noticing that I was doing funny things on my off-time from work. For instance, in the hospital, if the patient has an IV running, the RN keeps track of the patient’s intake/outputs. (Show me an ICU patient that doesn’t have some kind of IV going and I’ll show you a patient that has transfer orders.) Everything that goes in the patient, from a can of soda to a cup of juice, needs to be documented on the flow sheet. Every time they go to the bathroom, that needs to be accounted for as well. It was getting to the point where I was automatically going to write down my “intake” every time I drank a glass of water.

When I worked night shift many years ago, we drew our AM labs at 4am. Now I think that that’s a really stupid time to draw them, but that’s what we did. I remember that on my nights off, when I was in my bed asleep at home, I would wake up almost every night at 4am, look at the clock and think, “Ack! Time to draw the labs!”

We recently started using Voceras at work. They’re little phones that we wear around our necks. There’s a little button on them to press every time you want to talk to someone or answer a call, a la Star Trek style. We use them to tell someone on the other side of the unit that they have a phone call, we call the transporters to pick up labs or help us transfer patients, and we use them to call other personnel in the hospital who don’t usually frequent their desks: the clinical nurse specialist, our boss, the care coordinator, etc. It’s kind of nice because we can use them anywhere – we don’t have to be near a phone. My point is that I use it several times a day :-) One night I was at home in the living room thinking about going to bed, and my husband was somewhere else in the house. I wanted to find out if he was going to bed also; if not, I was going to leave the lights and TV on.

I actually pressed my chest, thinking that there would be a Vocera there. You know, to call him. Unbelievable.

All of the sinks at work are operated by foot pedal. It cuts down on spreading disease and all. Yes, I have walked up to my kitchen sink and have tried to turn my faucet on by stepping on a non-existent foot pedal.

Anyone else? :-)

We have a patient that makes me very sad. He’s been with us in ICU for almost a month. He came in for a straightforward procedure. But even straightfoward procedures carry risk, and he suffered some complications. He seemed to rebound briefly, but then experienced some more complications.

I don’t think he’s going to make it. Actually, I’m almost sure.

I have taken care of this man every day that I’ve worked for the last 2 weeks. That’s 10 days with someone who is critically ill. Ten days with a family that is teetering on a bridge that spans hope and despair. Every time we add some new treatment or some new medication that will hopefully save his life, my fellow nurses ask, “Why? Why not let him go? What is the family trying to do?”

I know where they’re coming from. I have been them. I have looked at critically ill patients in whose care I have not participated, to whose family I have not sat with day after day, and thought the exact same thing.

“Why must we continue with this when we already know the outcome?”

If you stop to think about it, we are obviously not treating the patient, we are treating the family. The family has, of course, given permission to us to go all out to try to save their husband, father, brother, uncle. In the end, they will take a small measure of comfort in the fact that we have done everything. This patient was supposed to have a procedure done, and be home by the next day. That didn’t happen, and now it’s becoming clearer by the hour that he will never go home.

He has started to do something that some of us call “fish breathing.” Even though he’s on a ventilator, it appears as though he is gasping for air. He looks like a fish out of water.

His family brought in pictures of him taken when he was a very strong and vigorous man. He currently looks nothing like those pictures. I would not have pegged him as being the same man. He is both swollen and wasted at the same time. His eyes are open, but there is no life behind them.

There is nothing for us to do but wait for our treatments to fail. None of us, including the doctors, feel as though we can approach the family about withdrawing care. We haven’t even broached the subject of not coding him.

If you’ve been reading this blog for awhile, you know how strongly I feel about not flogging patients that are doomed. I have written several entries about what it’s like to be coded, what happens when we withdraw treatment, and what happens when we don’t withdraw treatment. I like to think that I am an advocate for those patients who are going to die, but get stuck with all of this high-tech equipment that isn’t going to change the outcome. I certainly agree with giving the patient a chance to recover, and giving the family some measure of “we did all we could,” but I like to think that I can then steer them towards accepting that the end is near.

I can’t do that with this family. I have become a little too close to them. To bring up that subject after all we’ve talked about would feel like a betrayal. “Sure, I’ll participate in doing everything possible for this patient, but I really feel like it’s a waste of time.” I don’t feel like it’s a waste of time, I just feel very sad. I’m sad that he didn’t go home the next day, that he’ll never play golf again, that his wife and children will return to where they live without him. He is obviously very loved and has a very devoted family. I can’t bring up withdrawing when the doctors are still giving “guarded hope.” To go against doctors would immediately peg me as the enemy, and any relationship that I have built with this family will shatter. In this case, I feel as thought the docs are in a much better position to broach this with the family, because they have not spent hours and hours per day with them.

I have lost objectivity with this patient. On some very basic nursing level, I enjoy taking care of him. I know the orders so well that I have very few surprises when I take over from the previous nurse. I know the routine of medications and lab draws very well. I know the family well and enjoy hearing them talk about his life. They know my name, they thank me often, and make me feel appreciated. They literally pat me on the back. I am giving the patient the best nursing care that I know to give, but still the nagging in the back of my mind continues… I am not doing everything to help alleviate this patient’s suffering. But who am I to make such a decision? They teach us about being a patient advocate in nursing school, to do what’s in the patient’s best interest. And I want to do that. Every single doctor and nurse on this case knows how this will end. Does this sound harsh to the lay-person or medical professional who is not intimately aware of the realities of ICU?

Why is it I that must be so concerned about this patient? Why aren’t the doctors more willing to step up and have this conversation? They keep saying, “give it a few more days.” “We’ll discuss it with them next week.”

All the while, the patient lays on his bed, hooked to several machines, wires, and medications. He continues to fish-breathe. We sporadically give him pain medicine when his blood pressure tolerates it. He’s waiting for us to let him die.

I recently got a comment: I struggle with the question of why I am changing careers. I used to LOVE being a nurse – I loved my job and my patients and their family members could tell. As the years progressed, I fell out of love with nursing. Admittedly, I have only worked at one hospital, but the red tape just kept coming and I knew I couldn’t continue to work as a nurse.

I think nursing and hospitals face the same issues and problems that other professions and businesses have: incompetent management, too much red tape, not enough supplies to do the job effectively… the list could go on.

There’s a lot of paperwork that one must keep up on just to be a nurse. There’s licenses to keep current, education requirements to fulfill, proof of those education hours that needs to be kept, competencies on different machines and procedures that need to be renewed (and the proof kept). We each have little folders that we must maintain that contains all of these myriad papers.

Every once in awhile, “management” comes up with yet another piece of paper or activity that we need to do or keep track of. One afternoon, my colleagues and I were sitting around the break room table one day, preparing for shift report. We were complaining amongst ourselves about the latest memo that came out saying that we must now keep track of such-and-such. It quickly went the route of the “This is what’s wrong with nursing today!” conversation. The unit clerk was also sitting at the table and at the first pause in the conversation said, “Well, that all may be so, but you guys are living the dream!” Meaning, of course, that most of us had wanted to be nurses. We went to college and trained for years in order to be able to work at our chosen profession. She got quite a laugh, and the conversation was diffused, but I think she has a point.

Many people complain about their jobs. Some people really had no idea what they would actually be doing as a doctor, nurse, lawyer, astronaut, whatever. But if you used to love being a nurse, then it’s really a shame that you’d feel like you had to leave. It’s different from getting out of school and discovering right off the bat that it wasn’t for you.

I also strongly feel that nursing is different at different hospitals. If you truly enjoyed nursing, just try a different hospital before leaving the profession altogether. I’ve gotten really lucky with all of my jobs. I’ve been very fortunate to work with very talented, fun, interesting people. Are there problems? Yes. Every unit is going to have problems… but there are problems that you can live with and some you can’t. I happen to work for a hospital that has problems that I can live with. There really are hospitals out there that nurses like working for. Or if you didn’t want to work in a hospital, go to a school, doctor’s office, research facility, children’s home, nursing home, rehab facility, home care… the list goes on! We need good nurses staying in the profession.

You know, living the dream.