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Posts from the ‘Nursing’ Category

Nurse Photos from the Creative Commons

At the bottom of this post is a collection of some of my favorite nurse photos from The Commons section on Flickr. If you’ve never spent time perusing the commons on Flickr, I highly recommend it. It contains a vast amount of publicly archived photos from all over the world. Read more

What PPE should be used when caring for an Ebola patient?

There’s been a lot of chatter on twitter as far as whether hospitals are doing enough to protect nurses who come in contact with an Ebola patient. I’ve also seen the sentiment that we shouldn’t be spreading fear, because Ebola isn’t an airborne virus. And the rallying cry that, “Protocols work if we follow them correctly!” There’s no question that these discussions are needed. There seems to be much confusion over what we should be doing. Read more

Nurses Need A River

In 2007 I had an idea to build an aggregator for nursing blogs. At the time I was using an RSS reader to subscribe to blogs, but I felt like there was a better way to keep up with the content. I started trying to build it with a php based RSS tool called Simple Pie. At the same time Guy Kawasaki was putting together Alltop and someone suggested I contact him about creating a nurse category. Read more

Quality of Death

I watched someone die this morning.

Ever since I started working in the MICU I’ve been curious about what a death looks like but ashamed to admit to this curiosity. I remember reading some time ago about a serial killer and how he murdered because he was so fascinated by looking into his victims eyes and watching that moment when the light goes out. Because of this I find it difficult to admit to anyone that I am curious about watching a person die.

So on to this patient. He was in the room next to my patient’s room. He was 81 years old with sepsis. He had tons of comorbidities, and a declining state of health over the past year requiring multiple hospitalizations. Now he was in the MICU, not really waking up, getting progressively worse. A family meeting was held and they decided that it would be best not to prolong the inevitable and to let him die in comfort. They had made the difficult decision of changing his status from a full code to a DNR and they decided it would be best to withdraw care.

But not until tomorrow.

I do understand why people choose to delay this withdrawal of care. It’s a great amount of pressure. You are probably feeling guilt and denial. You may have this feeling that by turning off the ventilator you are killing your own family member. You’ve come to the decision that it’s best for your loved one to go in peace?but not just yet. So the healthcare team then feels obligated to keep this person alive until the family is ready to withdraw.

But usually no one thinks about the when the patient is ready.

So last night this patient was trying to die. All night long, little runs of V-tach, blood pressure waxing and waning, agonal breathing. His nurse would watch these goings on and get that momentary sense of urgency and then realize that there were really no measures that she could take. But she was so respectful of the family’s wishes, she was practically willing him to stay alive until the next day when the family would return.

Each little run of V-tach seemed to me like the patient was trying to take charge of his own death. The one thing the docs could do was make ventilator changes so they did that. It seemed to prolong the inevitable. Then right before change of shift, he lost his pressure. His heart rate started to fall. Even though his dopamine drip was increased his heartrate continued to fall.

He was determined. So his nurse was just kind of fussing over him. She kept cycling the pressure cuff and dopplered his pulse (for what?). I sat at the bedside computer and documented for her. I watched the monitor ? heart rate 90s, then 80s then 70s. A couple of other nurses gathered round. We had been expecting this all night.

The agonal breathing became more steady (even though he was still being mechanically ventilated). I watched his face and saw a momentary grimace pass through every thirty seconds or so. It was strange because he was so unreactive before and now his face was showing something…pain, anguish?

As he bradied down to the 40’s ?50’s, I was charting and the nurse next to me said, “Did anyone just feel a chill?” As she said it I realized that a chill had been vibrating through me for the last 10 seconds or so. As I became aware of this sensation, the chill was emanating, pulsating, prickling. Up until then I had been warm all night.

Then his heart stopped. We all entered the room and began cleaning it up, making it presentable for the family that was about to arrive. I checked myself. Did I still feel the chill? Nope. It was 100% gone. I felt kind of an empty feeling in my core, like something had vacated the space.

It was fascinating.

And as I read this I am amazed at my sense of detatchment. I just read Kim’s entry about her patient who died on Easter. (Damn Kim- You always beat me to the punch!) She had the luxury of sitting around with the family and hearing stories about what a great and wonderful life this person had. In the MICU on nightshift, we are often just alone with the dying or comatose patient, not knowing much about who they were or what they were like. We keep them clean, hold their hands, try to provide a peaceful atmosphere. We are just maintaining status quo until the family can make it there. This can go on for days.

Thankfully, we are starting a new committee in the MICU, the “Quality of Death” committee. This will hopefully help us to better educate families (and ourselves) on how to best prepare for a loved one’s imminent death. I can’t think of a better place to start a committee like this.

You want fries with that Atropine?

I know there are a lot of nursing students out there, as well as new nurses. I think it’s important to let you know that things do get better, especially if you have any experience waiting tables. With that in mind, here is a follow-up to the worst day ever.

Over the weekend I had another particularly difficult assignment. One patient was an FTW (failure to wean: unable to be weaned from the ventilator.) He had about a bazillion dressings that needed to be changed and documented on. He also was just awake enough to mouth words and attempt to communicate with me. This always gets me. I have this habit of dropping everything I’m doing in order to try and understand my vented patient as they mouth words to me. I just cannot read lips, no matter how hard I try. For now, the best I can do is ask:

Are you in pain? Are you warm enough? Are you comfortable? Do you need to be cleaned up? Do you want the TV on/off?

That’s about it. I find it pretty hard to do my job while my patient is looking at me, trying to tell me something, and I am powerless to figure out what it is. Can you imagine being say, an accountant, and sitting at your desk trying to crunch numbers while someone is sitting next to you, silently pleading with you, mouthing words you don’t understand? Can you imagine getting any work done at all?

So mentally, I’m in a state of frazzledom.

My other patient was admitted 2 hours ago, which means that she is busy! Lines to be placed, X-rays to be taken, CT scans, cultures, new meds, you name it, they are ordering it! Luckily she is comfortably sedated, and not mouthing words to me.

So I am just barely keeping up. I’m merely treading water but my patients are still alive, dammit! Doesn’t that count for something? It’s toward the end of the day and I’ve almost gotten everything done for one patient, and ready to move onto the next. And patient #1 goes into V-tach. Just like that. This was not part of the plan. And just like that he bounces back into his regular if not somewhat tachy heart rate. So now the docs are at his bedside, coming up with all sorts of new things for me to do. This does not fit into my plan either. The time I allotted for his care is finished and now he is eating into the time of patient #2.

So the treading stops and the drowning begins. But this time, I enlist the help of the charge nurse. Not only do I ask for help, but I tell her that I am drowning. She starts to take care of V-tach-er’s new orders so I can finish up my tasky stuff for patient #2.

The charge nurse tells me that she took care of patient #1 last week and he was so busy that she was unable to leave his bedside the entire shift. Nice to know it’s not just me. In the end, everything is finished on time.

But I go home thinking I am just not getting it.

A good night’s sleep leaves me ready for round 2. I am even hoping that I will have the exact same patient assignment. The devil you know and all.

Part 2: Be careful what you wish for…

In morning report I find out that yes, I do have the same patient assignment and also that the unit is extremely understaffed and everyone will be busy.

So more of the same. Only this time the v-tach-er has turned into a de-sat-er. He keeps dipping down into the low 80?s. I bump him up to 100% and suction. Bump him up and suction. Bump him up and suction. The theory on him today is that he has a mucous plug, and he is to be sent for a thoracic CT to confirm this. So I call the respiratory therapist in to see if she has any ideas. She does. Bag him, lavage him, THEN suction, with a longer suction catheter! Brilliant. I bag, she lavages and suctions, and together we pull up a couple of big gobs of mucous. Yay! Problem solved! We leave him alone for awhile and he is satting 99%.

Moral of the story #1: When you have a patient with a Bivona trach and you are using an inline suction catheter, you may need to switch to a longer catheter that will go deeper. It’s funny, if I read the above statement in a textbook I would never remember it. Instead, I saw it in action and now it will forever be in my arsenal of things to do when my patient desats.

In nursing school I had this one professor who loved to rant about the saline bullet. She would always tell us that there is no evidence that routine lavaging and suctioning with a saline bullet improves outcomes. In my literal-minded nursing student head what I heard was, Saline bullets are evil! Only bad nurses use saline bullets!

So I never used them. Of course now I will. I think what she needed to make clear was that ROUTINE suctioning and lavaging should not be done. Every once in awhile, if the situation calls for it, it can be quite useful.

At any rate, I got through these two shifts quite well. I did, however, confess to the charge nurse that I felt like I was not getting it.

Please, she said. Take a look around. Even the most experienced nurses on this unit have crazy, busy days. It’s just part of the job.

This was kind of an aha moment for me. It’s just like waiting tables. You get in the weeds (waitress speak for “I am totally freaking out of control right now and every single one of my tables wants something!”), and then you get out of the weeds. When you are in the weeds, you can’t see the other side of the weeds. When you are out of the weeds, you can even laugh about being in the weeds. One extremely important difference, though. When a waitress is in the weeds, someone might not get their chicken on time. When a nurse is in the weeds, someone might not get their (you fill in the blank – blood products? Pain meds? Epi? Atropine?) on time.

Moral of the story #2: If you are a nurse and you find yourself in the weeds, ask for help. Your patient’s life may depend on it.