code blog: tales of a nurse

This weekend we had a patient who had come in with chest pain. He was taken to the cath lab and was stented.

Normally this kind of patient would go home in a day or two if there were no complications. Unfortunately this patient had a big complication - he was an alcoholic. So by the time he was ready for discharge for his heart problem, his alcohol withdrawal had kicked in.

He is now on day 5 of his stay at the hospital. He spent at least 4 of those days in ICU which costs many thousands of dollars a day. He was still there Sunday afternoon when I left, and still on his Ativan drip. He was nowhere near getting transferred out to the floor.

I'll cheerfully bet you $100 that even after all of the hell his body went through detoxifying from alcohol, he will get some good 'ol ETOH from somewhere within an hour of leaving the hospital. You see, when he started getting goofy from DT's, we started drugging him. Probably with some oral Valium at first, then when that didn't work, we hit him with some continuous intravenous Ativan. Once the worst of the DT's passes, we wean him off IV Ativan back onto oral Valium. When he's stable on that, he gets discharged. I admit that I don't know exactly how that works, because we just transfer them to the floors. Does he get sent home? Does he go to some alcohol treatment center? I have no idea.

I do know that some of our detox patients are in ICU because they have presented to the ER for whatever reason and request to be detoxed. They've had enough; they want off the sauce. Even the relapse rate for this is high; I often see the same patients come back over and over again. And those patients want to detox.

But when alcoholics come in for other health problems, they are detoxed whether they want to be or not. It's for staff and patient safety, you know. People going through DT's can be very combative and can be dangerous to themselves and others. So if they don't get out of the hospital before the shakes hit, they automatically buy themselves a week's stay... or longer.

This practice is downright counterproductive. If the patient comes in with a health problem, they should be assessed (as they currently are) for their alcohol intake. If it seems that the patient is an alcoholic, they should be counseled about it ("you should really stop drinking, you know") and then be allowed to make their own decision. If they choose to keep drinking, they should be allowed to drink in the hospital. I know there are all kinds of possible ramifications to this idea, and I'm not talking about letting patients get sloshed. But if a beer or three a day will keep the DT's at bay, then they get a shorter hospital stay. Which would taxpayers rather pay for? A case of beer or a $40,000 hospital bill?

Obviously it would not be a good idea for everyone, but I believe that it would be very helpful for some. I can't tell you how many patients I've seen who come in for some minor surgery (appendectomy, chole, etc) and end up with all kinds of complications because we decide that they need IV Ativan more than they need a glass of wine or three at dinner.

They're adults. It is utterly ridiculous how we healthcare providers think we should fix every little thing about a patient when all they need is a stent and a bus ticket back home.

Wow. Life has been rather busy lately. I recently moved, my grandmother passed away necessitating a last-minute trip to the midwest, I'm in the process of starting a business and am chasing after a 16 month old. Oh, you want to see a picture? Ok!

Work has been as busy as ever, with both the regular and overflow units open. Lots of sick people this time of year as usual. Lots of scrambling for transfer orders so that we can get more sick people in. It's a revolving door.

Primarily working weekends, I am more attuned to the Weekend Syndrome now than ever before. This syndrome is characterized by a lack of decision making on the part of doctors who are covering their partner's patients on the weekend. I'm assuming that the covering doctor gets a sign out from the doctor who is off (usually - sometimes not) and they round on the patient over the weekend.

Normal decisions about a patient's care are typically made - adjusting medications and vent settings, transfer orders, that sort of thing. But if you are the patient and you are anywhere near close to death, forget it. The status quo is maintained at all costs. Is it somehow taboo for a covering doctor to make end of life decisions over the weekend? Apparently it is!

My patient, in his 50's or 60's had had a cardiac arrest and thus ended up with the usual trifectic sequelae of shock liver, kidney failure and ileus. Apparently he'd been in CCU for about a week. No family in the picture, and thus no one to make decisions on his behalf.

Of course he was a full code.

Perhaps it was just because I was seeing the situation with fresh eyes, but after looking at his hideously disfigured labwork, it was pretty obvious that this poor guy wasn't going to make it. And yet 5 doctors rounded on the patient, and only one of them was familiar with his situation. The rest were covering for the weekend. Every single doctor looked at the patient, wrote a note, and went on to the next patient.

The next day when I arrived on the unit, I found that his condition has worsened. I figured that withdrawing the vent and CVVH was too lofty a goal, so I aimed to at least change his code status to "no code." If his heart was to stop, I didn't want to have to shock him or do CPR. People who are that sick do not come back from the dead when we code them; or if they do, they certainly don't stay long.

As each specialist rounded on the patient, I informed them of his labs (worse than the day before), his labile blood pressure and the fact that I was needing to go up on his pressors. We were all pretty much in agreement that his prognosis was very poor.

Despite this poor prognosis, each doctor suggested getting a head CT scan. And that is what we did. I still to this day cannot figure out why we did that. Maybe it would have shown a bleed, or maybe it would have revealed that he had cerebral edema. It could have confirmed the diagnosis of anoxic or hepatic encephalopathy. But as the doctors discussed this amongst themselves, it was stated that there was no effective treatment for any of those findings. Oddly enough, although each specialist said that they wanted a head CT, not one of them would order it. It was up to the hospitalist to order it. She knew next to nothing about the patient and when I called her for the order, she could not have cared less about why the other doctors wanted it. "If they want it, go ahead and get one."

When I asked the cardiologist about at the very least making him a no code, he pretty much came out and told me that he wasn't going to do that because it wasn't his patient. I asked if we agreed that the patient was probably going to die soon. He said yes. I told him that I wasn't even asking to withdraw the vent - I just didn't want to code the guy. He flat out told me that it was the responsibility of the patient's usual doctor to make that sort of decision. Everyone concurred. Every time I asked about making him a no code, they all said that it would be addressed the next day... Monday. When the usual docs would be back around.

Meanwhile, my patient required frequent cleaning due to the lactulose he was getting. His blood chemistries were so out of whack that he was literally breathing over 40 times a minute. The highest rate I saw was 47. Go ahead - try to breathe 47 times per minute. See how comfortable it is before you pass out.

Because the usual doctors weren't on, this patient laid in the bed another day. Not to sound crass, but in addition to his probable suffering (I actually don't think he was conscious, but who knows for sure), he was using a critical care bed and his treatment required that he have one nurse to himself. Believe me when I say that many many thousands of dollars were spent on him during that day alone.

Why? Because we were waiting for family to come in from out of state so that they could say goodbye? Because one of his loved ones just couldn't bear to let go yet? Because the doctors truly felt as though he had a fighting chance?

Nope. It was because the doctors who could make the decisions were off that weekend and no one else stepped up. If it happened here, it's happening elsewhere, maybe many elsewheres.

Add it up.

I know you know that our patient was on isolation, because it's very hard to miss: 1) the big red "ISOLATION" sign on his door, 2) the big cart outside of his room containing gowns, gloves, and masks, and 3) me, standing at the patient's bedside wearing said garb. So when you come in ungowned and unmasked and I say, "Um, you do know that this patient is in isolation?" the correct response is not to hold up your gloved hands and say, "It's okay; I'm gloved up."

When told that this patient requires more personal protection equipment than gloves, the other correct answer is not, "I don't have time to bother with that shit. I'm not touching him anyway." Do you want to know how I know that this answer is incorrect? Because when you were bending over ever-so-slightly to listen to the patient's chest using your own stethoscope instead of the dedicated isolation stethoscope, the front of your shirt poofed out just a little, and just enough to brush the side rail. The side rail that has been touched by many many gloved hands probably containing all kinds of millions of organisms that are, you know, resistant to more than quite a few antibiotics.

And the "I don't have time to bother with that shit" comment? I did point out to you that I have to put on the gown, gloves, and mask every time I walk into the room, which was easily 1-2 times an hour, sometimes more often. For 8 hours. So you do not have to tell ME about what a pain it is to bother with it. I am well aware.

You did get one thing right. As you walked out of the room, you very correctly used the alcohol hand gel... and when I told you that the one of the organisms that the patient has does not respond to alcohol gel and that you need to also wash your hands, your snotty reply of "I know that, Geena" was a little unexpected. If you don't even know enough to use proper isolation technique, how am I to know that you know anything else about it?

And finally, when I remind you to clean your stethoscope, your answer of, "I already did that" is not fooling me at all, because I have been watching you closely out of the corner of my eye and I know full well that not only did you not clean your stethoscope, you handled it after washing your hands, thereby contaminating yourself again. Well, it was going to happen regardless. I wish it hadn't happened before you started putting your grubby hands all over the chart, though.

And although the pen that was sitting on the counter right next to you was my favorite pen, I threw it away after you were done "borrowing" it.

Right before I called the epidemiology nurse and told her alllll about you.

Awhile ago, I read a post from The Angry Pharmacist about Wal*M*art's $4 prescriptions. I really felt for his point of view - after all, isn't W-Mart responsible for putting zillions of mom-and-pop stores out of business? And over the years I've heard about them skimping on their employee's health insurance. I've always had the impression that W-Mart is pretty much squashing "the little guy" out there with its giant yellow smiley-faced foot.

Of course I'd heard about their $4 antibiotics. Is that what they started with? Just antibiotics? I was unaware that they've expanded their $4 drug list considerably until this weekend.

My patient was in the hospital for heart failure. We got him all tuned up, the docs tweaked his meds a little, and I was all set to discharge him. While talking to the doctor at the desk, I learned that the reason the patient had landed in the hospital with heart failure was because he was noncompliant with his medications.

I stopped caring about patients complying with their treatments a long time ago. Well, maybe it isn't that I don't care. Maybe it's because I've never really seen anyone "shape up." I've educated patients over and over and over again about the importance of taking their meds only to have them bounce back a month or two later due to their noncompliance. People are human - the best you can do is educate. What they do with that education is up to them. You can lead the horse to water and all that.

Anyway, the doctor wrote seven prescriptions for the patient to have filled. He had already been taking some of the medications, but many others were new. After I went through each prescription, explaining what the medication was for, I put them on top of his discharge papers and went about unhooking him from the monitor, etc. He'd been plenty chatty all morning, but he was suddenly very quiet.

He picked up the seven scripts and then put them down again. He said he didn't know how he was going to be able to pay for all of them. He said his insurance did not cover prescription drugs. I didn't ask him, but I wondered if that's the reason why he was noncompliant.

I left his room and asked another nurse if she thought that one of the social workers could provide him with some resources to help him with this problem. She said she didn't know if they could or not, but why didn't he just go to W-Mart and get them filled there? I said I thought that it was just for antibiotics, to which she replied, "Um, no."

So I went to the internet, hopped on W-Mart's website and printed out the list of medications that are $4. I went through and highlighted every. single. medication. that he was prescribed. All 7 were on the list. I took the list in to him and his daughter and suggested that maybe they try W-Mart for their meds. They looked at me with deer-in-the-headlight eyes. I told them that I found every med on the list, and that barring any restrictions (some meds are priced higher in CA due to state laws, apparently), he'd only have to pay $4 for each drug.

They just stood there looking at me incredulously. I was starting to feel a little weird until they turned to each other and smiled. My patient asked if he had to sign up for something, or have a specific insurance, and I told him that I didn't think so from what I read on the website.

The relief in the room was palpable. Then they started calling me an angel from heaven and all that, so I had to admit that it wasn't my idea :)

Just for kicks, I looked up how much each medication would have cost otherwise. I admit that I have no idea if what I was looking at was at all comparable to what they cost off-line, but by using W-Mart he'd save well over $100 per month. I would imagine that that's a substantial amount of money for someone on a fixed income.

I'm not naive enough to think that money was the only factor in my patient's non-compliance. But I do know that he was perfectly happy taking the medications I gave him. He even inquired as to what each one was and what it was for, which is something I cannot say for the vast majority of my patients. The ones who are conscious anyway. So although I am not naive to reality, I am hopeful that his noncompliance was due to economic reasons and not apathy.

Before I sent him home, I walked with him and his daughter around the unit to see how he tolerated activity. When we returned to his room, his daughter remarked that he seemed to be walking faster than he had in a long time. He agreed and added that he didn't feel out of breath, either. Here's to hoping he stays that way for a long time.

I'm not sure what to think about this $4 per drug business. It obviously puts independent and other chain pharmacies at a distinct disadvantage. I am sympathetic to their situation, but it's hard not to feel good about someone's father, brother, uncle feeling better because the drugs they need are affordable for them. Thinking long-term, his compliance will also keep him out of the hospital, thus saving even more money and leaving healthcare resources available for the 90+ year old demented bedridden urosepsis patients that populate our unit. I wonder if W-Mart has a fix for that.

Oops, guess I let a bit of sarcasm slip out.

I had a patient a few weekends ago that was elderly and had many acronyms wrong with him (COPD, CHF, CAD, s/p CABG, HTN, DM, PVD, was HOH, CRF, past CVA, TIA's and, um, osteomyelitis). During report, I asked the nurse to just tell me the diseases he didn't have.

Anyway, his CRF was turning into a nasty case of ARF and the primary care doc came in and ordered renal-dose dopamine. Does anyone actually still prescribe renal dose dopamine? Well, obviously, because this one did. But does anyone else? Being the dutiful nurse that I am, I started it at a whopping 2mcg/kg/min and sort of rolled my eyes at the whole situation.

The patient was one of those cantankerous sorts that I love taking care of:

Me: I have to give you a shot in your abdomen. It's a blood thinner that will help prevent blood clots in your legs.
Patient: In my stomach? It sounds like that will hurt.
Me: It won't hurt that badly.
Patient: Who's the patient here, me or you?
Me: I've had shots in the abdomen before. They aren't that bad.
Patient: (regarding me warily) Well, okay...

After I gave him the shot, he winced and said, "I thought you said it wouldn't hurt!!" To which I replied, "No, I said it wouldn't hurt that bad." Ha :-)

Anyway, about 15 minutes later, my patient started to desat. Out of the blue. I did all the usual things to fix it, but nothing worked. I finally resorted to putting an O2 mask on him. I went in later to turn him and he complained of being nauseated. I checked the residual on his tube feeding and got what I'd gotten an hour before - less than 10 cc's.

A lot of weird things were suddenly happening with my patient.

Because he was nauseated, he kept taking his oxygen mask off. Then he would desat. I went to talk to the pulmonologist, hoping we could just sort of settle for a sat of 88% or so, but he told me to tell the patient that if he didn't keep his mask on, I would have to restrain him. Come on!!! He's an old man with some really bad acronyms!! Leave the poor guy alone! My advocating went nowhere, however, and I had no choice but to deliver the news: "The doctor says that if you don't leave your mask on, I'll have to restrain your arms."

He looked at me as though I was nuts. Well, I felt nuts. The guy was quite oriented, not confused at all and here I am threatening him with restraints. Sometimes I really hate this job.

So I went back to the doctor and said, "Can I interest you in a Phenergan order for his nausea?" He was agreeable to that, but before he put the order in he paused for a moment. "But why is he nauseous all of a sudden?"

Well, a tiny little light bulb went on in my head and I smacked the doctor's arm and said, "It's the dopamine!" I remembered a patient we got from the cath lab a few years ago. The patient was on like 10mcgs of Dopamine and she was constantly green and dry heaving (Great for groin punctures!). It could be chalked up to quite a few reasons (pre-op medications, the fact that she'd just had an MI, etc) so I didn't think much of it. No antiemetic worked, however. But as I came down on the Dopamine, her nausea started to abate. When we had to put her back on it a few hours later, it came back.

So I went back to my patient and turned off the Dopamine to see what would happen. He had no idea that I'd even started it or that I was shutting it off. 15 minutes later I went back in because his sats (which were about 91% on a mask) had risen to 96%. I asked him if he still felt sick to his stomach.

Nope. No longer nauseated. And his sats were up, so I put him back on nasal prong oxygen. The sats stayed up.

Has anyone else seen this? Dopamine, even at a ridiculously low dose, really screwed this guy up on a couple of different levels. I explained the situation and all he said was, "Yeah, I figured you were probably a good nurse."

Well there ya go. Can't argue with that.

Ohhhh I have been away for awhile. I did not think anything could rival my blogging addiction, but my husband wanted to get an Xbox. Many hours have been sucked up playing Catan, Carcassonne, and Viva Pinata :-) I am completely hooked.

Anyway.

A patient I had a few weeks ago was intubated, even though she told her family she did not want to be. When the chips were down, they chose to tube her. She was pretty pissed when the tube came out.

I tried to talk to the doctor about it. I told him she didn't want any of this, and that her wishes should be respected. He said that she had been unresponsive at the time that the decision was made, the family chose to tube her, and in the absence of documentation to prove her DNI wishes, that was that. But the thing that really got me was this: "It's between her and her family. I'm not getting in the middle of it." He said that to me twice.

For some reason it really bugged me that he said that. Isn't that our job? To get in the middle of it? I understand the lack of documentation, but he brushed it all off, wanted to get on to his next patient.

The other thing that bugged me: When he came to see her, he sat at the computer, looked at her labs, wrote a note and left. He didn't even go in and see the patient. Was it because she was sedated on a vent? Or was it because I was doing a sedation vacation on her and she was actually awake but difficult to communicate with?

It is very difficult to communicate with people on ventilators. They try to talk but they can't. It's hard to lip-read around a tube. If you untie the restraints to let them write they either go for the tube in their moment of freedom, or what they write isn't legible. Communication boards are a nice idea, but when someone's coming off sedation, their limbs feel as though they weigh a ton. It's actually quite difficult for an elderly person to even hold their hand steady enough to point at a picture. If they can even see the pictures and words.

Still, I managed to ascertain that she was ready for the tube to come out whether the docs thought it was appropriate or not. It took me a long time to figure this out and I had to watch many bouts of frustration while she tried to get her message across. Many patients gesture wildly and when the guesses I proffer aren't correct, the frustration in their faces is heartbreaking. They sometimes literally throw their hands down and close their eyes in defeat.

It's hard when people who are in charge of your well-being can't understand what it is you're saying. It's scary to be tied down to the bed with a tube you never wanted stuck in your throat while you wait for test results to come back. Test results that determine whether we remove the offending tube, or whether we put you back to sleep to wake you up another day and try again.

I managed to figure out what she wanted, though. It took some time, lots of guessing, and perseverance. It took some patience waiting for her to get over her frustrated moments enough to try again. And then, finally, the tube came out, and she confirmed her wishes to me immediately.

After all that... I summarize the major plot points for the physician and all I get back is, "I'm not getting in the middle of it. She needs to work it out with her family."

Well good for you. Problem solved (for you). Now you can get on to the next patient. You may as well have written your progress note from home and faxed it in for me to put on the chart. Enjoy the fee you collected on your "patient visit."

His normal mood is quite sour. Typically indifferent. He's not chatty, never cracks a smile, never jokes around. All you normally get out of him are softly-spoken and terse, hard to understand answers.

That day he agreed that the prognosis was probably hopeless. When I called with an update on her deteriorating condition, he said he wasn't surprised but that he'd be in to see her. He was there within 15 minutes. His mood was elevated to what most people would describe as ambivalent. He seemed almost chatty. More willing to explain things. I was surprised.

During the procedure, his cell phone rang with what sounded like an annoying pop song. His eyes, usually partly cloudy, became dark and stormy. One of us was holding her still, the other was sterile. He fixed his troubled gaze at the one remaining nurse in the room and said, "Can you get that?"

Not an unusual request.

The nurse lifted up his scrub top a little to find the cell phone clipped to his waistband. She had some trouble getting the phone off the holder, and before she could answer it, he said,

Ask her what the hell she's thinking calling me right now.

Ask her what could possibly possess her to bother me at this moment.

Ask her!

The nurse and I involuntarily glanced at each other. What the...?

She opened the phone and said,

"Hello?"

"Um... he's busy right now... can he..."

"TELL HER I'LL CALL HER BACK WHEN I AM DAMN GOOD AND READY! TELL HER SHE'S AN IDIOT FOR EVEN THINKING THAT I COULD STOP WHAT I AM DOING TO TALK TO HER AT THIS POINT IN TIME!"

"Um... did you hear... ? Ok... Bye."

"What did she say?"

The nurse and I exchanged glances once again. This did not go unnoticed.

"Nothing. She said nothing."

Turning towards the nurse that was sterile, his eyes starting to clear from hurricane to mere tropical storm, he said, "I need the drill now."

And that was that.

I was out at the desk putting more paper in the recorder when a patient's wife came running out to the station.

"Please come quick! Someone come check on my husband!"

Not having heard any alarms, I quickly glanced at the monitor and saw nothing out of the ordinary (Not like that comforts me anymore) but headed into his room right behind his wife.

"He's breathing fast, he's coughing and his pulse is really high!"

I looked at the patient. He was on the ventilator and yes, he looked as though he was breathing a bit fast. The vent confirmed this, showing that he was breathing over 40 times per minute. Looking at the monitor, I saw that his heart rate was 88. I then turned towards the wife and she knew what I was going to say...

"Well, it was 102 a second ago!!"

"But it's okay now. And you're right, he's breathing fast. This is the second day that we've tried to wean him from the ventilator and he's not tolerating the lower settings. His nurse is in with her other patient; I'll go let her know."

Her shoulders relaxed almost imperceptibly, but then tensed up again as she looked back at him lying in the bed. She started wringing her hands and talking defensively. "I don't usually panic like this, it really does take a lot to..."

I put my hand on her shoulder as I interrupted her.

"But he's your husband."

I don't know what she was expecting me to say, but it wasn't that. Her face showed a split-second of surprise before her shoulders relaxed entirely. I don't know how to describe it except to say that every feature of her face soon followed in a display of utter and complete relief.

"Yes," she nodded. "He's my husband. Thank you for saying that."

Sometimes we take care of the families, too.

Sweet Mother of Mary.

When I decided to update my links over there off to the right, I did not realize that I would be adding sixteen more nurse blogs. Nurse blogs have really taken off! I couldn't be happier - the more people that can read about what nursing is really like, the better. And the chance to get to know other specialties (ER nursing, Psych nursing, Labor & Delivery... the list goes on...) without actually having to float to them is intensely interesting to me. I started this blog over 4 years ago (December 2002!) and at the time, I found several doctor blogs, but only one other blog written by a nurse. Now there are so many, it's hard to keep up with them. My sidebar has a sprinkling of the ones I read most often, but there are many, many, many more to discover here.

Anyway, I recently went back to work after 5 months off. It was a nice break, but I was ready to go back. One of my patients was a very sweet elderly man and the other was a very funny elderly man. My two favorite flavors! They were relatively easy but I soon found myself "in the weeds."

Here's why.

All shifts are busy on any unit, and I have worked all shifts, but flame me if you like - day shift, in my experience, is usually the busiest. There are daily labs to address, most procedures are done on days, most tests (CT's, ultrasounds) are done, docs are making their daily rounds (which means they're changing orders), and there are all of the daily meds to give.

Let me tell you something about the "give once daily" meds. 99% of them are scheduled for 8 or 9am. And some of our patients are on a lot of medications. Do you know how long it takes to give 10-15 pills to a patient who can only take them one ... at ... a ... time? It can take awhile.

I'm used to this, of course. I'm pretty good at time management. But all the old frustrations came flooding back when I couldn't get my patient's EKG tracing to pick up. Fixing equipment is my #1 frustration. I hate when gadgets don't work right. My job is difficult enough without having to take forever to troubleshoot and replace faulty equipment. I tried giving all the electrodes a little turn... sometimes that makes the tracing better and can at least pinpoint the EKG patch that's not picking up. The tracing wasn't affected at all. So then I went about changing all of the patches, which involved me having to take the old ones off (not even 24 hours old) of unshaved skin. Either it was an emergency, or the person who applied them is a sadist.

Meanwhile, the patient's doctors are rounding on him and I don't feel that it's very nice to be putzing around under a patient's gown while they're trying to talk to their doctor - the one who only comes 'round once a day. I finally got all the electrode patches changed (having shaved parts of his chest so that when they came off they wouldn't cause so much pain). Didn't change the tracing AT ALL.

The mental commentary of the list of things I needed to get done was becoming increasingly louder, which added to my frustration level.

Finally I decided to just change the EKG cable. Of course, to do this, I had to hunt down a cable to replace it with. I don't take cables from other rooms because who wants to go to admit a patient and find that they're missing an EKG cable? I finally found a cable and had to go through the whole process of untangling the wires, rehooking the patient up, etc, etc. Bingo - perfect tracing. Which is all well and good, I'm glad it worked, but faulty cables seem to be appearing more and more. The really frustrating thing? For kicks, I decided to see how long his tracing had been virtually unreadable, and found that it had been like that long before I came on shift. Argh.

And then there was the old "Insufficient quantity of this medication currently loaded" on the pyxis. Even though Mr. Pyxis is supposed to alert the pharmacy when it gets low so someone will come fill it. Bah, who knows... maybe it had run out 5 minutes before, maybe 5 hours. Maybe they hadn't had a chance to fill it yet, and I understand that... but again, it just adds more work for me when I have to send pharmacy a message and keep checking for the med.

They're small little things, but they can really add up over the course of a shift. Is it like this everywhere?

About a month ago, Flea wrote about some of the vaccine preventable diseases and what actually happens when one contracts polio, diptheria and tetanus. I had no idea what diptheria was before I read that post, but tetanus is a disease I have some experience with.

I've personally taken care of two tetanus patients within the last few years. One was an IV drug user in his 30's and contracted it through one of the many abscesses he had on his arms and legs. He went downhill fairly quickly and was intubated and put on a ventilator. Usually when a patient is intubated on a vent, we give them about 2 weeks to get off the vent before we start talking about a tracheostomy. Tetanus patients, I learned, get trached and peg'd after only a few days. It's understood that they are going to have a rocky course of illness and a very long recovery time and will have these procedures done sooner or later.

Tetanus is treated with antibiotics, anti-seizure meds and "supportive care." This means life support, intravenous or tube feeding, etc. It's intended to support a person's vital life functions while the patient fights off the disease. Tetanus is also treated with muscle relaxers, but in this guy's case, those weren't controlling his extreme muscle spasms. He was already in a "medically-induced" coma, meaning that we were sedating the heck out of him, so the only other option we had was chemically paralyzing him.

Paralyzing patients is a balancing act. Too much paralytic can affect a patient's heart rate (too fast, irregular) and cause them to spike high fevers. Not enough and you're stuck with the muscle spasms and unstable blood pressures. To determine if we are giving the correct dose, we use a "peripheral nerve stimulator." We put electrodes on the patients' wrist (thumb side) or along their temple. We then hook up this little box that sends electrical impulses. We set it to give 4 pulses at varying strengths. The doctor determines how deep he wants the patient. If the patient is not paralyzed enough, you'll get 4 muscle twitches at the eyebrow or thumb in time with the 4 pulses. If they are too paralyzed, you get no muscle twitches. We usually aim for 2 twitches out of 4 pulses at a moderate strength.

The other tetanus patient I took care of was in his 70's and was a carpenter. He actually acquired a big splinter in his arm, which was the supposed mode of entry. He came in with muscle stiffness but was talking and awake when he got to CCU. Within 24 hours, he was intubated on a vent due to respiratory distress and 24 hours after that he was trached and peg'd.

He was one of the most difficult patients I've ever taken care of.

This man's hemodynamics defined instability. In Flea's post about tetanus, he states, "The slightest stimulation can trigger muscle spasms: the ringing of a cell phone, the flash of a digital camera, or someone in the room burping." That isn't an exaggeration. It was very difficult to titrate the paralytics for this patient, even with the nerve stimulator. I'd check his twitches at a dose and find the dose adequate; an hour later I'd check again and find that the dose was way off in one way or the other.

Literally the slightest stimulation - conversation in the room, barely brushing the sheet that was covering him, an IV pump beeping - would send his muscles into tight tight knots. One could literally see them tensing. In addition to this, his blood pressure would skyrocket!! One moment he'd be at 80's/40's and you could literally watch it rise to 240/130 in a matter of seconds. It would stay there until it was dealt with, which meant giving boluses of paralytic or sedation (Propofol, the drug we use for sedation, will cause transient hypotension when given as a bolus). If given too little of whatever drug I decided to play with, he'd stay well over 200/100, but if given too much, he'd drop to 60/30. The difference between "too much" and "too little" was so negligible. If I actually managed to find the sweet spot dosage-wise one time, that same dose wouldn't work the next time. It got to the point where one nurse would have to bolus with paralytic or Propofol to ease the muscle tension while another was simultaneously titrating the Dopamine (a vasopressor) to prevent hypotension.

By the end of a 12 hour shift with that patient, I felt like my muscles were afflicted with tetanus. I was that high-strung afterwards.

Eventually, the wide swings in blood pressure abated and sneezing in the patient's room no longer elicited a body-wide charley horse. This last patient was eventually weaned from the sedation, paralytic and ventilator. A few months after he was transferred out of our unit, we asked one of the social workers how he ended up. I'm happy to say that he made a full recovery and was able to walk out of the hospital after a lot of physical therapy.

I like the happy endings.

I know I've written before about futile care and about keeping people alive past the time when they should have passed from this world. News flash: I'm going to write about it again. Right now.

When I first began nursing in an ICU, I was very naive. I remember one of my very first long-term patients. He was having a second heart bypass surgery. Or maybe it was his third. I remember thinking, "Just how many times can one have bypass surgery in one's life?" Well, in this guy's case - three.

The surgeons and perfusionist could not get him off of the heart-lung bypass machine after the surgery. He just didn't tolerate it. This necessitated them bringing the patient over to CVICU while still on it. Then it apparently turns into a VAD - a "ventricular assist device." The hope was that it would take some of the strain off of the ventricle so that it could rest and then we could wean him off the machine over a day or so instead of over a few minutes.

I remember how busy he was and how complex it all looked. He was truly the sickest individual I had ever seen.

Call it blind naive optimism or too many TV medical shows, but ...

It never crossed my mind that he would not recover from this.

He remained on the VAD for a few days or so. When he came off the VAD, he still required multiple pressors. He was swollen, sedated, and still the sickest person I had ever seen. He then followed a course that I was to witness many, many more times over my career: trach, PEG, weeks and weeks in the ICU, and once he finally left ICU he would come back several times before finally dying.

One thing I remember about him was that we would feed him ice chips with blue food coloring. In that way we could tell if the stuff he was coughing up from his trach was aspirated ice chips.

It was. Every time. Blue phlegm.

The other thing I remember is that his wife came to see him every single day and would stay for a long time. Maybe she had no other obligations, maybe she did but made him a priority. I don't know - all I know is that she was there.

This brings up a few things that I've been thinking about lately. I realized that for the majority of my patients and their family members, their loved one being critically ill is the first time they've ever seen anyone so sick before. Through hope and a misguided sense of medical science's abilities to cure, they have unbridled optimism. They don't see the same cases day in and day out. Just as when I was first exposed to someone so ill, they don't realize that there's really a chance that the patient won't recover.

This realization has gone a long way towards clarifying the thought process that goes into making someone who is obviously (to me) terminal a "full code." With the patient that I described above - I think it would have really shocked me if someone had suggested stopping treatment and letting him die.

The other thing that has been on my mind recently is the availability of those making decisions for the patient. We recently had a patient that was in ICU for over 3 months. It was clear to many of us nurses that she would never, ever leave the hospital (and turns out, didn't leave the ICU for more than a day or so on transfer before she'd be back). The family was adamant that everything be done for her and she lay in that bed and wasted away day after day. Her labs became increasingly abnormal. She developed bedsores despite frequent turning and skin care. She was trached and was on the ventilator. She was fed through tubes. She closed herself off from almost everyone, even nurses that she used to smile at before. She would barely look at her family... but there's the thing. The family. That family was there every single day to watch this unfold. Did that make it right? I don't think so, personally. But it made it a little better in my mind. At least they were taking responsibility for their decisions. They were at the bedside every day, watching the patient deteriorate as the months went by. That really meant something to me.

Yet a few rooms down, there is another patient in a similar situation. This patient is also trached and is fed through tubes. It's impossible to get him off the ventilator. The times that he has communicated with us through writing, he has told us that he's ready to die. Ready for this to be over. But his family is making the decisions. They've decided that everything is to be done for this patient. If his heart stops, we're going to pump his chest and try to get it restarted. Yes, the family knows his wishes - they've seen what he's written. They won't accept it.

The difference? The family very rarely comes to see this patient. Maybe once or twice a week for a few minutes. They've put this patient in hell and now they won't watch it. They won't watch what they're doing to him. They aren't present for the times he coughs and needs suctioning. They aren't there to step out of the room so that we can clean up his incontinent bowel movements.

They just aren't there. I think it's one of the saddest things I have ever seen.

Working in an ICU, there are of course instances when we decide to stop aggressive measures for our patients. One of the newer nurses (to ICU) had a patient whose family decided to stop ventilation and pressors. When the patient was extubated and pressors discontinued, we began waiting for the inevitable.

The patient had a permanent pacemaker, however. While he was being supported, his heart rate was sufficient enough to not need the pacer... but when we took it away, his heart rate started to slow down, as was expected. This is when the pacer started to kick in. The nurse asked how she would know when he died (from outside the room, just looking at the monitor) if the pacemaker just kept going. We told her that sometimes the heart just stops responding to the pacer and all she would see is pacer spikes on the monitor with no resulting heart rhythm.

One of the more experienced nurses mentioned that it was possible years ago to just put a magnet over the pacemaker (which is implanted in the patient's chest, but is usually visible as a lump under the skin) to shut it off. She then added, "But with these newfangled pacemakers, you probably have to turn it off using a computer."

Can you imagine emailing your pacemaker to tell it what to do? That would be a bad address for the spammers to get their hands on.

Several years ago, I came to work and took report on a patient that was very close to dying. For some reason, the curtain to the room was mostly closed, and I couldn't see the patient well. When I looked at the monitor, I saw that he had a pacemaker and had pacer spikes, as well as "capture." Capture is when the heart responds to the pacemaker and beats accordingly. I finished getting report - the offgoing nurse said that she last checked on the patient about an hour before and he was unconscious but breathing. I decided to check on my other patient first and got caught up in doing tasks, but every time I came out to the desk, I would glance at the dying patient's rhythm and it was always the same - pacer spike, capture.

By the time I got into his room to see him, I found that he had been dead for quite some time. He had that lifeless look about him, and the absence of respiration also tipped me off. There was of course no pulse, but up there on the monitor was a consistent and unwavering spike-capture rhythm. I learned a very important lesson that day - you can be in PEA with a pacemaker too.

Every procedure done in a hospital has risks. You even have risks going into a hospital. It's a pretty germy place, seeing as how people usually go there when they are ill. And even the most seemingly innocuous treatments or procedures can lead to more problems. IV sites can become infected and phlebitis can occur. You may have allergic reactions to the medications that are routinely administered for your condition.

Some people just have bad luck, I guess. We recently had a patient, a very elderly woman, who fell and needed surgery. While doing a workup for surgery, all kinds of labs and tests are done to make sure that the patient will survive anesthesia. Of course, this is usually the point at which some elderly people are diagnosed with a plethora of conditions. She did have some issues with her bloodwork and while correcting those issues, she had a bad reaction to the treatment. This reaction was the reason she came to ICU.

We worked to correct her imbalances but it became clear that she would not be able to go to surgery that day. She was in a lot of pain, which we tried to manage as best we could. The pain medicine made her itch. The other pain medicine we tried made her confused.

When she finally had surgery, it was determined that she would need invasive lines to monitor pressures in her heart and lungs. I shall qualify this by saying that she weighed about 100 lbs ... and putting invasive lines into someone so thin runs the risk of puncturing a lung.

Where do you think this is going?

She did fine after surgery, was extubated in the recovery room and returned to our unit (with invasive monitoring line still in place) on nasal cannula. A few hours later, however, she developed respiratory distress. Another chest x-ray was done and it showed a very large pneumothorax. Her lung had been punctured. Yet another doctor was consulted to put a chest tube in.

She certainly wasn't thrilled by the prospect of having a doctor come to insert a large plastic tube into her pleural space, but if it would help her breathe more easily, then... well... how could she say no?

The chest tube insertion went smoothly and we all expected things in that room to calm down. And they did. I kicked the family out and the patient napped off and on and seemed more comfortable overall, although still not as comfortable as I'd expected. The post chest x-ray showed that the chest tube had gone more towards her back than up towards her collarbone, but the doctor was hoping it would work well enough.

A few hours after all the drama, my patient put her light on. When I went to answer it, she said that she felt as though her "boob was bigger." Her chest wall on the tube side definitely looked a bit larger and had the rice crispie characteristics of subcutaneous emphysema, which can be a complication of chest tube insertion.

I notified the doctor and was told that she was elbow-deep in someone else's chest in surgery. As my patient was not in any distress, we agreed to keep an eye on it for the time being.

Another hour went by and I went to check on my patient, who appeared to be napping calmly. She awakened when I smacked her bedside table with my leg (ow) and I casually looked at her chest again. The swelling had definitely increased and it was very visible on her small frame. She appeared as though she'd been bench pressing, but on that side only. I called the doctor again, who still couldn't come. I called her partner, but he was far away at another hospital. My patient still wasn't in much distress, so I just decided to get another chest tube setup ready to go for when the doctor could get there.

The next time I went to check on my patient, I could see from the door that her chest was still bigger yet. We discussed how she was feeling and she looked down at her chest and said...

"Well, you tell those doctors that they have another thing coming if they think that I'm going to pay for this implant!"

Even though she'd endured complication after complication (and complications from the treatments for the previous complications), she still had a sense of humor. I love patients like that!

I called the doc again and informed her that our patient had gone from an A cup to a double D and that she really needed to come and fix her. She came over as soon as she could, still in surgical cap, shoe covers and face mask. We got another chest tube in the patient and she was finally 100% comfortable with her breathing (well, as well as you can be with two large plastic tubes sticking out of your chest.)

I was off for a few days after that, and when I came back to work I noticed she had been transferred.

Hopefully she got out alive.

Imagine this: a very thin elderly woman in a hospital bed. A list of her medical problems would be longer than your forearm in 12 point type. She's been very ill for months. She can't eat and is fed through a tube. At one point she couldn't even breathe on her own and was on life support. Her kidneys are failing and she is on almost-daily dialysis, which she sometimes cannot tolerate without the use of vasopressors. Her circulation is bad. She has a massive bedsore on her tailbone and her foot is starting to turn colors. Bad colors.

Over the last few days, she has grown increasingly unresponsive. Sure, she'll open her eyes when you say her name, and she'll barely move her head in response to questions. But for the most part, this woman who would clearly call "Nurse!!! I know I want something, but I don't know what it is!" last week is no longer even verbal now.

As I go about my day, preparing her medications and changing various dressings, I wonder what the point is. She's clearly dying. She has tremors, so the pulse ox on her finger sometimes doesn't read correctly; I have already gone in the room 20 times to adjust it. Usually it shows that her oxygen saturation goes from 98% to 60% in the space of 10 seconds, which is just not altogether possible... hold your breath for 10 seconds. I can guarantee you'd still be in the 90% range.

Except for this time. This time, I'm sitting in front of the monitors charting, and I hear the familiar dong-dong-dong and look up. My patient's pulse ox is reading 80%. I figure that her tremors are acting up again for the billionth time (and resolve to put the damn thing on her ear next time I go into her room) and continue charting.

Dong-Dong-Dong.

Perhaps 30 seconds have gone by. The monitor now senses that her pulse ox has gone to 60%. (DING! DING!! DING!!!) We've been here before, several times. I sigh and look up from my charting just in time to see her heartrate go from 110 to 54.

Crap!!

I run into the room where I see that her pulse ox has a nice, even waveform. Definitely accurate. Although her heartrate has come back up to the 80's while I was rushing into the room, her pulse ox is definitely in the 60's, and although her chest is moving, there is no condensation on the inside of her oxygen mask. She isn't breathing effectively.

I have some choices at this point. It would be entirely appropriate to find an ambu-bag and put the form-fitting mask over her mouth to force air into her lungs while I call for help. But for some reason, my instinct tells me to grab the Yankauer suction and stick it into the back of her throat.

Her eyes are open, but they are staring past me. I watch as the Yankauer fills with copious amounts of pale yellow/tan mucus. Part of me is relieved - this will surely fix her right up. But it just keeps coming and coming - where was all of this crap stored for heaven's sake??

Then it stops. I've lost suction. I look at the suction head on the wall. It's still set to high. I look up at her sats. They're firmly in the 80% range. I look at her mask. There's condensation on the inside. Good. She's moving air.

I pull out the Yankauer. What was on the end of it may very well haunt me for the rest of my days. It was long and the matter at the end was the size of a large marble. It was black and somewhat solid, not like sputum or mucus. I wiped it off with a paper towel, regained suction and stuck it back in her throat. More mucus, more sputum. Sats up to 92%, definite air movement. Whew.

I didn't figure sending the product of my suctioning session for culture would quite help us figure out exactly what it was. After showing the doctor, he suggested that we send it to pathology.

After the excitement died down, I wondered just what I did for my patient. Sure, I kept her from suffocating, but if that had happened in a nursing home, where she wasn't on a monitor... I can't really say I felt great about "saving" her. Does that sound a bit callous? I'm just not sure what I saved her for. More bedrest? An amputation of her foot? More infection? More dialysis?

Interestingly enough, she became a different person after our little incident. She began speaking again within the hour. She began calling out for the nurse again. Her children came to see her and marvelled at how she was so much more alert and responsive than in days past. She insisted she wasn't in any pain.

I had a few days off after that. I came back to work to find that she had coded and was reintubated the day after I had taken care of her. She remains that way now.

I also found out that what I pulled out of the back of her throat was described by the pathologist as "meat fibers."

Meat fibers. In a woman who hadn't eaten anything in weeks. No wonder it was unrecognizable.

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!"