The Art and Science of Nursing

When I was in nursing school my teachers would always talk about the "art and science of nursing". The marriage of scientific knowledge and the intuition we have as caring professionals. Back then I understood it on an intellectual level, and I saw it in the experienced nurses who, due to years of hands on nursing, had this way of balancing their care with scientific precision and  compassion that drove everything they did. Over the years I have learned it more myself but it wasn't until last night that I realized just what my teachers meant all those years ago.

When I walked into work last night and saw my assignment, I knew there was a potential to have a rough evening. My patient was a young man I knew well. A guy who had been diagnosed with ALS many years ago... a disease that slowly takes away all ability to move, eat, go to the bathroom and breathe on your own... eventually even takes away the ability to speak. It is fatal and it is characterized by this "trapped syndrome" where your mind is completely alert and aware and yet your body is a hollow shell of what it used to be. In all honesty... ALS is my very worst nightmare.

I had been told that my patient was at a point in his disease process where he was not willing to participate in nursing care. No turning, no bathing, no suctioning... basically we were there to give pain medicine and offer sips of water and such... but only when he asked. He was still able to talk through his trach, despite being on the ventilator and he would let us know what he did and did not want. Oh great.... I thought to myself... this is gonna be a fun night.

If I had been given this assignment four years ago when I began my nursing career, I would have had a large amount of anxiety surrounding his decision. As a nurse who knows the implications of not turning your patients (bed sores that go down to the bone) and not suctioning your patient (pneumonia that could kill you) and the list of other things that this guy won't let us do... how do you just not force it on him and take care of him the way I know I should? I remember having these dilemmas as a new grad.

Now... four years in, I realize that I have begun to understand that age old wisdom my nursing instructors were trying to impart in each one of us. This man that I cared for last night is a man who is dying... not only that but he is dying from a horrible disease that leaves you completely paralyzed. You can control nothing. Not your body, your environment, your position... everything in your life is in the hands of a health care professional that doesn't know you from Adam. And sadly... most of the time, with chronic patients... nurses and doctors avoid them because they can come across as being needy and demanding... all in an effort to cope with the loss of autonomy they have had. So... you are left with a grumpy, isolated patient who tries to demand even more as a reaction to his surroundings and refuses to do the things we know need to be done... and often times you have a nurse who just wants to get in the room and get out.

So, last night I knew that this is where I needed the art of nursing. Instead of explaining to him why I needed to turn him, I asked him when he wanted his pain medicine. Instead of running out of the room at every chance and trying to just get my work done and get on with my busy day... I sat in the room and watched Ricky Lake and chatted with him about his time in the service. We watched the news and talked about the recent CIA scandals and the depressing state of our government. We laughed over remembering the taste of dimetapp as a kid and I told him about the time I puked all over my poor grandma when she made me drink theraflu when I was sick.

The funny thing is that I can't remember the last time I had such a good night at work. It was peaceful and slow and it felt good to actually connect with this guy. At the end of the day I was really thankful for him and our time together and I could tell that he was thankful to have a nurse that didn't force him to have his sheets changed or try to convince him that he was getting too much pain medicine. In the end I have a feeling that our time together did more for the both of us than my turning him ever would have. He actually looked happy when I said goodbye to him this morning... and I think it was because someone sat and treated him like a person instead of a patient for once.

So... four years in I am finally getting it. I'm still learning it and will probably continue to fine tune that artful skill of knowing what lines are hard and fast and which can be blurred around the edges a bit. I will say one thing though... my nursing instructors would be proud :)

Nursing Burnout and Divine Appointments

 It is not a secret that my job has been difficult lately. So much so, that I have not felt a desire to talk about it on here much... at all. Summer time in a teaching hospital is difficult and even some of our most positive, peppy nurses have been sucked dry of energy, to the brink of burn out.

I have felt myself on the verge of it also. If I remember correctly and thankfully to the documentation of this blog.... this happened last year also. The difference is that this year my life is much more busy and hectic... but I am also a year more experienced.... so now I know when to say something and when I can just let it go.


I have a new love and respect for our medical students and I am thankful for those that have the zeal of someone who wants to help heal people and the humility of someone who knows they don't know it all. I wish our new interns and residents had the same mentality. It makes me sad when the physicians are at odds with the nursing staff. I promise we are not the enemy.... there is nothing more that I love than having a good relationship with our physicians. It makes my job so much easier and it makes everyone a lot happier. I can share my experiences and they can share their knowledge. That way everyone learns and everyone grows.... working cohesively for the better of the patient. Shouldn't that be the goal? Egos aside... the patient's safety and health is the most important thing, right?

There have been many times this past month that I have left work in tears. Exhausted and worn out. Taking care of people when they are sick and angry is difficult... especially when they take it out on you. You get opposition from all sides... the patient, the family, the doctors, the nurse execs. I have learned that sometimes the only allies you have are your co-workers.... yet, even they can fail you at times. I know I have failed a lot.


The other day a co-worker of mine overheard me explaining why I did not want to work an overtime shift and she said, "Well, you're ahead of schedule!" When I asked what she meant she explained that she was referring to the fact that the average dropout rate for new grad RN's is three years.


3 years is how long most new grad nurses last in this field. By year 2 of their career 57% of new grads will have left their job due to negative workplace conditions. *source Those aren't good odds but I have no desire nor do I have any plans to leave my job. I just simply don't want to work overtime.... hoping to preserve any love for nursing that I have left at the moment.


This past weekend I went to a BBQ with Chris' family and I ran into a random friend of theirs... an old neighbor and also a nurse for many years. This woman is now in her 80's, long retired but still very updated on nursing practice and technological advances in medicine. She has been a patient many times as well. I happened to mention something about my job and that led to about a 30 minute conversation about nursing and being a new grad and dealing with difficult physicians and the struggles of our line of work.


She told me that there were many days when she would go home in tears... so many times she had to stand up to the physicians who treated her disrespectfully even when they were in the wrong... and she told me about the time she was choked by a mentally ill patient and verbally and physically assaulted by many others. She reminded me how difficult it is to work 12 hour night shifts in the ICU. She told me that there are few careers like nursing that encompass so many sides of humanity and how there will be few people.... if any, who will truly understand what we deal with on a daily basis.


But best of all... she told me that I was not crazy... that the pain and the hurt and exhaustion I was feeling was normal and that it too would pass. She reminded me to take care of myself and take time away when it's needed. She encouraged me to lean into the relationships I have with my co-workers. She validated how I felt and affirmed that even though people don't understand how difficult it is... it does not mean that I am alone. She told me that the day I stop feeling so deeply and passionately about my job... is the day that I need to step away... but that I am not there yet.



It was a divine appointment. It was exactly the thing I needed to hear and it gave a voice to my fears and struggles and hurts. This 82 year old woman who did not even know my name gave me something that even the closest people in my life could not. Understanding... and relief.


For those of you out there experiencing burnout... whether on a scale large or small.... New grad or not.... you are not alone. And if at the very least... the next time you go to work and feel overwhelmed or exhausted or like you have nothing else to give.... know that you are not crazy. No, you are not crazy at all....

... and that this too shall pass. 

The difference between a great and not-so-great doctor from a nursing perspective.

Today I'm reflecting on what it is that differentiates a great physician from a not-so-great one from a nursing perspective. Working in a teaching hospital you deal with all types of MD's. Interns, residents, fellows, attendings... starting in that order from lowest to highest on the hierarchy... we get them all. Working night shift in the ICU we also have an on-call team that is here 24-7. Depending on what the night is like we will always have at least an intern and a resident on the premises. If the night is nutty and we have a lot of admissions or very unstable patients, the ICU fellow will usually stick around throughout the night as well.

It's been a while since I've dealt with a difficult intern or resident... to be honest the teams that have been rotating through have been really great and the doctors have worked along aside the nursing staff so well, which I'm so thankful for. Tonight though, I came head to head with a resident and intern that reminded me just how frustrating it can be to have a not-so-great team. At the moment, all the nurses on the unit are counting down the days until this rotation is over... kind of unfortunate really.

Now before I go into my rant about all the things that make a not-so-great MD I will say this... I get that there are not-so-great nurses too. I also get that during your residency you are sifted through so many places and units and services... each with their own set of protocols and "this is how we do it around here" politics and junk. The culture of every hospital and even every unit can be so incredibly different. I can see how it would be really tough and exhausting to adjust and learn in so many different places.

I know that all of the doctors I work with have dealt with probably some really not-so-great nurses and I assume that can make you a little leery of trusting or working on a peer level with other nurses in the future...

BUT...

I feel there are a few suggestions for future MD's or MD's in their residency that will get you some brownie points with the nurses you work with.
1. I've said this before but humility will get you far. Coming into a unit that you've worked in for a mere two weeks and talking to a nurse who has worked there for 30 years with a condescending tone... not a good idea. Having a superior attitude and an "I'm the doctor so you WILL follow my orders" air about you.... not a great idea either. In fact its a terrible idea. With the exception of a few, most of the nurses I have worked with are very intelligent and I think people underestimate just how much we have to know as nurses. We know how things work in our unit. We know what the attendings usually want and what the surgeons prefer with their patients. We have a knowledge of physiology and disease processes and medications that is probably more than most medical students and interns expect. A little respect and trust is all I'm asking for here... and that takes humility from both sides of the fence.

2. Learn how to communicate. I think 1 and 2 go hand in hand here. In order to communicate well it takes humility. What I have noticed is that most of the time when someone is over confident and condescending towards others its because they are insecure and are over-compensating by having a massive power trip. Or maybe you're just a jerk... still.. learning how to communicate on a professional level with your colleagues and patients is key.

3. Teachability...
Huge! Ok... I know you are a doctor and I know you had to do massive amounts of schooling to become a doctor. I'm giving you the benefit of the doubt that you are brilliantly smart and motivated and hard working... I mean you made it through med school, passed your boards and you are in a very prestigous residency... thats all fine and dandy but you are not God and you do not know everything. I don't either... trust me... I deeeeefinitely don't. Still, most of the nurses I work with have years and years and years of clinical experience that any physician can draw off of. If we can't teach other and work with each other's strengths and weaknesses we are gonna get no where fast. And let me tell you... if you treat a nurse like he or she is beneath you and doesn't know anything and you know everything... you will make an enemy... Guar-OWN-teed... as gradydoctor puts it. :)
Ok basically just be respectful, humble and learn to listen to those around you... those three things go a long way in the nursing world.

Example for you all:
When I came into work tonight, I found out I had the post-op heart surgery patient and I was ecstatic... until... he began dropping his blood pressure and started shivering like mad... flopping in the bed like a fish out of water. His peak pressures were increasing on the ventilator, he was clamping down on his ET tube and he was fighting the vent like there was no tomorrow. All really not good things... things that could cause this guy to seriously crash on us if we don't treat it ASAP. So...I hunt down my resident and intern and I ask for some demerol to stop the tremors (usually caused as a reaction to anesthesia) and help sedate the patient so he wouldnt fight the ventilator and bottom out his pressures by "clamping down."

Their response?

"Just go up on the neo (med that helps increase blood pressure) and increase the sedation."

"Ok well he is already on 5 of versed and 500 of fentanyl and thats maxed out and its still happening. Plus CT surgery doesn't like us using neo on their patients because of the vasoconstriction and I wouldn't feel comfortable titrating up unless we got the okay from the CT fellow. I think if we gave him demerol he would stop fighting the vent. I could always give him some fluid too. His CVP is only 10 and CT usually likes it around 12 at least."

"No. Give the sedation more time to set in and just go up on the neo." the resident stands with his back towards me, arms crossed and continues his conversation with the intern.

Awesome. Apparently I don't even deserve to be looked at while you bark orders at me and refuse to listen to basically anything I just said.

You all can probably guess what the night was starting to look like for me. It was only an hour into my shift and I was already irritated. Luckily the ICU fellow came by at the time so I pulled him into my room and showed him what was going on. The intern and resident see him at the bedside and rush into the room to see why I was talking to the fellow and not them. I'm sure they could see that I was clearly frustrated at this point and I was about to go above their heads to get what I wanted.

All it took was a few seconds for the fellow to look at the patient and say, "How about I give you some demerol? Do you think 50mg IV is ok?"

"Perfect! Thats all I wanted!" I throw my hands up in the air and head towards our med station.

"And in the meantime let's give him a 500cc bolus of LR for his pressures."

What a sigh of relief! All I could think was, "Thank goodness for the fellow and thank goodness for doctors that actually listen to the nurses and don't treat us like we are completely inept!"

The rest of the night I had respiratory therapists and nurses coming in and out of my room to rant about how frustrating it was working with this on-call team and this particular rotation of docs.  The rest of the shift ended up being fine for me but it got me thinking about the way you present yourself to people and the way you communicate and how it can completely change a team dynamic. Also it can just simply make your life miserable when you alienate the very people who are helping you and it's so unnecessary.

Now if you really want a good laugh... see the list of ways to make your life completely miserable in the hospital, on gradydoctor's post here. I was dying of laughter the entire time I was reading it.

10 things I've learned being an ICU nurse

In honor of my 100th post I figured I'd write 10 important things I've learned these past two years of ICU nursing. 10 things  I would tell myself as a new-grad... if only I knew then what I know now. I think it'll be fun to do this and see how it might change over the years.

10. When in doubt gown up!
Self explanatory really but if you're interested... Read this post and you'll see just what I mean. Also, since we are on the subject... it never hurts to have an extra pair of scrubs in your locker and this can be applicable to any hospital health care worker.

9. It's all in the details...
Even if its the smallest change or just barely off vital sign, lab value etc... sometimes its the subtleties that add up to a very important diagnosis. Example: A nurse once sent home a pediatric patient with a temperature that was slightly below normal. 96.9 f (normal  is 98.6 f) The child ended up back in the hospital the next day with full blown sepsis and ended up later passing away. The below normal temp. was a sign that the patient was in the "cold" phase of septic shock.

8. Some things just take time.
No matter how much you study or how many classes you attend...some things just come from experience.... and that just takes time. Don't stress about trying to get the "difficult" assignments... they will inevitably come to you and when they do... trust me... you'll miss the days of getting the patient up to the commode 10 times in one shift.

7. A little lot of humility goes a long way.
If there is one thing I've realized about myself and people in general while working in the ICU is that a lot of the time when people are cocky or defensive it is because they have some major insecurities they are trying to compensate for. Consciously having humility will always get you so much further than being domineering or prideful towards others... especially when you are working in a team setting.

6. Never, ever say things like, "I'm bored." "Man, it's slow." or "It sure is quiet around here these days!"
Phrases like that are certifiably going to buy you at least one nasty code blue or a few gnarly admissions in the middle of the night... if it's quiet just enjoy it while it lasts!

5. If you are unsure about something STOP and double check before you proceed.
Probably one of the hardest lessons I have learned since becoming an ICU nurse. Even if it is in the middle of a code... even if people are rushing you or yelling at you... even if you are afraid of looking dumb... if you feel unsure about a drug you are giving or a procedure or a protocol... stop and ask! Trust me... it is always worth taking the extra minute or so to double check or to ask for help. It takes only a few seconds to make a fatal mistake and only a few seconds more to prevent one from happening. It's always worth the extra time and people will trust you and respect you more if you know when to ask for help.

4. A good report sheet and a checklist can keep you sane.
The thing that I love most about ICU work is the detail of it all. As ICU nurses we care for our patients from head to toe. Most of the time our patients rely on us for everything large and small... from oral care to breathing. No task is insignificant and sometimes remembering it all... even if you have only 1 or 2 patients... can be daunting. Having a thorough report sheet and a checklist of things to be done can be a complete lifesaver when things get crazy.

3. Choose to be happy.
The ICU is often times a really difficult place to work and if you aren't intentional about being happy in the midst of that... sometimes it can really bring you down. I think sometimes we have to make a conscious effort to smile, laugh and be happy because usually... the people around us are really sick and scared and are often times in the worst physical state they have ever been in their entire lives... it never hurts to try and bring some joy into the ICU.

2. Leave work at work.
When I first started I used to always bring work, home with me. I think its only natural to do this to a certain extent but it has to be in moderation. It's a good thing to maybe re-hash your day on the drive home a bit... maybe there is something you forgot that you need to communicate to the nurse who followed you.... or maybe something went wrong and it's good to think about how to do it better next time. But seriously... learn to just let it go. Take a deep breathe, go for a run, read a book, take a hot bath... do something to re-center your mind or the stress of working in the ICU will have you on the burn out list before you can say "help!"

1. Follow your intuition!
Because most of the time you are completely right on and it may be that the "hunch" you have can be the clue that can save a person's life. I can guarantee that you will never regret bringing up the small things to the physician even if they seem silly... however if you ignore what your intuition is trying to tell you, and it means you miss something huge later on... well that will be something you will definitely regret.

Thank you goes a long way

For those who know me, I think most would describe me as being a pretty feisty character. I make up for my vertically challenged 5'1" self by having a large personality and a seriously scrappy side. Now granted... I have my moments where confrontation is difficult and there are times when I think I could use a little more gusto in speaking up for myself... but on the whole... sharing my opinion is not usually an issue of mine.

In a lot of ways I think its a very necessary trait to have as an ICU nurse... especially an ICU nurse working in a teaching hospital. I know I've mentioned it before but I will say it again... working in an environment where sometimes the physicians you are working with have such little clinical experience can be tough because often times we are all learning together.

In my unit the residents and interns cycle through their ICU rotation on a monthly basis. When I first started working here it was completely discombobulating because every month... just as the old ICU team settled into their routine and figured out how we worked here ( and usually just as I was remembering their names)... they were headed off to their next rotation and we were left to adapt to a whole new set of residents and interns. It's tough also because with each new set of folks you have to figure out which ones have more experience and which ones work well with the nurses.... which ones are good about putting in orders when you ask them to and which ones will actually work with you and not above you... if you know what I mean. To put it plainly... the rotation process of working in a teaching hospital sucks.

Image Credit

But... now that I'm starting to head well into my second year in the ICU there are some things that I am starting to really appreciate about the teaching hospital environment. One thing I have really been loving recently is the fact that I'm starting to see some of the physicians come back for their second rotation here. Those scared, unsure interns that we worked with last year are now coming back as confident, more experienced residents... and not only that but most of the time I know them well and have built a rapport with them which is so cool. I love seeing the growth in them and I love feeling invested in their growth as burgeoning, competent doctors.

What's even better about it, is that in many ways I think we as nurses can be a strong resource of clinical experience and encouragement for them (or a serious pain in the you know what... if you so choose). I have to admit that I have been known to have my bad days with interns... especially when they decide to do basically everything in the book to irritate you. 

See: How to Make Your Life Miserable in the Hospital--Guar-OWN-teed: A Ten Step Guide  by my favorite blogging doctor for a great example of what I mean.

But now that I'm starting to see these people come back through their second ICU rotations... I understand the value in actually investing into each one of them...

A few weeks ago we had an intern in our unit who managed to do basically everything on the "How to piss off your nurse" list and  it ended up being a very rough night. Poor thing was trying so hard to be nice and I don't think she had any clue what she was doing but I wasn't reciprocating the friendliness. When the morning came around and she thanked me for doing such a good job and acknowledged how busy the night was... my response was less than friendly, "Just part of the job I guess... but I appreciate that." My tone was not enthusiastic.

Then a few nights ago I walk into our breakroom and this same intern left one of the most thoughtful notes on our bulletin board. She thanked us all for being the "best and most intelligent nurses" she has ever worked with... "Thank you for teaching me, guiding me, feeding me and making me a better doctor!" 

Instantly I felt like a terrible person because I knew that the one on call night I had with her was completely horrendous. I guess the good news is that I definitely learned a good lesson here... no matter what the situation... there is always room for more humility and grace on my part... and also...a genuine thank you seriously goes a long way.  

Why I love working in a teaching hospital

My hospital on the fourth of July; every holiday they bring out these flags and it never ceases to take my breath away.

When I was a student working in the ICU, I remember something that was so exciting about learning in this environment was the fact that we were in a teaching hospital. Most of my clinical experiences… actually probably half of my nursing education was done in the private sector which is completely different from a teaching hospital. In a private hospital you don't deal with residents, fellows and interns… most of the time you deal directly with attending physicians and for nursing, this usually means a lot more of directly following orders and a lot less collaboration and less of a team approach to patient care (at least that was my experience)… so when I came to the VA and started in the ICU it was such an exciting and encouraging place for me because I instantly saw the value of multidisciplinary care and nursing input during rounds was welcomed and even expected!



Now, of course with all good things, there comes a downside. I also quickly discovered that working in a teaching hospital meant that we would be forever working with people who are learning. The direct impact on nursing is that we have to be incredibly diligent about checking and double-checking orders or things that seem strange. One of the best lessons I have learned is to not assume or take anything for granted. If you don't feel right about something… stop and listen... even if it's in the middle of a code because that single minute you stop to double check, could be the one thing that prevents someone from making a huge mistake… but I digress.



This past summer has been a tough one in our ICU because I think a lot of the nurses on our unit are seeing the impact of the teaching aspect of our job. It's strange because there are many, many times when we will be working with physicians who quite literally have no clinical experience or have never worked in an ICU at all. A lot of times this means that the ICU nurses will often have years of critical care experience with knowledge to draw from that the ICU residents/interns just simply don't have. This is one of the downfalls of working night shift also… you have an intern and a resident on call overnight… if you don't agree with their orders or a judgment call they've made… well that means you are paging your fellow and sometimes even your attending at 4:00am, at home. I unfortunately have had to do this multiple times in the past few weeks and it hasn't been fun… at all.



For months…since the new batch of docs started in July, it's been a whirlwind of long nights with unsure interns and lackadaisical residents who are so scared to do anything that I end up having to go up the chain of command to get anything done… and let me just say that for an inexperienced nurse, it's really hard to learn to trust your instincts with this stuff. When I page the fellow I'm basically saying… " Hi, ICU fellow… I know it's 4am and you're trying to sleep but your intern or resident said to do fill-in-the-blank … or they aren't doing anything about fill-in-the-blank… and I think they are wrong, so I've decided to go above them and get a better answer (hopefully) from you." Yikes… scary.



Well… all that to say that finally... finally… there is justice! This week we got a new cardiothoracic surgery fellow. I love cardiac surgery patients, so when we have a crappy CT fellow it can make or break my day. Luckily, this time our CT fellow is completely awesome. Incredibly competent, very personable and works so, so well with all the services and nursing staff. Seriously, this week was one of the best I have had in a long… long… time because I had one of his post-op surgery patients the entire week and working with him was such a joy. It reminded me of why I love working in a teaching hospital so much. It brought me back to that original excitement I had when I first started in the ICU and when I first started working with cardiac surgery patients in particular.



A moment I will remember for a long time coming… it was the second day I was working with the patient that had a 3 vessel CABG with a post-op course that ended up having some major complications. This guy bought himself 3 IV poles worth of drips, continuous cerebral perfusion monitoring and a bunch of other complicated things that I won't go into here. To put it bluntly… this guy was sick.


There were a few things that our ICU team had asked me to do that didn't make sense to me and so I started to discuss it with the CT fellow. We started talking about the plan of care and quickly discovered we were on the same page about everything and all of the stuff I was hoping to do (and not do) he was completely on board with. It was a totally collaborative, peer level dialogue that I haven't had with any of our docs in a while.


"Awesome!" I said, "No fighting to get what I need for my patient. Today is gonna be a good day."


What he said next was one of the best compliments I've ever gotten…


"Andi, seems like you've been doing this for a long time."


"Nope, I've actually only been a nurse for a little over a year… I just love cardiac patients. I think it makes a difference when you love what you do." I said with a smile.


Then he says… "You graduated and went straight into the ICU?! That's crazy! Well, it's gonna be a great couple of months for me if you're gonna be here. If you need anything else just call me directly."



Sweet… my day just got even better. No arguing, no fighting, and I had just been complimented by one of the most competent CT fellows I have ever worked with. This is exactly why I love working in a teaching hospital… the collaboration, growth and encouragement that can happen here… well, my job could not have gotten any better at that moment. :)

Baby, Get Your Roller Skates On!

Maybe it was because I was just oblivious to it last year.. or maybe it was because I was in my preceptorship or getting easier assignments since I was the new grad. Or maybe I've just been given the rite of passage into the tough assignments (seriously, even my experienced, co-workers have agreed I've been getting crazy assignments lately) but I'll tell you that work recently.....  work. has. been. insane.

I'm talkin' full unit, code bed only, emergently intubating 2 patients at the same time, right at the beginning of my shift - crazy. Hematocrit of 11, post surgical patient...yup, you just bought yourself a ticket to CT scan and guess who's comin' with you? The resource nurse... aka.... me. 3 IV pumps, ventilator, pressure bags, blood warmer...the works...5 person transport team included.... here we go folks... gonna be another busy night.

I think Ive just decided to come to grips with it and I've come to realize that...well..this is the ICU.

I think it's been a factor in my recent feelings of burn out. It's been better, it really has but there are still moments, certain shifts that simply leave you tired and angry and just so over it.

Last night could have been one of those shifts, earlier this week when I was also resource...yup, definitely could have been one of those shifts.... but I hung in there.... I stuck it out.... with minimal complaining too. Despite the fact that I have literally only assisted with one emergent intubation in my entire life. Its not fun... I promise. Can I also add that it included a straight up fight between the ICU team docs and the surgical team of one of our patients. A full blown, yelling included, argument about whether to intubate the patient or not.... meanwhile the guy is unresponsive... making buzzing noises with foam coming out of his mouth.

Wow... I love my job...

But... if anything I'm learning to roll with it... "Get your roller skates on baby!" a friend of mine said last week.
Check and check....  a piece of advice that is so simple yet so valuable.

Get ready to roll with it and when its time... leave the crap at the door. When you go home... you do the best you can to breath and leave it outside.... or maybe stuffed in your locker somewhere at work. Otherwise, I'm convinced this type of job will eat you alive well before you celebrate your five years of service.
Phew... had to get that one out.... at least I'm in one piece and still smiling at that!
Also on a really fun note... saw Step Up 3D and WOW...can I just say
Great music + Crazy-off-the-hook-dancing + some seriously gorgeous boys = great movie to watch after a long day. Totally lovin' the soundtrack to it... can't wait to go running to it soon.

How'd everyone else enjoy their weekend? :)

Note to self...

When a VA patient tells you he drinks 1-2 glasses of wine a night...
times that by 6.

Seriously though, if there is anything I have learned when it comes to our veteran's....it's that they like their alcohol. Some are more obvious than others and most will never admit it outright, but 95% of the time you can safely guess that if a patient is coming to you from surgery... be prepared for alcohol withdrawal symptoms.

For example... right now I am taking care of a post-op CABG x1 with an AVR. Basically, he had a one vessel graft on a coronary artery and a prosthetic valve placed in his heart. He's a relatively healthy guy considering what we are used to here. No history of drug use, smokes a pipe, told his surgeon he drinks one shot of gin a week. Told the social worker he drinks a shot of gin a week AND 1-2 glasses of wine a night....

"Yup, that explains it." I said to myself.

When I came on shift, I noticed the patient had been having minimal signs of alcohol withdrawal, just some tiny tremors that I thought looked strange. I pulled the intern and resident to the bedside to have them take a look.

"You know when a dog is sleeping and they're dreaming about something and you see them do that funny twitch thing, or you see them start to move their legs like they're running."

I can't believe I'm actually explaining a patient's symptoms like this.

"Uh huh," the resident nods as the intern begins doing a neuro check on my patient. The docs are nice enough to humor me.

"Well, thats what he's been doing. He isn't doing it now but if I mess with him at all, like do a fingerstick or anything, he starts doing it." Luckily, just as I was about to touch him to see if it would happen...he began twitching on his own.

"SEE, like that!" I point at him, SO thankful that this time, when I actually get the doctors about something, it happens when they are at the bedside and not the second they leave instead...
I swear I'm not crazy.

We all came to the conclusion that we weren't quite sure what was going on, and since his pressures didn't drop too much when it happened and he was remaining stable... well we basically all shrugged our shoulders and decided to just hope it'd stop.

It didn't...

Around 2am, this patient who had been on enough fentanyl and versed to knock out an elephant and should have been zonked out of his mind, SAT UP, in bed, wide eyed and reaching for his ET tube. I jumped up, grabbed his hands and began explaining to him calmly that he was in the ICU and his surgery was over and he was fine...but that he had a breathing tube in his throat and IV lines everywhere and cannot grab them and needed to go back to sleep. Yes, the longest run on sentence ever. He looked at me for a while, nodded his head and then began to fight me like mad....at which point I decided I needed back up and yelled for my neighbor to come in and restrain him while I increased his sedation.

This is the classic case of the patient not admitting to the true amount of alcohol they drink on a daily basis. The amount of sedation this patient required was a sure fire sign that he had quite a tolerance built up. Anyone who can wake up on 5mg/hr versed and 500mcg/hr fentanyl has got to knock a few back pretty often.

All in all it ended up being fine. Thank goodness for dexmedetomidine... the wonderful drug that sedates you but doesn't depress your respiratory drive = we can extubate you and keep you calm at the same time. :)

And next time, I'll remember to pay a little more attention when someone says they drink "1-2 drinks" a day.

How to spot a night shift nurse

The other day I was walking into the break room at work, just before my shift. As I came down the hall I could hear people exclaiming,

"I slept so good today! I got a full 8 hours!"
"Oh not me, I slept maybe four and this is my ninth day" replied the other nurse.
"Wow, I don't know how you handle that!" I replied as I walked into the room.
"Hah, do I LOOK like I'm handling it well?" We all laughed.

Probably the most common topic all night shift nurses have is sleep. The first thing we do when we see each other is say hello and then proceed to ask how many hours we slept that day. We exchange tips and tricks on the ways we manage to get as much sleep as possible. Ambien, trazadone, lunesta (yuck, I hated that one. It leaves this TERRIBLE taste in your mouth all day) benadryl, nyquil, advil PM, tylenol PM (by the way all of which are basically benadryl with other stuff added). A glass of wine before bed, those funny looking eye covers, black out curtains. Some of us switch our schedule on our days off and actually try to stay up during the day and a few of us don't (most of the time that's me).

Either way being a night shift nurse isn't always easy, especially when you work 12 hour shifts. Still, I prefer it over days because I get paid more and it is usually less stressful. You also learn to be very independent because you don't have all the resources around like you do on days. When you don't trust what an intern decides to do about your patient's crashing blood pressure at 2am....you learn to call the resident or the fellow. You learn to trust your intuition and you learn to ask A LOT of questions. Especially being a new grad like I am.

One of the ways I have learned to handle night shifts and 12 hours shifts much better is by making my food at the beginning of the week. Seriously, the last thing you want to do when you stumble home at 8am is make your lunch or dinner for the next night of work. You also don't want to have to put together breakfast if it means cutting into more of your sleep, and you sure as hell aren't getting up early to make food either. Plus, it stops me from eating junk food that is laying around my house or at work. Nurses are the worst at bringing sweets and fattening stuff to work.

So, I decided to take pictures and maybe share some of the recipes I have from what I made this week. This can help anyone who has a busy schedule; for 1-2 hours of work you have food for 5 days. I did this (sometimes) when I was in nursing school and working 18 hours a day, too. If I had done it every week then maybe I wouldn't have gained the 30lbs I did. Stupid nursing school.
Well, here's to eating healthy from now on!

Asparagus and green beans from the farmer's market by my house. I decided to go the easy route and get pre-cut, baby bella mushrooms (they were on sale).

Lots of garlic because I absolutely love garlic. Some chopped white or yellow onions too.


Some garlic powder, salt, pepper and a bit of olive oil to saute it all together.

There's one of my veggie dishes. Next I put some foil on my broiler pan and on one side had petite red potatoes sprinkled with salt, pepper, paprika and a bit of garlic powder.

On the other side of the dish I had brussel sprouts, some of the sliced mushrooms with garlic, (I really, really love garlic. Can you tell?), sprinkled each sprout with olive oil and salt and pepper.

I roasted them both at 350, the brussel sprouts cook first so I check them frequently and took those out when they were done and put the potatoes back in to finish cooking.

Next I put together some salads for the week. Heirloom tomatoes are my favorite because they're a little sweet, really beefy with virtually no seeds and they don't wilt the lettuce if you mix it in and package it up or a few days. And yes, those are edible flowers also. Another great farmer's market find.

Next, I made some sandwiches and instead of using mustard or mayo (yuck, I hate mayo) I used garlic roasted humus as my spread. Lean turkey meat, avocados, heirloom tomatoes, some of the lettuce from the farmer's market and the 100 calorie sandwich thins by Oroweat.

After it was all almost done I put together my dinner. Some of the salad, brussel sprouts and potatoes. On the side a basil, tomato, parmesan bocca burger (wasn't my favorite, it over cooks too easily and resembles a cement frisbee more than an edible patty at that point.)
The next day I was able to get the day off by using my vacation hours since our census was low. I ended up replacing my bocca burger for turkey burgers. Bread crumbs, garlic powder, tiny bit of paprika, salt, pepper and parsley mixed into ground turkey made for a great tasting turkery patty. No pictures of that though, sorry.
After I ate, I finished chopping up all the fruit I had. Boxed it up and was done. (By the way, I had some of this fruit with fat free cool whip for dessert yesterday and it was delicious and low calorie too!) I also threw some lite, canned fruit in with fat free cottage cheese to have for breakfast.
There it is. I have enough food to last me through 5 work days. I have a good amount of variety and just in case I need some snacks on the side I have fat free yogurt, wheat thins and progresso's healthy soups. (0-1 points on weight watchers)
Yum, now Im hungry. I think I'm going to get some banana bread that just finished baking. Recipe for that soon to come too!

ICU Tip: When in doubt, gown up!

Wow, this has been a pretty crazy week. From heart patients to a massive GI bleed and crazy families to boot. I can say without a doubt I could not be happier that it is the begin of my weekend!

Spoiler Alert: This post might be a little graphic for those that don't appreciate gory details.

I remember in nursing school and when studying for the NCLEX, isolation techniques and universal precautions was a big thing. For some reason I got a lot of those question on my board exam.

"When leaving an isolation room which do you remove first?"

A. Gloves
B. Mask
C. Gown

Uhhh. Whichever has the most blood on it? I have to admit though, the far off voices of my nursing instructors were ringing in my ears this week. You know its going to be a long day when you come in to get report and one of your patients is in trendelenburg, getting three lines placed. He was admitted for persistent nausea, vomiting, diarrhea and an acute drop in his hematocrit. The residents get his central and arterial lines in place and I begin chasing after the eternally long list of orders I have. Three units of packed red blood cells, 2 units of FFP, labs, bolus of bicarb. and the ever so fun job of inserting the foley catheter (for you non-medical folks...take a wild a guess at where this goes and you're probably right). As I'm explaining to him the procedure and setting up my sterile field, he nervously asks, "Have you ever done this before?"

"Oh my dear, I wish I could say I never have, but unfortunately I have inserted more of these than I can count. It's definitely not the highlight of my job." Probably not completely reassuring but its true. Being a nurse in the VA hospital means that 95% of the patients we have are male. I am not a stranger to the male anatomy, to say the least.

Anyways, at this point I am still drastically behind and in the meantime am putting out fires with the family of my other patient. A whole other post in and of itself.

Luckily the nurse who precepted me as a nursing student was my neighbor and was able to help me catch up on stuff. The next thing I had on my list was NGT lavage which I haven't done since nursing school. Diana was nice enough to get everything together while I caught up on charting. In nursing school we were always taught that if there was any possibility of being splashed by any bodily fluid, you wore a gown. Add a mask if necessary. Keeping that in mind, I watch Diana as she begins inserting his naso-gastric tube and my patient begins heaving like mad. I grabbed some gloves and the suction and jumped to try and help save my patient (and my clean bedding of course). This whole time I'm praying that he doesn't start throwing up all over. Of course he does, but luckily it wasn't too bad. Still it was enough to make us realize that the tube we had was too small and would be clogged up to quickly in order to do a lavage.

So here we go....Round Two!
We get a bigger NG tube and I was smart enough to grab two gowns and masks with face shields. I bring them in the room and offer the gown to Diana and she declines. "No, its fine." Huh? Ok, well she was my preceptor at one point....maybe it will be fine?

Could not be more wrong.

Within the next few minutes the patient, the bed, the floor and yes....I was completely covered in old GI blood, and vomit. The worst part. I had short sleeves on, so the space in between my gloves and my rolled up sleeves was completely covered in coffee ground emesis. At this point all I could think was, "Note to self: Next time wear the gown!"
At least my patient and I survived the horrible night and we even laughed about it later. Also, luckily I was smart enough to have recently put an extra shirt in my locker. (Another great ICU tip: always have extra scrubs!)

Just another day in the ICU.

ICU tip: Watching Trends

If there is one thing I could tell people about staying prepared for anything in the ICU it would have to be to always, without a doubt, watch your trends. I am nerotic about checking the trends on my charting. Heart rate, blood pressure, cardiac output, fluid balance are all things that I like to pay attention to in terms of where they are heading.

Example: The other day I was taking care of my second open heart patient. I was still on orientaiton, but since we were short staffed and they had no one to precept me, I was placed on my own for the last four hours of my shift. When I received the patient around 1:00pm his heart rate was somewhere in the 80's. Normal Sinus Rhythm, no ectopy at all really.

By 4:00pm he was somewhere along the lines of 99-103 in his heart rate. I brought it up with my charge nurse and my preceptor. "Did you check his lytes? What's his potassium and mag. levels at?" "How much fluid has he gotten? What's his CVP? (central venous pressure) His pressures look fine."

"I know his pressures look fine and his lytes are fine...all replaced and on top of that his CVP is 12, right where we want it. But his heart rate is in the 100's now."

The respone I get from everyone: "He's probably fine, he's not really that tachy so I wouldn't worry." Even the doctors said they wouldn't be concerned until he reached over 120.

So here is where the trends come in. If the patient's heart rate was in the 80's upon arrival and has increased by 20 beats per minute in the past 3 hours...where do you think he will be by 7:00pm? (this btw, is conveniently the time when our incredibly intimadting CT surg. attending comes to do his rounds...trust me, the man is scary)
Yup, you guessed it...around 7:30pm the surgeon comes by and my patient is trekking along at a heart rate of 130. Definitely not a good thing for a fresh, post-op CABG patient. I also noticed he had started to shiver a bit, despite the fact that his temperature was completely normal.

My alarms are going off, meanwhile the ICU team (who is also scared to death by our CT surgeons)is trying to decide what to do and probably trying to stall until CT surgery arrives.

To make a long story short the outcome was fine. CT surgery came by and I explained to them the trend I had been noticing. The treatment was much different than expected though. Probably a mix of the patient coming off sedation from the OR and not being properly sedated in the ICU meant he was slightly waking up...while he was still intubated.
We increased his sedation, gave him demerol for the shivering and then ended up giving vecuronium (a paralytic)to help him relax and not tense up so much. This is why I love our scary but brilliant CT surgeons. It worked like a dream and my patient went back to normal. At least long enough for me to give report and get home...far away from the craziness that is the ICU.