JS-BS and Biscuits 'n' Gravy

I asked some of my co workers to read my blog. I asked them to suggest what else I should write about or what they would like to read about. I got a lot of interesting feed back. I heard some great ideas and I heard some "colorful" suggestions. Mostly it came down to, "Write about what you know."
I thought long and hard about that. What do I know? What can I say that nobody has heard before. I could blog for pages about staffing and the nursing shortage. I could go on and on about the doctors I like and the ones I don't. I could tell you my biggest mistakes and my greatest achievements. But, when I think about the blogs I have read, I realized that I have already read all of that stuff several times. I want something new and different.
So, I want to tell you about my "nickname game". I have a habit of giving people and/or odd situations funny, and sometimes clever, little pseudonyms or catch phrases, if you will. Its a game I play to entertain myself when I find myself staring out into the pitch black night. Often, these names or phrases cause quite a ruckus amongst my peers and coworkers.
I have two short stories (details and names changed, but true to a 'T') to illustrate my amusing pass time. Story #1: When I was a new nurse, we used to take a 1/2 hour in the morning to sit together for breakfast and discuss our night, or plans for the day, the oncoming night, the staff, the docs, the people we knew and things we did. Mainly, the real reason we got together for breakfast wasn't so much about the shift (we where all there, we knew how it did or didn't go). We met to check out the new residents and study them in their element. Well, one fine fall morning, stuck in the basement cafeteria, we all noticed this poor young doc, looking lost and unsure. Looking hungry and preoccupied. That poor guy...Someone piped in that he looked like he had just fallen off the tractor on the nearest farm. Another chimed in to say, "He looks like he came straight out of a Nebraska cornfield". I ended the conversation with, "I bet he went in hunting down a big ol' plate of biscuits and gravy." Sure enough, at that moment this poor young farm fed Nebraska 'husker walked out of the grub pit with nothing short of a mountain of biscuits and gravy...He is an R3 now. The top of his game, a chief in medicine. He is a great doctor and a tremendous surgeon. But to me, and to everyone at that table, he will always be "Biscuits and Gravy".
Story #2: Often in the most tragic and unbelievable of events, we see the selfishness in people shine through. You would be amazed at the lengths some people will go to in order to make sure that they are never out of the spotlight for more than a split second. It never ceases to amaze me how crafty and egocentric people can be and how they are so accomplished at turning someone else's tragedy and pain into their own source of vanity driven stardom. Such is the case with a recent tragedy we all experienced. An entire family destroyed by tragedy. The kids harmed and the parents clueless. So wrapped up in what they would or could get out of the catastrophe, they failed to see that really the most important factor was/is the children. I never realized the vanity of people until the day I saw the family of this traumatically injured child put their own selfish needs above the safety and needs of their loved one. I couldn't believe the lengths and limits they pressed to ensure that everyone knew who was to be the center of attention. In giving report, I coined it the JS-BS of the day. Just the kind of BS you would see or watch on Jerry Springer...
To most people, that situation isn't funny. And believe me when I say, its not. However, I have learned that if you loose your sense of humor around here, you loose your sense of coping. Finding even the smallest way to see things from a different perspective makes the situations we have no control over at least somewhat tolerable. If there is some way I can laugh, even (and most often) at my own expense, then I know I can get through the roughest, most formidable, most unimaginable situations. I guess humor is our greatest safeguard against tragedy.

Even the Sickest Still Need a Bath

Its been over a week since my last post. I have been working, and I have to say, its been the most challenging week of my career. I decided, for whatever reason, that I would step it up and start taking some sicker patients. I have a lot to learn and although there is always room for improvement on time management and organization, I feel like I have straddled that horse for long enough. I am finally ready to exercise my critical thinking skills, open my "never done that" doors, find my limits and break them. I decided I needed to challenge myself. What was I thinking? My first night, a really sick burn patient. I didn't do much but sit with her niece and wait for that long inevitable moment. I didn't get to change her linens or give her a bath. She was too sick, too unstable. She was on all the drips; epinephrine, norepinephrine, vasopressin, LR at 750ml/hr.... We weren't going to code her, but we were trying to keep her "chemically coded" until the family could arrive from out of state. I tried; maxed out my drips, maxed out my fluids, maxed out my vent, maxed out her heart, her lungs, her body.... She waited until I could do nothing else but call the doctor and say, "There's nothing else I can do." Her niece held her hand. I turned off the monitor. She died at 0555.

The next two nights, I took the sickest medicine patient. I don't know why. Maybe its because nobody else wanted to take him. Maybe its because his leg was rotten, and I had a stuffy nose, so it didn't really bother me that his room smelled striking like a bag of 3 day old dead fish stuck under a pile of sun ripened baby diapers... Maybe its because I knew he was sick and I wanted to keep up my goal of self destruction, I mean self challenge. Whatever the reason, I got him, dead leg and all....

What I found out was that "all" turned out to be way more than I bargained for. He dumped his pressures, right off the bat. 80/40. Then he went into arrhythmia, A flutter, then A fib...I got his labs back--K+ of 2.0. Mg++ of 1.0. iCa of 0.74. Metabolic acidosis. No urine output. No A line. Crappy triple lumen. Unreadable CVP. Depressed ST. Bradycardic to 30!! Atropine given. ...and this was all in the first 4 hours. Time management and organization went out the window. Critical thinking skills, oh my. "Never done this before", oh my. Found my limits, then broke them, oh my, oh my, oh my... I stepped into a whole new world of "what the hell do I do now?" He survived the night. I corrected his lytes. With that, I brought him back into a sinus rhythm. He pressures came up, with a liter an hour bolus. He stabilized out. I went home exhausted.

Day three, same patient. RN report, "he went to the OR and had an above the knee amputation." OR report, "we did this, we did that, he got a ton of blood and even more fluid. He has no pee. Boy did he smell bad." General surgery took over his case. Although he is a DNAR, we will treat him they say. More fluid. More drugs. More blood. More lytes. I work my ass off for the second night with this guy. I feel like I am fighting a loosing battle, knowing he probably will not survive his extreme sepsis. I know he has a very slim chance of surviving the next 24 hours. But, with all of that, I know the most important thing I can do for this man is not titrate his drips or give him more fluid. The most important thing that I can do for him is simply give him a bath. He has smelled like rotten flesh for three days. We have treated him, medically, surgically, and chemically. Now it was my job to treat him compassionately. If I were in his position, what would I want the most? I would want to be clean. I would want to die smelling like a human, not a dead animal. So, I set aside my swan cath setup and put down my flow sheet. I got out my soaps and lotions. I bathed this man as I would my own child. I cleaned him and washed his face. I combed his hair and shaved his week old stubble. I cried as I did it, because I knew that I was giving him the one thing that medicine often overlooks, his dignity. Whether he lives or not is out of my hands. I cant say I saved this man, but I can say that I did give him the compassion and humanity he deserves, that we all deserve...

Most Memorable Moment

I often get asked what my most memorable moment was/is. There are numerous memorable moments. Lots of firsts. Lots of bests. Lots of worsts. But there is always one that stands out. One that makes you realize how much of a gift life really is. Being a burn and pediatric nurse makes you understand, in a rapid fashion, how fragile the thread of life can be. All it takes is an instant, and the thread snaps. My most memorable moment was neither a burn or a kid. When I started on this unit, the prospect of taking care of a burned baby scared me beyond the worst traumas, the sickest adults, or even the biggest wounds. I guess its the innocence factor. What I consider my most memorable moment took me by surprise. I remember it distinctly. It was a calm and quiet April night. I was up for the next admit and excited to get something other than the standard 80 something old lady who fell off her step and smacked her head. Although I had secretly hoped for something interesting, something exciting, something I could learn from and gain another notch in my belt...I had no idea of what was in store.

Report from ER-- 20 yo F. Spontaneous bleed. Neg drug tox. No family here yet. Boyfriend at bedside. Devi stating. Unstable. Organ Donor.

Oh my God I thought. She is younger than I am. She was a good girl. A college girl working her way through life. Happy. Healthy. She was just like me. When I went to the ER to get her, I immediately found myself personally involved with her story. She was at home with her boyfriend. She had a bad headache. She was sitting on the couch in his arms. Then, he said, "She just went limp." He was there. Her boyfriend. Distraught and devastated. Her brother had just arrived. 18 years old, the first family member in house. He became the decision maker. Mom was away on a business trip on the east coast. Dad was in route from rural where ever. We brought her up. It was clear she was brain dead. Neurosurgery had already completed the first of two brain death tests. Her pupils where fixed and dilated. No cough, corneal, or gag. No painful stimuli response. Unstable vitals. The organ donation team was there. The brother being asked what she would want. The boyfriend crying and shaking. The nurse crying and titrating drips. We could save her organs. We could save other lives, if not hers. A good heart. A good pair of lungs, a good liver, kidneys, pancreas, intestines, corneas... I began to fight to save people I would never meet. People I would never know or take care of. I became the advocate for what good she had done and all she had left to do. I became her voice. I hugged her brother, held her boyfriend's hand. Prayed. Hoped. Cried.

Her dad made it in just before the second brain death test. I finally had her stabilized and ready for OR. We had most of her organs placed. She was ready to complete her role. I had become her mode, she became my muse. I helped her family say goodbye. I helped her friends let go. I helped her boyfriend brush her hair. I left the end of my shift as she was taken to OR. I know she saved the lives of 6 strangers. I know her family and friends are closer to each other because of her death. I know I am a better nurse, better woman, better person for what she taught me, for what she gave me. I remember her the most, because with her death I realized that life is but a single thread in a endless blanket. She taught me that when one thread breaks, others will bind.

My First Float

Today I floated to another unit for the first time. I had the interesting opportunity to go to the Neuro ICU for the last 8 hours of my shift. Its a nice unit, full of nice people, nice patients, nice pictures...I have nothing bad to say about it. I enjoyed my time there. Nothing exciting, but then, maybe that's a good thing. I met some new and interesting people. It is always humbling to be put in a situation where you are out of your comfort zone. To be thrown into a place I have never been, let alone worked, before is quite intimidating. I like new challenges and I enjoy a change in atmosphere from time to time. It makes me appreciate the comfort and stability of my own unit. Knowing the people you work with, knowing who you can count on, who you can trust, and where the things you need are always kept is an essential and often unrecognized attribute to critical care nursing. Its often the little things, the minor details, that make or break your shift. Comfort with your surroundings is one of those things. When they say "you will be floating", they dont just mean that you will go from your unit to another. They mean that you will just be there, floating in midair, waiting for the end of your shift, hoping nothing happens, because you dont know where anything is, who to ask for help, or what the unit norm is. You just glide along, float on through your shift, and at the end, come back down to reality. You know you did your best and your patients survived another night because you did all the right basic things. They floated because you floated.

1 Year Today!!

Today I celebrate my first year as an ICU nurse. I cant believe I have come this far. I cant believe all that I have done, seen, experienced and been a part of. If you would have asked me a year ago where I would be now, I don't think I could have said here. I always knew I would be a critical care nurse. I have always, since the age of 7 or so, thought of myself as a healer and care giver. Just ask my mother...I even tried to help the mashed butterflies on my Dad's truck grill. Helping others has always been a part of my being. But, when I think back to nursing school, I distinctly remember saying, "I love nursing...but I will NEVER do three types of nursing. I will never be an OB/delivery nurse. I will never be a burn nurse. I will never take care of sick or hurt kids." One thing is true, I have not set foot in a delivery ward since second semester of junior year. As for the rest, well, I learned to never say never. I find myself now, at this moment, sitting in a room with an adorable 3 year old, who happens to be 40% burned. It has occurred to my recently that I have an incredible knack for getting myself into places I swore I would not go, and then realizing none too late that I am in way over my head...Its sink or swim. I am happy to report, I can swim. After a year I can, on most days, keep my head above water and get my things done. Its been a huge learning curve for me and most mornings, I go home mentally, physically, spiritually, and emotionally exhausted. I have learned more than I can ever express in words, both about my career and about myself. I have redefined priorities and ethics. I have extended my beliefs and searched my soul. Perhaps that has been the greatest challenge of all...Perhaps I was always a good nurse, I just needed to become an ICU nurse to discover who I am as a person. Perhaps its what I said I would never do that led me to become who I really am...