PixelRN

So today I have an interview another great hospital in my city, the mental hospital. I've spent a lot of time there as a student and was convinced I wanted to do psych nursing. Somewhere along the way I was on monster.com and noticed that Nurse Anesthetists make >100K/year. I also noticed that you need 2 years of critical care experience to even get accepted to a NA program. I thought, hmmm. Well, I certainly wouldn't want to rule that out, and besides, if I can do critical care, I can do anything, right?

I don't know if this was such a good idea. Nonetheless, here I am. I know what to do if someone is coding, I know how to titrate pressors, I wean people from ventilators, I can keep a million lab values in my head and spit them back out to you on command but I am weary and unhappy.

This is where greed gets you, I guess. I have officially ruled out the possibility of becoming a nurse anesthetist.

Since contemplating leaving the MICU, I ask myself after every shift, "Are you sure you are making the right decision?" The answer every time lately seems to be a very resounding, YES!

Yesterday I was caring for a 36 year old bariatric patient, very difficult to sedate, had been on the ventilator with ARDS > 1 week. Today the physicians wanted to go the whole nine yards and extubate. They turned her tube feeds off at midnight so she wouldn't aspirate. Her sedation was cut in half. She did fine on her spontaneous breathing trial so they cut her sedation off completely in hopes of extubating her. I was completely on board with this. If I know what the goal is then I will do anything to try and help achieve it. She was thrashing around in the bed. No many how many times I would boost her up she would slide back down. (Some people just have that kind of anatomy). She was breathing okay, but occasionally setting off the apnea alarm, (you would too if you had all of that sedation on board). The apnea alarm didn't bother me. I was watching her closely, she was in no distress. She would wake her self up and take a huge breath. I knew that very shortly she would eventually wake up completely and the apnea alarm would go away.

She was satting 97%-100%. I drew a blood gas. It looked identical to the one I drew while the ventilator was doing all the work of her breathing. This girl was ready to fly.

I went to find the physician so we could move to the next step. All I could find was the intern. He consulted with his team and came back and said, "We're going to have to keep her on the vent and start her sedation again. She needs to have a CT scan. She has had unexplained fevers. and we need to see if there is an abscess."

"Are you sure?" I said. "I mean, look at her. She is ready to go. And she's currently afebrile. Her blood pressure is 180/100. It's not really looking like she's about to go septic. Once you start getting her sedated again it's going to take forever to wake her up again. You can extubate her and send her to the CT scan tomorrow."

AND she had a CT scan 2 days ago, which showed a sinusitis which may have contributed to the fevers.

But I guess at GHOAT we like to be 100%, without a doubt, unequivocally sure. The intern consulted with his team and the decision to keep her intubated was made.

So I gave her hypaque, and attempted to sedate her again. Meanwhile she was continually thrashing around in the bed and now she was pooping all over herself.

After cleaning her up and changing her linens several times (and finally inserting a 'flexiseal" - flexible plastic tubing which goes into her rectum and collects all of her stool into a bag,) she was transported to the CT scan, and transported back to me.

I checked her blood pressure, it was 80/49. Shit.

The transport tech asked me if we had a MAP goal. (translation: MAP = mean arterial pressure and we use a MAP goal when we are titrating pressors).

At this point I felt like screaming, "No we don't have a freakin MAP goal because her MAP hasn't gone below 100 all day long!" (A MAP goal is usually > 60)

But I didn't scream this because he doesn't know that, and it's not his fault.

Instead I said, it's probably all the sedation boluses she's been getting. I will turn down her sedation and see if her MAP will go back up to baseline. and of course I will inform the physician of her change in blood pressure.

I turned down her sedation and her blood pressure came right back up to where it was before.

Then the physician ordered to change out her foley because her urine culture was growing something.

Of course it's growing something, she is laying in stool and probably has been periodically throughout the week. (just to clarify - we do not leave our patients lying in stool purposefully. But think about it. If you are lying in bed, snowed on narcotics, on a ventilator, it is almost inevitable that you will poop all over yourself. And when you are in an intensive care unit, there will be times when the patient next to you is coding, or bleeding out and all of the resources of the unit are taken up by this emergency. You are lying in stool but at that particular moment you are not dying, so you will continue to lie in stool until someone is free to clean you up.)

So my opinion is to get someone closer to being able to control their peeing and pooping themselves. Extubate as soon as possible, don't fool around, get her sitting up and moving, get her using the bedpan. Please don't make her lie around in bed sedated on the vent one extra day if you don't have to.

I don't know. I think part of my problem is that I'm just too emotional to work there. My instincts were screaming at me that this woman needed to be extubated and that the CT scan was just a CYA type maneuver (or perhaps for educational purposes). I communicated with the doctors, I expressed my opinion. They did not listen to me. And why should they? They have been through umpty-ump years of medical school and I have not. I have not even been a critical care nurse for very long. They are a team, I am one person. And also, it is their decision to make, not mine. And I guess medical decisions are to be based on scientific data and standards of care rather than instincts and subjective observations (she is buck-wild and ready to reach up and rip that tube out herself!)

I read somewhere that nurses have a very high success rate when predicting whether or not a patient is ready to be extubated.

Is there anything I could have done differently? I went to the intern who in turn went to the resident who in turn went to the fellow. That's where the final decision came from. I have a feeling that if I went directly to the attending and told him my opinion it may have been taken more seriously.

But isn't that the just the essence of a bureaucracy? When it takes 5 people to make a decision, and no one can agree so you just sit on it another day. Is that any way to heal ARDS?

But still... there is a tiny little nagging voice in my head that says, "You just don't have the courage. You don't have the self-confidence to go up to the attending and interrupt whatever conversation he's in (because no doctor is ever just standing there doing nothing, it's always an interruption) and say, "Hey, I really think you should extubate this patient and put the CT scan off until tomorrow." Because what if you're wrong? What if they extubate her, and the patient goes back into respiratory failure and then has a difficult intubation (which is quite possible, considering her obesity) and then she dies or is brain dead (I've seen this happen on my unit - Did I mention that she's only 36?).

So when I am telling you this story, I want you to get something from it:

I respect the doctors. I respect their experience and education, and I respect the fact that when they make a decision, a person's life is on the line. They have to live with that. I can throw my 2 cents in but ultimately, it's not my decision, nor should it be.

Personally, I just don't think I'm cut out to work in an environment where doctors write orders, and nurses carry them out. The MICU at first glance, appears to be a place where nurses have autonomy (it was presented to me this way in the beginning because we use "protocols" rather than going to the physician for each and every order) but in the end, we really don't have much autonomy. It's false to think that we do.

And some might say, well, what exactly was it was that you thought nurses do?

I dunno. Take care of sick people?

Well, yes, they do (we do, I do) but you still need an order for just about everything you do. In critical care a lot of your day is taken up with collecting data and then making the physician aware of this data, or else weeding out what the physician does and does not need to know.

Kind of like a secretary.

And then you write a bunch of notes. "K=3.2. Dr. Welby made aware. 40 of K given per the protocol, will recheck in 2 hrs." (duh) or "Pt's blood pressure in the toilet. Dr. Killjoy made aware and at bedside."

or, "Pt is continually weeping and states, 'I want to go home. I'm going to die.' Dr. Beedlemeyer made aware. No interventions ordered at this time. Will continue to monitor."

But every once in awhile I'll have a conversation with a patient or a family member and get a feeling that I have really helped them and then I'll remember, "Oh yes. This is what nurses do."

Meanwhile I'm looking into nursing jobs that involve less orders and more conversations, because I think that's what I am good at.

Hence the psych interview today. Hospice interview (hopefully) next week.

I am thinking about leaving the MICU for another type of nursing. I've been in the MICU for almost 2 years (if you include my student rotation). I've thought about leaving before, but up until now I hadn't crossed the threshold of thinking, "I'm leaving because I can't do this" to "I'm leaving because I don't want to do this."

What has set this in motion?

I went to a workshop hosted by GHOAT's palliative care nurse. I've mentioned her before. She kicks butt (palliatively, of course). I think of her as "the angel of the MICU," always swooping down to talk us through when we need it the most. When I think about what position I would like to be in 10 years from now, hers always comes to mind.

The workshop was enlightening, thought provoking...but not entirely helpful when I went back to the MICU.

I just finished a three night stretch. Here's a sample of some of my patients:

17 year old girl with a terminal lung disease. She's had the diagnosis for 12 years and is most likely in dying process now. The attending (from what I am told - You don't get to participate in rounds when you work night shift) feels that because of her age, she still has a chance so they are "doing everything possible." Mom has earned the label of "crazy." She has been caught trying to feed her daughter strawberries (the daughter is trached and on the vent - food right now could kill her). The other day Mom gave her some sips of Coke. The next minute the daughter was gagging so Mom pulled out her OG tube while HER TUBE FEEDS WERE RUNNING. This girl is considered a difficult patient. Every moment she's awake she is mouthing words to you. It's usually something simple like "wipe my face" or I'm cold, I'm hot." if you were to respond to everything she says you would be stuck in an endless loop of taking off blankets, putting them back on, rearranging pillows, swabbing out her mouth, probably for 12 hours straight.

So you learn to set limits.

I gave her all of the PRN Ativan and fentanyl that was ordered and LET HER SLEEP. Even if it meant I could not get all of my MICU rubber-stamp tasks done on time.

The next night I came back and the charge RN had switched my assignment. (I didn't ask her too but figured it it was for the best.)

My new patient was a 50 year old woman with endometrial Cancer, morbidly obese. She's had a THBSO (total hysterectomy and bisalpingo-oophrectomy) and her wound is infected and not healing. I've gotten several reports that she is "developmentally delayed" and at the functioning level of a school-aged child. I can't find this documented anywhere but I did find it documented that her father says she graduated from high school.

In my opinion, she was a lot like the 17 year old.

I went into her room and introduced myself. The first thing she said to me was, "The horse broke its leg." I knew we were going to get along.

(For anyone following horse racing news you will know that she was referring to the Preakness, in which the favorite horse had to be pulled out of the race with an injury. I had just happened to be watching the race the night before and had unexpectedly burst into tears as I watch the whole tragedy unfold.)

She wanted to talk to me the whole time I was in the room. It was challenging. she was on a face mask with oxygen and it was difficult to hear her. Fortunately she was my only patient so I was able to spend time with her.

Several times she would cry out, "I don't feel good."
"What's wrong?" I would ask.

"I want to go home. I'm a mess."
and
"I'm going to die."

It's hard to know what to say to that. Especially when I feel as thought she is correct: she most likely is going to die. She has cancer. They won't start chemo until she's more stable. She's been teetering between 50% 02 via face mask and re-intubation (hence, they are keeping her in the MICU). The resident feels that because of her morbid obesity, her surgical wound will never heal.

In light of this I suggested a palliative care consult to the resident.

"Um... okay.... I'll bring it up on rounds."

Not exactly a ringing endorsement. However this was the same physician who earlier in the night a nurse was explaining "the five things" (a common theme in palliative care in which there are five things that the dying patient needs to hear before they let go) to him.

"Where did they teach you that. Nursing School?" was his smug reply.

At any rate, I set some limits with my patient. I explained to her that that I needed to leave the room for awhile to do some other things, (we received 4 admissions that night and withdrew care on another patient, so the unit was quite busy) She actually got some sleep but in between I spent a lot of time talking to her. I found out she was from my neighborhood. We talked about her family, her church. I listened to her when she said "I'm going to die," but I also did my best to distract her. Part of her problem was simply that she was awake, bored, but also keenly aware of her failing health. By the time I was ready to leave she grabbed my hand and said, "Thank you for being so nice to me." I realized that probably no one had given her the attention that I had given her that night. Granted, I had the luxury of time on my side (she was my only patient.) But still. How do you listen to someone weep and say, "I'm going to die," and ignore her because she is "developmentally delayed," and hence, "acting inappropriately."

I don't think I am cut out for this unit anymore. I'm thinking of pursuing hospice care.

Although part of me feels that I should stay and "fight the good fight" when it comes to palliative care in the MICU. After all, isn't that why they keep sending us to these workshops?

But how do you change the culture of the Greatest Hospital Of All Time?

The answer is, you don't. I just did a search at the GHOAT nursing website of the word, "hospice." No results were returned. I did another search of "palliative care." The only result was pointing me to the workshop that I had just attended.

I've crossed to the Other Side. It's been 12 long years and I never thought I'd go down that road again. Some told me "never do it!" Others said I'm crazy not to.

I went and bought a Mac.

It was those new commercials that did it. You know the ones with the cool guy and the nerdy guy standing around talking. Nerdy guy = PC, Cool = Mac. In one commercial, PC guy is coughing and sneezing because he has a virus and Mac guy says, "Oh, I never really get viruses."

Concurrently, my PC was hit bad by an insidious virus. One day I just snapped and went straight to the Apple store and bought the iMac with the 20-inch screen. Oh how it gleams. And yes, I know I could have bought an apple mini and paired it with a higher end monitor and saved some bucks. But I am helplessly enamored by the fact that there is no hard drive that I can see. It's inside the monitor.

I also bought the iPod nano and now there is music in my life again. I started libraritizing my CD collection and it's funny how everything gets dumped in the "90's music" folder. It's as if music stopped existing for me after the 21st century. No worries, though I have pandora.com to keep me current.

Not to mention GarageBand, which I am coaxing my husband to play with more and to work less.

So how does a pixelRN afford all of this you may be wondering? Well, no babies on the way yet...it's good to be a DINK.

As the warm weather sets in we see less and less pneumonia in the MICU which can only mean one thing.

 

Liver season!!!

 

It’s so strange how liver disease comes in waves. Four beds, side by side, in the MICU have liver patients. I started calling my end of the hallway liver alley.

 

Which leads me to Liver land.

 

Liverland is a place where I like to believe my patients go when they are in the throws of hepatic encephalopathy. It’s somewhere between the initial changes in mental status associated with liver failure and actual hepatic coma. The patient watches you as you are performing patient care with a curious look. You’re flushing his IVs, checking his CVP, drawing blood from his arterial line and all the while he just watches with this half-way interested look. You could be a bartender mixing up some cocktails. He might make some garbled sounds and you answer him in an assuring voice. You explain what you are doing and he nods his head. You ask him if he knows where you are and he calmly whispers something incomprehensible.

 

It’s this apparent lack of anxiety that I find so comforting when caring for my liver patients. They are not in the MICU, they are in Liverland. I imagine that it’s a nice place to be. No fears or worries. Maybe it’s like revisiting a fun place from your childhood. Once I had a patient who was in Liverland but I could understand what he was saying. He seemed to think we were out on the town together…”C’mon. Pay the check. Let’s get out of here.” or “Where’s my cigarettes?” I swear I would give him his lactulose and he would sip it like a cocktail and say, “This is delicious!”

 

This is in stark contrast to Lungland. Lungland (which I think is more due to the Fentanyl and Versed than the actual lung failure) is a demented and disturbing place. Just go to Bob’s dreams and you’ll read about what it’s like to be a bodiless head, in the back of a van with two people slicing you up like deli meat.

 

It’s easier to care for your patient if they are in Liverland. They don’t seem to feel much pain or discomfort. Thank God because their bellies are so swollen with fluid that it looks like they could give birth to a small farm animal. When they seem anxious or scared you just talk to them in a soothing voice and then they are calm. It doesn’t even matter what you are saying. As long as it sounds soothing.

 

With Lungland it’s different. The Versed gives them amnesia. They might be soothed for 5 minutes, but then they forget and the reality is that they have a tube jammed down their throat with makes them gag. Or they have delusions that you are draining their blood, or trying to harm them in some way.

 

So you snow them with more narcotics.

Which makes it really hard to wean them from the ventilator.

And the cycle goes round and round until they finally are ready to be awake and breathing on their own.

But then they realize that their lungs are permanently fried and they have a bedsore on their bottom the size of a three egg omlette. 

 

So if given a choice I’d rather be in Liverland, although I don’t know if anyone has ever lived to tell about it.

 

When you enter Liverland one of two things will happen. You will either pass gently into the next world (if there is one), or you will reach the top of the transplant list, and are wisked away to the OR. You receive your new organ and then recover in the SICU!

 

I was explaining Liverland to a colleague as we were placing a fecal incontinence bag on our patient’s posterior region. The patient was tolerating the procedure rather well. (of course he was - he was in Liverland!) My colleague said, “Like Mr. B from last week? He was in liver land, right?”

 

Sadly, the answer was no. Mr. B (fake name, of course) was not in liver land. He was very lethargic, but his mind was still with us in the MICU. He was feeling the pain of his 100 pound fluid-filled abdomen. At one point he was crying out and weeping from the pain. I begged the doctors for more morphine to give him. Whatever they ordered, it wasn’t enough. The problem was that he was #1 on the liver list, and so they were afraid of over-sedating him.

 

(as I write this I am wondering why that would be a problem. By virtue of his MELD score and his lack of infection, he has secured his place at number one. If a liver became available and it was impossible to assess his mental status due to his receiving Morphine, would they really bump him and go to #2? It seems so cruel.)

 

I came back from three days off to find that Mr. B had bled out from his esophagus and died before his liver became available. I was very sad to hear this news. He never made it to Liverland. He understood that he was #1 on the list. I had actually explained to him, that because of his position on the list he could not get more morphine.

 

“I don’t care!!!” he cried. “Just knock me out.”

So you can see why it’s good to be in Liverland.