How to Survive Night Shift Nursing

For five years I have been a night shift nurse in the ICU. I never thought I would make the transition to day shift nursing but this past month I made the leap and for me it was the best decision I have made in years. I think I forgot how wonderful it is to sleep when it is actually dark outside and my days off are now actually days off! I'm not perpetually catching up on sleep or trying to rotate my schedule to accommodate work or my pathetic attempt at a social life.

Despite the horrors that the night shift bestowed on my life I do know that for many years I was happy on nights and I think I can share a few tips for those of you venturing into the graveyard world. Being a new grad nurse almost inevitably means you will start out on nights... even a seasoned nurse who moves to a new hospital starts at the bottom of the food chain and has to usually work the night shift. So, for those of you looking for some help in surviving beyond the land of the living... here goes.

1) Your schedule has to be the most protected aspect of your life. Whether you choose to work multiple days in a row or not, this is most important. You have the choice to stay on the night shift for a stretch and then switch your sleeping to match day shift on your stretch of days off or you can work one or two days in a row and then just stay on a night shift schedule always. Most night shifters I know work 3-4 days in a row (I never recommend more than 4) and then have 3-4 days off in a row to flip their schedule and live among the land of the living for those few days.

2) Plan your meals ahead of time. Sleep is the most important part of surviving night shift and what I found to be most helpful was planning all of my meals the day before I started a long stretch at work. The less time I'm worried about packing 12 hours worth of food, the more time I get to spend in bed and that is awesome.

3) Learn to say no. Being a night shift person unfortunately means that 99% of the time people will not understand your schedule or the need to protect your sleep. Social events can be really hard to plan because sometimes people don't understand that yes 1:00 pm is in fact WAY too early for a night shift person to wake up. Especially if it is your first day off! That first day off after working a long stretch... take my advice and don't make any plans. That day is ruined... a total wash and when you need to plan something that you can't get out of either do it right after work or very late in the evening.

Being a night shift nurse is incredibly hard. I did it for five years and I know many people who have done it for their entire career. Yes, it is quieter and slower and there are less people to deal with which is nice but you also work with fewer staff and you need to have more autonomy and the ability to trust your clinical judgement. Night shift also doesn't get nearly as much recognition as day shift. In fact I received my first present from a family member this week! 5 years I have been working at my hospital and this was the first time I have been given a thank you card for taking care of  a patient. It was nice and I realize now just how glad I am to be working again in the land of the living. Still, I value the time I had on nights because I learned a lot and hopefully my tips can help someone else too!

Random Thoughts of an Insomniac

Night shift nursing can be brutal sometimes. I have not had a normal night sleep in months. Right now, it is 5:00 am, I slept yesterday from 6:00 pm until 11:00 pm and now I am trying to pass the time by finishing up research for my last project in school. In August I will finish my BSN program and I will never have to attend school again if I don't want! I will probably end up in a Master's program at some point but for now a girl can dream...

I will also be getting surgery on July 22nd (nothing major, just hand surgery) and will be out of work for a month so I will probably be bored out of my mind the entire month of August. I don't think I have had that much down time since I graduated nursing school in 2009.

Still, I am looking forward to having some time to do some work projects and catch up with friends and house projects. Sleeping during normal hours will be absolutely divine too. Anyone have any good suggestions for good reading? I just finished "A Thousand Splendid Suns" by Khaled Hosseini and I loved it. I have a few on my list... Unbroken, Game of Thrones... but I am wondering what you all have been reading these days?

Hopefully, I will get some time to do some photography too... especially since I will be a new honorary auntie any day now! :) Can't wait to meet this little one! I will have baby shower pictures coming soon. I swear in my other life I was an event planner... okay not really but I do love hosting parties at my home.. which is honestly strange considering how crazy introverted I am. I think it just gives me a reason to be crafty.

Alright, I'm pretty sure I have 5 Candy Crush lives waiting for me so until next time... send me your book recommendations! 

Note to Self: His mercies are new every morning...

Right now I am supposed to be reading “Ladies and Gentlemen, to the Gas Chamber” and every time I switch my browser to my school's page I just can't seem to get up the mental fortitude to go there. I keep thinking about the week that I had... four very long twelve hour shifts in a row. Lots of homework and lectures and tests and papers in between. Death. I am tired.

I have been a nurse in the ICU for four years now come this July. I still remember when I started this blog as  a new grad about three years ago. It doesn't feel like it has been that long but the weariness in me reminds that it has. 

I thought yesterday was going to be a good night. It has been a really rough week and my stress levels have been physically impacting me and I feel at my wits end. I needed it to be a good night. It started off with a perfectly wonderful conversation with my patient's family members about the perils of quitting smoking. We laughed over the crazy things we would all do during our peak addiction days just to get a cigarette. Laughing over things only an ex-smoker would be able to laugh about. It was nice to connect with the family, you could see that despite the severity of the situation... there was an ease. A trust that they felt things were moving in the right direction and knowing that their loved one was in very good hands. It was nice and despite my exhaustion I was thankful. 

Then not an hour into the shift I hear his wife yell out, "He's bleeding!" and immediately the flood gates open. Ruptured esophageal varices that eventually found its way out of his mouth and nose with force. The next four hours were a furry of attempting to get the bleeding under control with massive transfusions of blood products and a procedure to clip the bleed in his GI tract. His poor family was ushered out to the waiting room and I felt horrible. 

No, this is not a good night. Not for me... and definitely not for them. What is so difficult sometimes is knowing that despite how hard you work and all that we do to save lives... sometimes it fails.
Sometimes people die of lung cancer, probably from the 40 years of smoking a pack a day.

Sometimes people die from a GI bleed from years of binge drinking and a failing liver as a result. 

Sometimes death is peaceful and wonderfully fitting.... and sometimes it is not.

This week it was not. 

So for now, I just don't have it in me to read "Ladies and Gentlemen, to the Gas Chamber" or anything else that talks about death and sadness. Right now, I will stop and say a prayer for that family and I will spend some time here and I might also need to give these girls a call... their smiling faces and silly laughs always make the world a little better. 

Maybe tomorrow will be brighter and the world will feel a little less heavy and burdened...

ICU Nursing 4 years in...

For a while now I have been thinking about why I have such a difficult time blogging about nursing these days. I think it is a collection of things but the main one is mostly just because I have nothing to share anymore. When I first started this blog I found excitement in everything I did. I enjoyed finding the shareable moments in every experience... good or bad. Being a new nurse meant that every task was a challenge and it was fun to share it with others. I also loved the moments where I felt the reward of nursing... the tangible patient care moments that "made it all worth it."

I think if I am honest with myself, I would say that those moments are rare now. The work is still difficult but in a different way. It isn't challenging anymore... just hard. Long hours, night shifts and a messy sleeping schedule. The politics of a failed economy and its impact on a government hospital inevitably mean that budget cuts create a not-so-great work environment. All of that to say that I guess considering everything, I have not much of a desire to come to this space of mine to write about my job. Because to be honest that is all it is right now... a job.

Not to say that I don't have aspects of it that I still appreciate and maybe even love... but for the most part I have to pray to God multiple times a shift to remind me of why I wanted to be here in the first place. The good thing is that I am making some efforts to open up other doors in the future. I am chugging away at school so I can get my BSN and eventually my MSN (not sure in what yet). And truthfully I think things are in a good place because I don't hate my job like I did a few months ago. I think I am just beginning to consider the possibilities outside of the ICU. So we shall see...

The Invisible Casualties of War.

It has been nice to see everyone acknowledging the true meaning behind memorial day. There were only a handful of the blogs I follow who didn't mention at least something small about our fallen soldiers and for that I am thankful. Memorial day has nothing to do with days off from work and BBQ's.
Being a VA nurse is not always easy. I see a lot of PTSD, addiction, alcohol abuse. I see a lot of homelessness and dysfunctional family relationships. I don't understand why so many of our nation's veterans end up on the streets with no adequate support system. Either way, I am glad that I can do my part in helping heal the wounds that being in the military has given them.

I worked this memorial day and for the first time in a long time I felt proud to be a VA nurse.... and even though I ended up floating to a unit that wasn't my own I had the opportunity of seeing first hand what true sacrifice is. Memorial day exists to honor those who have fallen in combat... but what most people forget about and often times don't even see are those men and women who come home suffering from traumatic brain injuries or spinal cord injuries or combat related wounds. What about the men and women who die years out from deployment as a result of the injuries they suffered while at war.
Those are the kinds of soldiers I see. We have had more and more of our OEF (Afghanistan) and OIF (Iraq) soldiers showing up in our unit these days. Kids who are my age or younger and have suffered from devastating physical wounds and emotional scars related to the wars they served in. In our hospital we have phenomenal Traumatic Brain and Spinal Cord Injury Rehab units and yesterday there was a rapid response called to one of those units. Since I was in charge of the code pager I answered the call and lo and behold it was for a patient that had been in our unit earlier this year. A kid not too much younger than me who had suffered an IED blast overseas and had to have half of his skull plated and a shunt placed in his brain. His injuries are so extensive that he is virtually paralyzed and is completely non-verbal. When I saw him in our unit none of us thought he would ever make it out of the ICU alive. We watched as his wife dutifully sat at his bedside day and night, helping with his rehab and withstanding every surgical procedure he would barely make it through.
When I saw him yesterday he looked like a completely different person. Still non-verbal but looked much healthier and was even able to track you with his eyes when you called his name. When we were trying to assess his mental status the nurse who had been with him in the unit leaned over him with a tightened fist and said, "Hey man, give me a fist bump so I know you're alright." Surprised and somewhat confused, I looked over at the patient and watched as he slowly reached his weakened, contracted arm up towards the nurse. He clenched his fist and sure enough he gave that fist bump, confirming he was in fact okay.
Today, as I was spending time with Chris before I headed back to work, I was sharing with him about my night yesterday and I told him about this story. I didn't realize it until that moment but I understood it then... that patient was a gift to me yesterday. God knows, yesterday was a crappy day. I had to float to another unit and work has already been difficult recently. I was tired and overwhelmed having to answer the code pager for the hospital. In many ways I have forgotten what it means to be a VA nurse. I have lost that passion.
Yesterday though... yesterday was a gift. That patient reminded me of what it means to be a soldier and on a day where we are honoring the fallen soldiers of war... I was able to see the true sacrifice of the families and soldiers of those who have served. It gave me hope and it humbled me in ways that I can't quite explain. As I was telling Chris the story of this patient... tears began filling in my eyes and it reminded me of just how rewarding my job can be.

So today I want to say thank you to the men and women who have served...
Thank you to the families who have sacrificed their loved ones.
Thank you to the men and women who are the invisible casualties of war... the ones who die after they come home.
Thank you to the soldiers whose lives are forever changed because of the service they gave to our country and especially to the sacrifice they made for their fellow soldiers.
Thank you, it is an honor to be your nurse.

It ain't about me... or is it?

Warning: I'm about to get brutally honest here so hang in there with me... this won't be one of those mushy "nursing is so great!" posts.... cause truth be told, nursing has not been so great recently. In fact it's been tedious at best. I have not been at my best recently either. I'm tired and to be honest I'm a little bored these days. I find myself counting down the minutes until my shifts are over and my fuse has grown short with people.
I have to say that there are a lot of times in my job when I take things personally even though I have no business doin' so. In my line of work you deal with people at their worst. Sick, broken and teetering on the edge of life and death.
For some reason, recently people have been straight up crazy though. Like kickin', hollerin' and bein' down right mean -crazy. Most of me gets it. I get that when you are at your worst you don't have much to give, especially if you really aren't in your right mind... which happens a lot in these parts. There is a reason ICU delirium is a legit diagnosis.
Most of the time I'd like to think that I handle these situations okay. I see what happens when people get defensive and try to argue instead of understanding. It just doesn't work and usually it just makes the patient angry and you more frustrated. If I was in that hospital bed who knows how I would be? Just take a look at me around 4:00am on any given night shift and you'd probably have a slight clue.
Lately I have been in this weird place. Apathetic in a sort of way to what goes on around me. You see sickness and death all of the time so when a patient comes in with cancer that has ravaged their face you aren't moved the way you once were. Or when a patient with severe pulmonary disease is throwing the biggest fit in the world because they have to be on an obnoxious bipap mask all night... you tend to not have as much sympathy as you once did.
No... now I find myself annoyed at every call light I have to answer. Tired of the same old routine that doesn't challenge my brain but injures my back and zaps every ounce of energy I have left. Frustrated because I can't understand what my patient is trying to say... it's difficult when you've had half your tongue removed, ya know? That is not what crosses my mind though... the fact that he is angrily pointing at these scribbled, jumbled letters on a piece of paper like I am supposed to magically understand them... that is what I see. Frustration and pain and exhaustion... from both parties.
Finally I discern what he is trying to convey...

"It hurts when I swallow... is that ok?"

"Yes, that's totally normal." I nod my head eagerly. 

Relieved to finally be able to communicate, the man breaks down in tears and starts profusely apologizing.
"I'm sorry. I'm so sorry." he mouths as he lays his head back on his pillow.
The floodgates have now opened and I instantly feel like a horrible person.
He knew I was getting frustrated too and I probably could have done a lot more to hide that fact. To have patience and understanding for a man who is battling the big C and now has a very long and brutal recovery ahead. Today I will go home and I will crawl into bed a healthy person... sleeping in my own house peacefully.
This man will not.
He will not have anything close to that and the least I could have done was given him a little room to be frustrated without me being annoyed or inconvenienced back.

I told him that he did not have to ever apologize to me for something like that. I held his hand and told him that I was sorry too.

The worst part of it all is that I don't really know what to do from here. I come to work every day. I do my job as best I can but I'm realizing that my best sometimes just isn't what it should be. I am tired... all the time. I am bored with my job and don't feel challenged but I have no desire to change. I am holding it together on the surface just fine but inside I feel like something just isn't right. And I can't help but wonder if the problem is everything else or if it starts right here... with me.

Happy Veteran's Day

 To all of the veteran's out there who have fought and sacrificed for our country. The service you have given us all never ceases to amaze me. Thank you from the bottom of my heart. I appreciate you.

This week was crazy and like very other week I had the privilege of caring for some of our nation's veterans.

After a long and tiring week where one of my patient's got a total of 2 hours of sleep and was teetering on the edge of health... he looked at me, tired and struggling to breathe and says,

"You know what Andi? You are a darn good nurse."

It made my day, knowing I could be there for a man who was probably at his worst and it's moments like that where I would not trade my job for any other in the world.

"You know what?" I said, "You're a darn good patient."

 

If you see a veteran or a soldier today... thank them. They absolutely deserve it. 

Have a fun and safe weekend everyone!

7 quick takes Friday

--- 1 ---

Studying is not fun. I have been trying to cram for my CCRN exam (to become certified as a critical care nurse) and to put it plainly... it sucks. I have not been doing well on the practice exams which is incredibly frustrating because I only have a week or so left before the test. At this rate I honestly wonder how in the world I even made it through nursing school. I promise I'm not a horrible nurse, I'm just a horrible test taker.

--- 2 ---

I decided recently that I was going to go back to school for my bachelors degree. (As of right now I only have my ASN) Originally I had planned to go through Cal State Domniguez hills because its online and its geared for nurses who work full time. The program is about 3 years long if you take classes part time which is what I was planning on doing. Luckily my wonderful bff Bethany discovered a program through UT Arlington that offers the same degree with the same credentials but with half the amount of units required. End result = I only have to go to school for 15 months instead of 3 years. (Which I guess is the norm and Cal State DH is just unusually long) Yay for me!

--- 3 ---

I have discovered that the root of all evil is lack of sleep. Seriously there were two days last week were I got over 5 hours of sleep both nights and I literally felt like a different person. A less angry, less irritable, more energetic version of myself and I really enjoyed it. I'm pretty sure my co-workers did too.  Now this week.... a whole different story... back to grumpy Andi :P

--- 4 ---

This week we are trialing new TB isolation room masks. I was the lucky one stuck in the TB room for two days straight which meant that I got to look like a storm trooper for two days.. either that or one of those super sick kids who has to live in a bubble.

--- 5 ---

I finally joined the rest of the iphone user world and got the instagram app and I love it. Took this picture on a drive a few weeks ago and it makes me smile. I love where I live :)

--- 6 ---

This week I have officially met my favorite patient of all time. Him and his wife are truly the cutest and sweetest people I have ever met and they will be getting a post all of their own soon.

--- 7 ---

And since I have nothing else for you I will wish you all a wonderful weekend. My goal is too study and sleep like mad. YAY it's Friday!

 

For more Quick Takes, visit Conversion Diary!

7 Quick Takes Friday

1. It has been a long week and it isn't over yet. My sleep schedule has been way off and it has really made this week exhausting. I have said it before and I will say it again... working night shift is tough. People often times are inconsiderate of your sleep schedule and you feel jet-lagged 24/7. Most people don't seem to understand that waking up in the middle of the day is the equivalent of you waking up at 2am and not being able to go back to sleep... and then having to go work a 12 hour shift in the ICU. Yeah... not fun. Luckily I have only one more 8 hour shift left and then I can hopefully catch up a bit on some Z's. :)

2. This past Tuesday it was my birthday and that unfortunately has contributed to my lack of sleep. I hate working on my birthday so I asked for that day off that way I could go to dinner with some close work friends instead of getting spit on like previous years. In order to get my full amount of work in though I had to work night shift the days before and after my birthday. Having one day off in between a stretch of work is horrible being a night shifter because if you mess your sleep patterns up you are basically screwed the whole week.... but that also means you spend your one day off being up all night while everyone else is sleeping. :/

3. I promise that I won't talk about sleep anymore during this post.

4. My birthday was incredibly fun and the celebrating isn't over yet. This weekend I will be heading to Santa Cruz Beach Boardwalk with some of my favorite people in this world. We will spend the day on fun rides and rollercoasters and will also enjoy the oh-so-yummy junk food the boardwalk has to share. It should be fun. Hopefully I'll have some pictures to post after. :)

Image Credit

5. This past weekend I ran my first half marathon since becoming a marathon maniac. It was held in San Francisco and was a charity race sponsored by The SF Giant's for Project Open Hand. The course was along the same road that the SF marathon began on, The Embarcadero. Best part of the race had to be meeting Brian Wilson and running it with some of my favorite running buddies. Actually I almost dropped down to the 10k distance but luckily my running buddies convinced me to stick with them and finish the full 13.1 mile distance. So glad I did too. Good times indeed.

6. I have been getting back into yoga lately. I bought a groupon for 25 yoga classes in my area and I'm excited to get back into practice. I have been fascinated with a form of yoga called Ashtanga Yoga. It's really cool and people who are really good at it can do things like this...

Image Credit

7. One of the reasons I decided to run multiple marathons this summer was because the more events you do with the Rock n' Roll Marathon Series, the more medals you get. This week I got my "Rock Encore" medal in the mail for running the RnR Seattle and San Diego marathon! This thing is heavy and large and super sparkly and I totally debated on wearing it to work that day. Don't worry... I didn't :)

Happy Friday Friends! Have a great weekend!

Welcome to the ICU... the end

It is now day three of my week. I haven't slept much and the last 48 hours have taken a lot out of me.

I wake up to a text message from a fellow night-shift co-worker who was working a day shift. 

Things were not going well... my patient was not doing well.

They were about to transition him to comfort care.

I read those words and my heart sank. It hit me like the weight of an elephant on my chest.

I stepped out to my balcony and began to pray.

"Lord please give us a miracle. Be with his family now. Be with my patient... please Lord."

Tears begin to fall and I feel a deep sense of loss. 

I have never been impacted by a patient this way. It is hard to explain.

As a nurse your job is to heal people... in any way you can...
but this time I had no answers... this time I had no control and I felt helpless.

I go to work and he is still alive. 

Things are worse now... I have never seen lab values like this. 

I have never had a patient as sick as this. 

There are no answers... 

Just sickness...

I began my shift with his minister at the bedside. Reading him the Psalms...

"The LORD is my shepherd, I lack nothing.

 He makes me lie down in green pastures,

he leads me beside quiet waters,

 he refreshes my soul.

He guides me along the right paths

   for his name’s sake.

 Even though I walk

   through the darkest valley,

I will fear no evil,

   for you are with me;

your rod and your staff,

   they comfort me.

  You prepare a table before me

   in the presence of my enemies.

You anoint my head with oil;

   my cup overflows.

 Surely your goodness and love will follow me

   all the days of my life,

and I will dwell in the house of the LORD

   forever."

I go through the motions... his family is there... his grandson asks me,

 "How long would he have lived if he didn't get the original surgery."

I take a deep breath.

"My dear only the Lord knows the answer to that."

He nods and grabs his grandfather's hand.

"I love you papa" and he leaves the room.

A while later his wife has a discussion with the ICU team.

It is time. He is not getting better... she wants him to be comfortable.

We give everyone time to say goodbye and I explain to the family what to expect.

And then... one by one... I proceed to remove the medications that are giving him life.

At the end he is left with sedation and pain medicine only.

His family joins in a circle of hands... praying and singing over the man that they have known for years to be grandpa, dad, brother, husband.

Within minutes the monitor shows nothing but a ragged line... he is gone.

He has passed.

I enter the room and find his wife...

"I am so sorry but it looks like he has passed. I will call the physician to come in and confirm."

She begins to cry harder.

"I am so so sorry for your loss." I place my hand on her shoulder.

She waves her hand as she covers her mouth and I step away to inform our ICU fellow that he is in asystole. 

After some time... after his family have said their goodbyes... they leave in a state of shock.

I am left with this man that I have to clean and take the morgue.

My patient.

A man that I have cared for and fought for. 

A man that I don't really know... but a man that I desperately wanted to live.

In that moment I feel lost.

I feel like a failure.

I am confused and frustrated.. but most of all I am devastated.

We are supposed to save people. 

We are supposed to heal them...

but sometimes the Lord calls us home... sometimes medicine is not enough. 

Sometimes we don't have answers...

and sometimes it just isn't our fault...

it is just their time.

As I prepare my patient's body for the morgue... I grieve...

I grieve for his family... I grieve for the loss of life.

And in that moment I realize that I have experienced the truth depth of nursing...

 in a way that I never have before.
I begin to feel the tears of the ugly cry and I have no reserve to hold back. 

My charge nurse encourages me and thanks me for caring so much for this man.

With help from co-workers I get my patient in the body bag and begin the trip up to the morgue.
I am silent and somber and as I walk the empty halls of the hospital all I can think is, 

"Welcome to the ICU dear... 

Welcome to the ICU."

Welcome to the ICU... part two

It is day two of my week and I come in to work early to check on my patient.

He is back from surgery and is on CVVH... a form of dialysis.

There are four IV pumps in the room.... each with 4 channels full of medications that are keeping him alive.

Christmas trees of lights and IV bags and a symphony of alarms. 

My charge nurse asks if I would like to have him back.

"Yes, please!" I want to help... I want to know what is wrong... I feel a sense of responsibility here.

 He was my patient for so long... I want to do what I can to make it better... even if it is only for my own peace of mind. There are drones of people circling his room. Doctors from every service and every free nurse is there to lend a hand. His wife is waiting to see him outside.

After group report I head to his bedside and get report from the dayshift nurse.

It is going to be a long night... he is much worse now.

There are still no answers... only speculations as to what caused this rapid decline.

One by one his family cycles in through his room. Praying for him... crying over him... kissing his head and telling him how much he is loved. It is a busy shift. Managing his dialysis, his IV medications, his vitals are mostly stable... his lab values aren't good but they don't change overnight.

I get in the zone and before I know it morning has come.

As I give report to the new dayshift nurse he begins to crash. 

His alarms chiming in telling me so...

his pressures are unstable and I quickly get the doctors at his bedside.

I do the best I can to coherently explain the last 48 hours and luckily his dayshift nurse was one of the people helping yesterday so she is familiar. 

I drive home... exhausted and weary again... but still praying for a miracle...

praying that he will make it through the day.

to be continued...

Welcome to the ICU... part one

It started out as a normal weekend shift.

Two stable patients, one of which I'd had before. 

Both vascular surgery patients, one that was two weeks out from a complicated case.

He recovered well and was slotted to be transfered out first from the unit monday morning. 

A funny guy... slightly confused but in a pleasant way. 

Had a smile like a cheshire cat and hair like Don King. 

We laughed a lot with him.

 We were all glad he was doing so well. 

His family was glad he was doing well too.

Midnight rolls around and as I enter his room something is different now. 

He looks uncomfortable... something is not right. 

He is asking for cold medicine and because he is suffering from ICU delirium I know this is not good. 

I listen to his lungs and hear crackles in the bases and wheezes throughout his upper airways. 

A sign that fluid is building up. 

I page the respiratory therapist and a treatment is given.

The symptoms don't change. 

I page the intern... three times. 

No response.

I complain to everyone around me about how much I hate July in a teaching hospital.

I page the resident and right as he comes out the code pager goes off.

"E-TEAM, 2nd FLOOR"

I quickly relay the symptoms. He orders a blood gas and says he will be back to check the results and then is off to the code downstairs. 

While he intubates the patient downstairs we try to get blood from my patient's artery... a painful but necessary process. He is acidotic.... not a good sign.

I look at my patient and he has that look.... that look of doom.

His breathing is rapid and labored.

He looks frustrated and scared.

He is getting tired now.

I can feel it in my gut... this patient is sick.... and I mean sick sick.

It just isn't adding up... something is not right.

It is one of those times when a nurse's intuition kicks in. We order a chest x-ray, bipap mask to force air into his lungs and lasix to help get rid of the fluid in his lungs. 

Meanwhile I bring the intubation kit to the bedside... I just have a feeling.

Sure enough within the hour the patient is intubated... we are inserting central lines.... arterial lines.

I tell him that it will be okay... we will put this breathing tube in until we find out what is causing his respiratory distress. We will fix this and hopefully in the morning we can get the tube out. 

I give him the sedation that was ordered and I watch him close his eyes 

as he falls into a deep chemical sleep. 

From 3:00am until 8:30am I am in the room assisting the docs with the intubation and line insertions. I am giving drugs and starting drips to maintain his crashing blood pressure.

We are drawing labs and throwing around possible causes. 

Aspiration?

A clot?

A pulmonary embolism?

An illeus? 

We run the tests and everything comes back inconclusive. 

We have no answers but the patient is not getting any better.

He is getting worse.

By the time I give report the surgical team has been in to assess. We are trying to get him stable enough to go to CT scan... and yet we only continue to add more medications to chase his crashing pressures.

I ask if anyone has called his wife? 

It is now time to go home and my patient is still not stable.

I give report amidst the craziness in the room. I thank the co-workers that helped me and as I drive home... exhausted and weary... I say a prayer for my patient.... knowing that he will most likely head back to the OR that day. Hopefully they find out what is wrong.... 

To be continued...

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. 

July

I despise the month of July. Truly there is nothing good about it. It is hot and the rainy season is long gone and still far, far away. There is way too much to do with no time to do it. We are always short staffed at work. It's impossible to sleep during the day. The hospital is inundated with gobs of new interns who have egos the size of Jupiter and an experience level the size of an ant. (ok maybe not all but most.)

Seriously. I hate the month of July more than I hate peas... or bacon... and let me tell you... that is saying a lot.  

I don't enjoy feeling this way. I don't enjoy that feeling of dread as I read the assignment list every day. There aren't any "good" assignments these days. The patients are either really sick or really crazy or really violent or really mean. I am thankful for my co-workers that keep me sane but even a few of the good ol' standby people have been in a bad funk too.... might have something to do with the fact that they have had to work literally 19 days in a row. 19 days. 12 hour shifts..... 19 days in a row. Yeah, I'd be grumpy too if I worked that much.

When your career is one that involves taking care of sick people it is easy to get tired and burnt out fast. Especially when the people you are taking care of are crazy and mean and unappreciative. I always think its funny... when people (usually the docs) say things like "oh don't take it personally they aren't in their normal state"

hmmm... ok well how about this.... how about I go take a nap in the on call room while you sit here and get spit on and called a whore and a stupid b*tch for the third day in a row and then tell me you aren't gonna be a little bit worn out after 3 days and 12 hours of that. Oh and btw good luck getting a break to go to the bathroom or a break to eat your dinner. Sound good to you?

I am thankful that I get to be an advocate for my patients and I am thankful that I have a job that I usually love... a lot. But sometimes.... just sometimes, I think... I know I am your advocate but who is mine? When you go home every day practically in tears from exhaustion and you know you have a month straight of an insane schedule with no time to re-charge.... it is daunting and it makes you wonder how in the heck you are gonna survive another week.

At this point I don't have any good answers...

Did I mention that I hate July?

Life and such...

First things first... can someone please explain to me how it is already the end of May?

Seriously, where has the time gone?

I feel like my days are just melting into one long sleepless night.

I don't fully understand it but life feels like it has been busy lately. Or... more correctly, I feel like I haven't been able to keep up with my life and all of the things I wish I could be doing....
I don't think I've picked up my camera in months.
I have way too many photos that need editing and not enough hours to do them.

I'm also really tired these days.

I should be running more.

Especially since I will be running my first marathon race in less than TWO weeks.

Eating better would be nice too but that requires actually going grocery shopping and cooking.

Seeing my friends feels like a luxury because I hardly see them at all it seems these days .

I should probably start studying for the CCRN exam that I stupidly signed up to take mid-August. yuck.

 (CCRN = certification for critical care nursing.)
Work has been seriously crazy lately.

Did I say that I miss my friends already? Cause I really, really do.
Especially the ones who are in other countries right now.

I should also probably make a point of cleaning my kitchen at some point.

Our sink has been full of dishes since the weekend...

I went on a mini cleaning strike because my roommate and our mutual friend who was visiting this weekend decided to become sloppy boys and make a mess of the house.

I was annoyed and decided not to do the dishes... hoping they would magically disappear at some point.

They haven't.

Bummer for me.

I don't know how people who have kids manage to have a life... or keep their house clean.
It seems like there has been a lot of talk about kids and babies around me lately and to be honest I'm a little overwhelmed about it.
Chris wants to have three children.
Up until very recently I wanted to have no children.
I'm coming around to the idea of  having children.
Really the "ren" part of that should be in parentheses but we shall see.
Thankfully the kids issue won't need to be really dealt with for a while but its crazy/busy times like this where I think, "How in the world could I manage kids and my life and my sanity?"
Seriously, how do y'all do it?
Yes, I just said "y'all"
And on that completely unrelated note I think I need to go get some coffee.
It's only 2:00am and I'm already starting to count down the minutes until my shift ends.

Such is life.

7 Quick Takes Friday

1. First things first. TGIF! I think that statement is sufficient in and of itself.  :)

2. This weekend I am running a race in Big Sur! It will be a 9-miler, training race. I am really excited because this is undoubtedly one of the most beautiful places in the world and I will most definitely try and take a ton of photos along the way. Just as an example for you... a photo I found on flickr of the Big Sur coastline. Gorgeous, right?!

Big Sur, California, originally uploaded by ` TheDreamSky.

3.  Two weeks ago I did a 23 mile run. I could probably do an entire post just on that run because it was so. flippin. hard. BUT I will spare you all the torturous details of the 5 1/2 hour endeavor. (Yes, I ran for 5.5 hours) What I will share with you though, are the photos of what happens when you decide to run for 5.5 hours without sunscreen.

This is right in the middle of the peeling stages. It was so awful I had to sleep with ice packs on my shoulders for days and couldn't lift my arms above my head. I also have lovely burn lines on my calves from the capri pants I was wearing. Not cute. Moral of the story: wear sunscreen.

4. I might get to meet a fellow blogger next week from one of my favorite blogs Be Still and Know! This will be a first for me and I am very excited. She feels like a bit of a kindred spirit with her journey into becoming a missionary in Africa and it will be awesome to meet her and her husband if it all works out :)

5. One of the perks of working night shift is that you get to catch things like the royal wedding on TV because I am essentially on Europe time. Even though I am not a wedding person at all, this wedding was actually pretty amazing and fun to watch. Kate was absolutely stunning with such poise and beauty and grace. Didn't expect to care at all but when I watched it I ended up feeling incredibly nostalgic and happy for the two of them. Best part was definitely her dress. Just gorgeous.

 

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6. Next week I will be running 26 miles. It is my last long training before my first marathon. This is essentially a marathon actually since a marathon is just .2 miles longer and I'll probably just end up running the extra .2 miles so I can say "I ran a marathon!" Especially since I have to work the next day and I'm pretty sure I am going to be incredibly miserable and sore.

7. Funniest thing I heard this week at work. Actually I didn't hear it but someone told me about it and I was dying of laughter. Ok... picture a guy who looks like he came straight out of the 1970's with slightly shaggy hair and a crazy thick mustache who is just in general a pretty goofy/funny guy. This is one of our ICU fellows and during rounds after apologizing for his phone ringing he says, "I take that back. Never apologize for White Snake." hahaha  That is just awesome.


Happy Friday Friends! Yay for the weekend!!!

7 Quick Takes Friday!

1. I finally finished editing Lebanon photos! Yay! There will be a Lebanon post (or two... or three) coming up in the next week or so. Stay tuned!:)
2. Is it a full moon or is it just me? The way this night has been going I swear more than half the patients on our unit are completely off their rocker. Seriously, what is up with all the crazies man?! It's starting to make me go a little nutty myself! I just keep telling myself... "one more night... just make it through one more night."
3. This week I almost had a complete melt down while cleaning out my fridge. Ok... I am an ICU nurse and I know I come in contact with all kinds of disgusting germs all the time but I can't help it... I am a complete germaphobic neat freak. ESPECIALLY when it comes to my kitchen and bathroom. Earlier this week, I pulled out a whole chicken I had in the freezer and moved it to the fridge to de-frost.... only to come back the next day to find an ENTIRE shelf covered in bloody, disgusting, chicken juice. All of the food on that shelf was covered and I was so mortified I basically threw out everything on that shelf and proceeded to freak out as I vigorously scrubbed down my entire fridge. Few things scares me more than bacteria from raw meat. Yuck. Yuck. Yuck.
4. I am running my third half marathon this weekend! Technically I'm only supposed to be running 6 miles for my training so I plan on taking this suuuuuuper easy... mainly because I have a 22-23 mile run next weekend but it will be a pretty course along the coast so hopefully I'll get some fun pictures.
5. I AM SO OVER MARATHON TRAINING. I cannot emphasize this enough. I am not physically overtrained because I am doing hardly any running these days but I am so SO mentally drained. I'm pretty much down to only doing my long runs on the weekend with an occasional mid-week run because I know that it would be a disaster and a half to skip those long runs but seriously what I used to love about running has some how vanished. I think after I am done with my marathons this summer I will take a break from races. I'm signed up for one or two, half marathons this fall but those are nothing compared to marathon training. I also think I need to get back to trail running... just hitting the trail and running until I get tired and calling it a day. No running for distance or speed.... just running to feel good.
6. This week I got training to do CVVH or Continuous Veno-Venous Hemodialysis. It was pretty cool. These patients are usually pretty sick and since they are so unstable and cannot tolerate regular dialysis we put them on a machine like this one pictured and we dialize them continuously for a small yet steady effect. It definitely felt good to be challenged in my work again. :)   

    

7. Last but not least a sneak peak of Lebanon photos for you...

Happy Friday Friends!!

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.

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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. :)

Week Re-cap

Monday: Stayed in bed all day because I was so sore from the half marathon that I could barely walk. Fell asleep at 7:30pm because I was so exhausted.

Tuesday: Woke up at 6:30am (yup thats 11 hours of sleep) cleaned my house and then went to work that night and found out that a patient we've had on the unit for months coded over the weekend and was now on comfort care :(

Wednesday: Went home after work and since I had been up for over 24 hours at this point slept from 10am-530pm (miracle!) and then had a paired assignment at work that night that was really busy. One stable patient + one intubated patient with respiratory failure, acute pancreatitis and was now becoming septic very quickly with an elevated lactate and a pH of 7.17, CO2 in the 70's and a paO2 in the 40's.... ended up having to go above the intern and resident (they said that the blood gas "looked fine")and paged the ICU fellow at 4am.... not my idea of fun.

Thursday: Got into an accident in the parking lot at work and then had to go home and deal with insurance etc. Didn't sleep more than 4 hours and then went back to work for my 3rd 12 hour shift in a row. Survived 4 hours of our unit's annual competency fair and then had my septic patient for the next 8 hours.... luckily we had him completely sedated, paralyzed, on a ton of drips and even though he was still sick, sick he held steady all night .... my favorite kind of patient :)

Friday: I come home from work this morning and fall asleep from 10am-11:30am and have been awake ever since.... I've desperately been trying every trick I know to get some rest... meds, hypnosis tapes, guided meditation, eye covering, ear plugs, watching tv, reading.... still. wide. awake.

Since Monday morning I have had a total of 24.5 hours of sleep = I'm averaging 4.9 hours of sleep a night = I'm not a happy camper.... plus I have been too tired to go running this week and it's just making me more grumpy.

Another thing I tried to help me fall asleep was to look at pretty pictures of fall and rainy season.... fall is my favorite season and I would be the happiest person ever if it rained 24/7... seriously I love rain.

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   There is something about fall and about rain that is so comforting to me.

On an unrelated but happy note... I get to go to Colorado in a week! It'll be great to see it in the fall cause after all these years I've never been there during the fall. Plus I'll get to see these guys :D

Happy Friday Friends!