At Least I Know What Unit I Don't Want To Work On

I stood in the hallway outside the room, nervously looking on at my first CRT (Critical Response Team) incident. Before the CRT was called, the woman was on a bedside commode, slumped over and moaning softly. “Clara,” her nurse, shook her shoulder and put the woman’s head between her hands, trying to get her to open her eyes. “Mrs. Jones, open your eyes! Can you hear me, Mrs. Jones? Try to look at me.” The woman was virtually unresponsive. The nurse I was working with ran into the room and asked if Clara needed help. “Call a CRT. Now.” Within minutes, the small room was swarming with help and the woman was whisked off to ICU. The relief Clara felt after the patient was stabilized and off our unit was palpable.

CRTs are sort of a pre-code blue; they are called by the nurse in the hopes that help will arrive and the patient will be stabilized before they lose consciousness and stop breathing. They are not called frequently, particularly on the unit where I work, so it was several months into my training before I experienced the one above. The charge nurse will show up quickly, as will all nearby nurses on the floor, and the ICU charge nurse and another ICU nurse will come down to assist as “another pair of eyes” to help assess the situation. The room fills almost instantly with helpful (and sometimes just curiously nosy) bodies.

Since ending my orientation on the unit and beginning to work on my own, I had a list of three (albeit irrational and somewhat ridiculous) fears that I had successfully avoided dealing with on my own. A month or so ago, I conquered all three of them in a single 3-day workweek, from 3rd most feared to the number one most feared, strangely enough. #3: Changing a PICC-line dressing on my own. (For those other nurses out there, I know this is bizarre. But I’m always afraid they’ll slip out!) #2: Putting a Foley catheter in. (I somehow managed to not put one in since nursing school.) #1: Transfusing blood/blood products. (Legitimate to fear, but still not worthy of months of avoidance.) In any case, I thought I had conquered the worst if it and have been feeling, for the most part, pretty competent at work. The last lurking fear I had that occasionally stressed me out was walking into a patient’s room and finding them unresponsive (or worse) and having to call a CRT or code.

The other day I squelched that one and made it through my first CRT. The man was a diabetic in renal failure who had been evading his nephrologist for some time who wanted to start him on dialysis. He came in for an unrelated surgery and when his labs came back the morning after, a slew of doctors convinced him to stay in the hospital and have a dialysis catheter (Permcath) placed and hemodialysis started. For this surgery, he needed to be NPO (nothing to eat or drink) for at least 8 hours, which can be tricky for a diabetic. Toward the end of my 12 hour shift, I was in the room with him and noticed a slight alteration in his mental status and also that he was profusely sweating. My suspicions proved correct when I checked his blood sugar and it was 30. This is quite low, and can be very serious – the normal accepted low is at least 70, but normal blood sugar is closer to 100. I began to follow our hospital’s protocol for hypoglycemia but despite two attempts, we couldn’t get his blood sugar higher than 60, which is still too low. I notified the MD and implemented the orders. He was started on what is essentially a sugar-water IV drip and I thought everything would turn out alright.

An hour later, I was in the room with him explaining his surgical consent, and within minutes before my eyes he began to decline; he was sweating worse than before and was extremely drowsy, mumbling, and tremulous. I checked his blood sugar immediately and was shaking as I waited for the results, knowing they would be awful. His sugar was 26. I ran into the hall calling for help and snagged a bottle of D50 (very concentrated sugar water) and told someone to call a CRT. In under a minute I had half a dozen nurses in the room assisting me, and within 2 minutes the full critical response team had arrived. My hands were shaking so badly I couldn’t draw up the D50, but someone graciously took over that task. The patient eventually stabilized and after a maddening amount of arguing with the internist, we transferred the patient off the unit.

I will still have lingering worries about worst-case scenarios and crashing patients, but at least I feel like I’ve had a little taste of the worst things this unit has to offer. One this is for sure – with those embarrassingly shaky hands, I sure as hell know the ICU isn’t for me!

Dementia; Or, the First Time I've Felt the Need to Post Since Graduating

“Do my daughters know I’m here? I need to see my babies, they need me to tuck them in at night. I always tuck them in.”

“Your daughters are all grown. They brought you here a few hours ago. They’re doing very well.”

“Do they know I love them? I need to tell them I love them. I love them so much. I’m so lonesome for them.”

“I know you are, but I’m here for you right now. They do know. You told them over the phone a few minutes ago, and they love you very much too. They told you so, and they’ll be back in the morning.”

“Why are you spying on me? I want to go home to the lake. I should’ve never fallen down that manhole. Why did they leave the cover off that manhole? Do my daughters know I’m here? They need me to tuck them in.”

“Your daughters are all grown up and they know you’re here. They love you very much. They’ll be back in the morning.”

“Why am I in prison like this? I just want to go back to the lake with my daughters. Please can I go?”

That is how the entire second half of my twelve hour shift went. She had dementia and was incredibly sweet, pleasant, and cooperative, but she couldn’t remember anything that I told her and was surprised every time I repeated my stock answers to her litany of questions. I’ve never dealt with someone whose mind was more like a sieve. She was, of course, a fall risk, and I had the bed alarm turned on so that a blaring noise went off whenever she tried to get out of bed without one of us there. For 6 hours, this went off almost every 10 minutes. I do tend to exaggerate at times for comedic effect, but I only wish I was exaggerating about the previous sentence. I repeated the same thing every time I went in and reset the alarm. I sat with her for a solid hour and a half, but she was insatiably lonely and immediately tried to get out of bed as soon as I left. I distracted her with magazines, foods and drinks to nibble, tried to find a show for her to watch, and even asked her to “help” me fold towels and washcloths to keep her hands busy. None worked for more than a few minutes, ten at best.

I can’t imagine being the caretaker for someone with a disease this severe. It’s unfathomable and devastating. When I finally caved and called her daughter after several hours of repeated pleading, I could hear the tension in her child’s voice over the phone. She apologized to me, saying that she wished she could be there, but she needed a break. Just a little break and some rest. I couldn’t blame her for failing to warn me what my time alone with her mother would be like. I had to hang up the phone even though she wanted to tell her daughter that she loved her one more time.

I cried on my drive home, my first time crying because of work since I started in February at my first real career. I’ve been so proud of myself when the other nurses ask how many times the job has made me cry. “None!” I’ve said, and they’ve been surprised. I’ve been emotionally drained from patients before, but never like this. Everything I did for her and said to her was pointless. Hopeless. Irrelevant. She couldn’t remember all the times I’d repeated myself over the past hours, but somehow, her frustration was building and all she could recall was that I was keeping her hostage. “This is America, you know. The United States. I’m not a prisoner. I’ve had my picture taken with the Statue of Liberty. I’m free.” No matter how much I soothed her, hugged her, held her hand, stroked her face, and reassured her that both she and her daughters were safe and loved, she forgot it within 5 minutes. I kept my voice calm and gentle with her, but as soon as I left her room I would lose it. Over and over.

I’m not entirely sure what to make of this day, or this post. It’s cathartic. And depressing. And terrifying that it may happen to someone I love. Terrifying to think I might have to do this for more than a day, way more than a day. I don’t think I’d want to live if I was that way. At what point do you just give up?

New Town, New Job, New Life

It's official (and it has been for some time now) - I've graduated school and passed all the necessary requirements to practice nursing in Texas! In this state, in addition to the NCLEX, there is also the Jurisprudence Test that must be taken to be registered as a nurse. It's extremely easy though, and it's essentially open book (or open browser - it's online and any resources can be used.) It's also official that my husband, The Pug and I are moving! This is a big deal to me - I dislike almost everything about Texas, particularly the conservative rat hole devoid of any concept of social justice where we currently reside. Texas does have its redeeming qualities though, most notably the generally friendly and endearing "Howdy y'all!" populace and the liberal progressive oasis of Austin. We'll still be in Texas, only in an exponentially better location.

I also have a job! As a graduate RN in Texas, many people mistakenly assumed that finding a job would be easy. Unfortunately, at the time of graduation in December, more than one third of my 100+ person class was still jobless, and that included myself. Several hospitals around here even have a hiring freeze, as do several of the places in our new city. When even the job outlook for nurses in Texas is bleak, something must be seriously wrong with the economy.

I tried to sell myself as best I could, and even with the magna cum laude on my diploma and volunteer work on my resume, I only got one bite at one hospital. And holy crap, was that a nerve wracking job interview. I practiced for hours before hand and am pretty sure that I bombed several questions, and then had to wait over 3 weeks for a callback. Luckily I got the job for the only position I was even considered for. There were only 3 positions even available, even on a 64-bed Med-Surg floor. Apparently budgets are pretty tight right now.

Anyway, the hospital is, unsurprisingly, religiously oriented. It does a metric ton of charity work in the area though and is not-for-profit, and that's something that I'll be proud to be a part of. (I don't want to get into politics at this moment, but let's just say that I don't think health care should be a for-profit venture and everyone should have access to quality healthcare.) It'll be interesting to see if there are any signs of the hospital's religious background in my day-to-day nursing experience. Obviously there are crosses on every wall and a point is made to notify visitors and patients of the hospital's mission, but hopefully it ends when it comes to employees. Overall, I think it will be a great place for me to start out and is full of opportunities.

I am excited to be able to continue on relating stories of the amazing people I come across and how they change my thoughts and views. I can't wait to grow as a person and care for my future patients. Next week, I start a new life.

Graduation: The Pinning Ceremony

For the past four years, I have looked forward to the day I graduate. It wasn’t especially exciting for me to graduate high school, because I knew that three months afterwards I would be starting yet another four years of school until I actually was able to start real life. And lo, the time has come! In December, I will walk across the stage and be able to wave adios to college (until graduate school, but I’m going to try and forget about that for now.) For those of you who aren’t familiar with graduating from a nursing program, there is a special ceremony (aside from the typical graduation ceremony) that most schools have – it’s called a pinning ceremony.

I can’t speak for any more than the couple nursing schools I know about, but generally, each student nurse walks up on stage one by one and gets a special pin with an insignia from his/her nursing school pinned on him/her by a special person in the graduate’s life. For example, as a side note, I’m hoping my husband and mom can pin me, but my husband has extreme stage phobia to the point where he needs medication or else he’ll faint and my mom already told me she’s going to bawl her eyes out just looking at me, so it looks like I’ll have to recruit my dog to pin me. Anyway, back to the pinning ceremony. So all the students get pinned by a loved one, some faculty members give a few speeches, and we eat some cookies or something. Oh, and did I mention the Florence Nightingale Nursing Pledge that we all recite (AKA The Nightingale Pledge)? Ahem. Here it goes:

I solemnly pledge myself before God and in the presence of this assembly:
To pass my life in purity and to practice my profession faithfully;
I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug;
I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling;
With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care.

This is what I am dreading the most – well, besides the fact that the pinning ceremony is going to be held in a megachurch (I’m in Texas, remember?). There are some more modernized and updated Nightingale Pledge variants floating around, but I’m not sure which one my class pinning committee has decided on. I have heard many older nurses mention “the Pledge,” normally in addition to whatever else they’re using to deride us about something or other. “Hmph. New nurses these days… don’t they know about the Pledge?” So at least for older nurses, it is considered something relatively important in the field of nursing; it’s essentially our Hippocratic Oath.

I personally don’t think it’s necessary at all for us to take an oath (or for anyone to ever take an oath, for that matter – it’s not the Middle Ages.) Any licensed medical professional should be competent enough to understand the main concepts of caring for other people: don’t hurt them intentionally, strive to prevent errors and mistakes, and abide by all of the general ethical principles of veracity, fidelity, beneficence, nonmaleficence, etc. It’s common sense, and they should be followed regardless of whether an oath is taken or not – it’s part of the job, and part of the responsibility we bear as health care workers. It’s ridiculous to think that student nurses aren’t going to behave ethically until we robotically repeat some century-old phrases.

I am ecstatic about graduating and can’t wait to actually begin practicing in the field that I have worked so hard for, which will undoubtedly provide me countless stories to retell here. Even though I don’t necessarily look forward to some parts of the pinning ceremony, I understand its symbolism is well-intentioned. Unfortunately, I have the sinking feeling that I might be the only student nurse at the ceremony not pledging myself “before god” and passing my “life in purity”. Instead, I’ll strive to be a rockin’ nurse who treats all patients equally and has the benefit of not being biased toward any religion or god at all. But for now, that’ll have to remain my little secret.

A Difficult Conclusion

I have known of quite a few patients in the ICU that I’m in that have died. I have even cared for a few of them on a day shortly before their deaths. However, I have not yet seen a “code” situation or watched a person die, let alone clean up their bodies afterwards.

Today I had that experience. When I arrived on the floor a little after 6AM, the night shift nurses were all unusually busy, and both the night shift charge nurse and day shift charge nurse were in the same room, along with two other nurses and a respiratory therapist. They were shaking their heads frequently and running around, saying the patient's O2 sats were in the 70s-80s (which is pretty bad, but is by no means a death sentence.) When the charge nurse came out, I purposely (unknown to her) asked to be with a different patient, even though I knew the previously mentioned patient would certainly be an intensive learning experience.

Since my first day on the unit, I have been unbelievably petrified of having one of my patients code. The charge nurses always try to give us very sick patients because they are the best learning experiences for students – so I have gladly welcomed opportunities to learn. Regardless of my desire to learn, I have still been, simply put – TERRIFIED – of being in a code situation and having to give chest compressions, bag them, push epinephrine/emergency meds, etc. It doesn’t help that I have a pretty low level of confidence in myself, which is almost crippling at times. So this morning, there was something in the air about this guy – and I did NOT want to be on the front lines when he crashed, which seemed pretty likely.

About two hours later, I hear the calm, almost robotic voice of someone calling a code blue over the intercom system of the hospital. People came running from every corner of the campus – cardiac, chaplains, pharmacist, anesthesia, respiratory backup – everyone. Not to mention the three students (including myself) that were already on the unit. I walked over from my patient’s room to the room where the code was happening, and there were already 20 or so people crowding the room. The large glass doors were flung open, and one of the nephrologists (he was in the room when the patient coded) was giving chest compressions – but the nurses were clearly running the show. I walked over at the same time as the patient’s three family members came rushing to the room, and my heart broke. In a matter of seconds as they saw the nightmare scenario before them, they began crying and quivering and clutching each other while sobbing. I wanted so badly to say something to them and comfort them, but I started crying just looking at them and had to control myself and look away to remain “professional.” It was frightening to me too; I’d never experienced anything like it.

In a shortened version, here is what actually happened to cause the code blue. The man was (clearly) ridiculously ill. Among other things, he was on continuous renal replacement therapy (dialysis) and the nephrologist was in the room with the nurse to secure a usable access site for the dialysis. During this period, the nurse noticed that the patient’s already low O2 sats were getting lower, and he had no pulses – this is called PEA or Pulseless Electrical Activity. It means that, essentially, the patient’s cardiac electrical system is working just fine – so on an EKG, the heart appears to be just beating away and working fine. However, it is pulseless, meaning that though the electrical conduction system is working, the contractile abilities of the heart are gone, and so the patient’s heart isn’t pumping a drop of blood. The body can only sustain this for a small amount of time, because eventually the cardiac muscles stop receiving oxygen. At this point, this particular patient went into ventricular tachycardia and then ventricular fibrillation. The defibrillator was fired up while CPR was done, and then the patient was defibrillated. On the first try, they brought back a rhythm and pumped him full of a number of emergency drugs to bring up his blood pressure. Even though they brought back a heart rhythm, he was in respiratory arrest as well and his blood pressure was really almost nonexistent. Shortly after that he went down again and they attempted CPR, but the doctors told the family that there was nothing more they could do.

An hour or so later, one of the nurses asked if I would like to help prepare the body. I said no, but went anyway. We were taught about this in school, but I hadn’t yet ever experienced a death. Basically all of the tubes, IVs, catheters and other lines need to be removed and the body is bathed. Clean sheets and gown are then arranged, so the patient looks as clean and “normal” as possible for the family. This all sounds simple and nice, but I’m going to be honest – it was pretty disturbing. Because of chest compressions from CPR, air gets pumped into the patient and they kind of burp when you roll them – and it smells of their insides. Because the blood pools, the skin on the underside of the patient becomes mottled and purple. He also bled out of some of the small holes where his IVs were because his body wasn’t clotting any longer, and along with other body fluids, it was kind of messy. The oddest part of this was how the room smelled and how he smelled – it wasn’t any cleaning solvents, medicines, or blood or body fluids – I could distinguish those well enough. The smell was not unpleasant… it was almost a sweet odor, musky and fleshy. I wondered if that is what death smells like, when the body is just beginning to disassemble itself and dissolve back into the ground.

The whole day didn’t necessarily make me sad, but it got me thinking. Mainly I feel an awful, painful sympathy for the patient’s family. The look of terror and despair on their faces was more than I can handle, and I’m not sure I could work on a unit where that look is commonplace. It made me realize just how important a role nurses can play in saving a person’s life with smart, efficient decisions and delegating. But at the same time, I felt a deeper knowing of how gloomy, disheartening, and achingly real it can be.

To Judge or not to Judge

Again, it has been far too long since I posted an entry. I think it is largely because even now, I am afraid that I will somehow get into trouble for writing about my experiences. I do believe though that as long as I divulge no specifics, I’ll have done nothing more than share my boring life with the world. In any case, I have had an interesting semester so far. Here is a brief list of some of the craziest/saddest/most fascinating stuff:

-Saw a “drive by” birth; i.e. the mother comes rolling down the hall at 9cm dilated with no prenatal care and shoots the baby out within minutes. Oh, and she spoke no English. And my god, she screamed as though she was pushing out a bowling ball covered in razor blades.
-Saw far too many children slowly being eaten up by repeated bouts of cancer
-Caring for and feeding babies so premature they are the size of water bottles
-Two words: necrotizing fasciitis. Due to the misfortune of catching such a horrible infection, my patient passed away just the night after I met her.

There have been other things of course, but the vast majority of my stories are more subtly heartbreaking rather than so mentally or visually disturbing. I have quite a few more days left in my ICU rotation, and I’m sure I’ll see far more depressing, ethically challenging things before I’m done.

Specifically, I cared for an emaciated critically ill man who had been transferred from prison to nursing home to the hospital. He required intensive, detailed, gentle care, and during the day as I watched him grimace and slowly deteriorate I wondered what he had done to land himself in prison. He looked so helpless and childlike, it was hard to imagine the life he'd led. I later found out that he was a murderer. It made me feel strange to know that, but it didn’t change how I felt about him or my day. It’s interesting to learn about patient’s lives – who they love, who they are, what they’ve done, their transgressions. I have to constantly remind myself to not judge patients and their family members for ignoring or neglecting one another. A dying grandfather whose family has deserted him, while appearing sad and lonely, may have been an unremorseful pedophile or abuser. A middle-aged woman’s family may seem calm and relieved after learning of her impending death - not out of malice but out of love – she’ll soon be out of her extended misery. A forlorn bald child with cancer whose family rarely visits – her parents may be doing all they can to make enough money for her treatments.

I know it all sounds cliché and stupid, but I swear, half of this “being a good nurse” stuff is about working through the emotions of it all. Making sure I don’t turn myself one way or the other. Most of all, I'm trying not to judge what goes on in a hospital – almost everyone is at their very best or their very worst, and you have no idea who’s who.

Dang!

It has been nearly 3 months since I've posted. I feel bad about it, like I'm neglecting my baby or something. This blog was meant to be my baby after all.

Luckily, I have found myself settling in to nursing school and feeling more comfortable with my fellow students. But school is practically over now; in December, I will graduate! More and more often, life takes the opportunity to smack me across the face with the realization that IT NEVER SLOWS DOWN. I feel old and haggard already and I'm not even 22 yet. It seemed like just yesterday when I started this blog.

In any case, it's now the NEXT semester. I have Labor and Delivery, Critical Care, and Pediatrics this time around. Since the beginning of school, I've kept my mind completely open about what field of nursing (there are dozens) I want to get into. I've always had a special place in my heart for pediatrics, however, so I'm excited to see how I actually like it. Enjoying working with the little ones is probably the one stereotypical girl thing I possess. I think it's because I find it difficult to not be able to touch patients for fear of lawsuits and charges. Nurses are certainly allowed to touch patients, but it is more suggested that we do small things like holding a hand or petting an arm. But sometimes, someone just looks like they need a big hug! And with adults, it's much harder to know when that's appropriate or not and whether the patient would feel comfortable or not. Hell, there've been plenty of times when I have needed a hug but I don't know how to ask for it or I feel awkward initiating it. On the other hand, with kids and babies, it's pretty well established that hugs and touching are requirements for proper growth and development. It makes it a lot easier for someone like me!

Also, wiping a kid's butt is a lot less weird than helping an embarrassed grown man use the bathroom. I don't know if that's a common perspective, but it's how I feel and it's hard for me to get around it.

But enough of the chatter! This is a blog chronicling, to some degree, my dealings with religion and nursing. So far, more of the instructors than not have mentioned religion in some form. When one student sneezed, "GOD BLESS!" popped out of an instructor's mouth before the sneeze was even completed. Another discussed her entry into L&D nursing: "You never know what god has in store for you." Several of them graduated from Baptist schools or have husbands that are pastors or reverends. I am curious as to what it is about nursing that draws overtly religious folks. Perhaps it is a Bible Belt phenomenon.

By now it is easier for me to not be outwardly surprised by the things they say. I am intrigued and nervous about what they will teach us about circumcision, breast feeding, and labor and delivery care in general. With some things I can bite my tongue, but when I come across something that is being done just because "it's what we've always done!", I don't tolerate that very well. In general, Western birthing culture seems to be a bastardized, sterilized version of what nature intended. Don't get me wrong - I'm not saying our technology isn't wonderful and life-saving. In the case of circumcision, in probably 99% of cases it is unnecessary (I will probably dedicate a post to the topic as it deals directly with religion). Additionally, many Christians in this country do it because "It's in the Bible!" Yes it sure is; but it's referring to the Jewish peoples' covenant with god. Last time I checked, Christians aren't Jews. See how my sarcasm is cropping up already? It should be an interesting semester.