The scariest story I've witnessed in my career thus far.

Got another patient story. I'm sitting on an office chair, typing beside "Teresa". (Teresa is actually a nurse who happens to be in my line of sight. She is eating cheetos and charting.)

"Teresa" is in her 40s, married, and has two teenage daughters. She's got some significant vascular problems, a handful of comorbidities. She came in to Dr. Surgeon for some peripheral vascular plumbing. The surgery went well and Friday she was sitting up, eating, talking, discussing the plan to start physical therapy to do some actual walking.

Her nurse's name wasn't Emily. Emily's a good nurse and I always have a good start to my day when I follow her. She's thorough; she cares about what she does; her patients like her. It was her turn in stepdown and she had three patients, all walkie-talkies, all on telemetry (i.e. three lead EKG, not five). Todd was the telemetry tech/unit secretary. Pleasant, decent guy.

Like most ICUs, we RNs do not have our own bank of telemetry monitors. The tech watches each pod's bank of telemetry, lets us know when something funky happens, yells when something bad happens. Our pods happen to be larger than some units in town, which means a lot of patient heart rhythms to watch. Yes, there are alarms for everything.

You tele/ICU/ED RNs can see the story I'm setting up, can't you?

Emily saw Teresa around 10:30a, brought her some meds, assessed her, blah blah. Teresa's younger daughter was at the bedside. Teresa wanted a nap, so Emily partly drew the curtain and left her to snooze with her daughter reading in the chair.

At some point, Teresa came off telemetry. Nobody knows why, and at the time, nobody noticed.

At noon, Emily came in to see Teresa and found her pulseless, apneic, and unresponsive. Emily said to the daughter: "Honey, I need you to step outside for a minute, I don't think your mom is breathing."

They coded her for 25 minutes. Nobody knows how long she was down.

Jack took over for Emily, post(mid)-code, with the patient now intubated, with iv pressors, and completely unresponsive. He is swimming upstream trying to get the patient stable. Family members are understandably freaking out, each one wanting/needing a comprehensive explanation for what the hell happened. Jack explains what he can with one eyeball on the systolic in the 200s and the junctional? no, sinus, no now, fibby, no, junctional...rhythm.

Enter Jo, coming in for her Friday night shift. Jack takes me straight into the room to show me her labile pressures, unstable rhythms and now freshly degenerating neuro status. Teresa is now decerebrate posturing, pupils fixed and nonreactive at 7mm, deviated up and to the right, absent blink, inconsistent gag, no w/d to pain.

Teresa's daughter and husband watch her begin to seize.

....

The patient's been followed closely by one of my favorite intensivists, my favorite neurologist, a primary care I don't know and...Dr. Surgeon.

Right now, Teresa's heart has a solid rhythm and her pressures are being managed adequately with prn IVP drugs. She is ventilator-dependent. She has stopped posturing. She now does not respond in any way. I have her eyelids lightly taped down because she cannot close them.

....

The family is planning to extubate soon. (If you're not a medical person, that means she's going to die, probably quickly and painlessly.)

Right now, if you have any heart at all, you feel horrible for Teresa and her family.

Right now, if you're a nurse, you are feeling a sympathy bony chill of horror for Emily's livelihood. Could it have been you? Sure it could have. How many times a day are you too busy to be able to check on each patient hourly and on the dot? How long does it take for anoxic encephalopathy? Four minutes? Five?

....

I saw Emily yesterday morning, and I asked her what happened. She rattled off the events in a concise manner consistent with the H&P and Jack's report off to me on Friday. I nod. I ask, Emily, are you okay?

It was like she fell down like a waterfall. Hands shaking, she quickly snapped up a kleenex and pulled herself together. Emily is not okay. Emily is living every RN's worst nightmare. I couldn't do anything but hug her.

Bony chilly finger down my spine, all weekend long.

Change of Shift is up!

Over at Parallel Universes. Check it out.
/jo

Another turning point in Jo's career....Of Magnet, of autonomy, of managing my license like a business

MyHospital (let's call it 'MH') is working toward Magnet status, and I anticipate this effort will be ultimately fruitless. I have been part of my Nurse Practice Council (NPC) for 18 months before I sent in my resignation on Saturday. I started the ICU's NPC with my co-chair, G. G resigned Monday. Several nurses on the ICU committee are also abandoning it now, too.

I'm not interested in telling you specifics, and MH may find an arbitrary reason to fire me if I do. (Not that I find this bothersome...I'm an RN, for chrissakes. How many RNs among you have gotten flyers/emails/recruiter taps in the past month?) Besides, the specifics of MH aren't interesting.

The point is that I believe MH has parsecs of vacant emptiness between the offices and the bedside. It doesn't appear to matter that some of those offices contain people who have sat for, and successfully passed, the NCLEX. No understanding appears to exist between the two. No honest conversation happens in both directions, it's radio broadcast from one side only.

I needed to get involved. I came from the consulting world. You hire a consultant for your organization to come in and identify the root of your organization's effed-up problems for you. They recommend changes, they help you implement the changes your organization can tolerate and they leave when the problem is resolved or at least tolerable. This suits my mentality. I am not interested in bandaids. I am interested in resetting the bone.

I believe this to be true of most bedside nurses.

It was natural of me to find stupid things on my unit, within the organization at large and try to become part of the solution. I observe the direct correlation between your overtime dollars timed to the implementation of your ludicrously obfuscating computer charting system, for one example. And I say you made a blunder of enormous proportions that can be salvaged with the more than willing cooperation and collaboration from the bedside.

But such observations are unpopular among administrators at MH. I was hauled into the principal's office for that one. (Remember when Linda Blair's head spun off her shoulders? Yeah. Dude, you should have seen it.)

But I can't do this anymore. It's not that I met a brand new managerial howitzer that is pointing directly at me and my partner, G. It's that the meeting was the last shred of proof to me that it's no longer worth the fight.

I'm not even sure if I believe in that Magnet crap, anyway. I only believed in the ability to work to improve things for my patients and my colleagues. I am afforded less and less an opportunity, as the tools of divide to conquer and fear of arbitrary reprisal are pulled out. As my friend, a charge RN (read: quasi-management), makes a sincere attempt to mediate and is told to 'keep her nose out of it'.

Another friend is talking to a recruiter. A third is now picking up shifts at a sister hospital. A fourth has switched to part-time. Etc, etc. The experienced nurses leave my unit, leaving an ICU full of cheaper new grads who don't know defib patches from pacer pads.

...

So now. If I'm mentally checked out of trying to fix the bureacracy from within, I'm left with what my next set of goals are. I'm the kid of person to grow in the job I've got until I've gotten all that I'm interested in getting from it. Then I find a new place to grow. I'm just started growing in the ICU, and I'm comfortable there. I know everybody; the things I know, I know well. I learn something new every day. I know the docs, work well with the majority. I'm friendly with the pharmacists; when I send a med-gram for drugs I need, I get them (a bit unfairly) fast.

But there are a lot of ICUs in town, and they might be interested in having some more prn nurses.

Considering looking at Jo, RN, as a business. A business needs to have something to offer (which I do), be fiscally sound (and there's certainly several ways I can improve that). And a good one continues to grow, refurbish, repolish, try new tools, new skills.

I love my unit, because I really care about the people there. It's one of the most fun, interesting curious bunch of people I've ever worked with. I'd rather not leave.

But a business can, and maybe should, have more than one client. Maybe I need to consider that, too.

...and then there are good days.

Today's patient:

Patient came in on a cardiac alert. Massive MI, cored twice, once in the field, once in the ER...sent him to the cath lab and now he's with us. Cath lab guys roll him over to us, and he's crackin Monty Python jokes, talks about how great it is to be alive. Positively *giggling*. Says how lucky he is, how thankful he is to the paramedics and the nurses and docs downstairs, to cath lab, to us. Can't believe how good it is to be alive, where are his children? Can he see his wife soon?

I love that.

Some days? People are .....good. There's good reason to help them get well.

The myopia of Dr. Surgeon.

This is an addendum to my story about Margaret, my patient from earlier.

True story:

Jo has parked in Margaret's room because Margaret requires 1:1 RN care. She needs the titrating of vasoactive meds, dialysis, ventilator tweaks. She wishes to have "life support" care withdrawn 36 hours from now. She'd had a complex vascular surgery the previous week, done by Dr. Vascular Surgeon, to improve the circulation to her legs and feet. She is 84.

Dr. Vascular Surgeon walks into room Monday morning at 0700. He and Jo exchange polite good mornings.

Jo: "I have some concerns I'd like to share with you about how Margaret's doing, once you're ready to hear them. Here's her chart if you'd like to look at it first." I hand him the chart.

Dr. S thanks me, leaves room with chart, comes back five minutes later. He looks at (but does not unravel) the dressing to her leg. "When did you change this last?"

Jo: "At four this morning."

Dr. S: "And how are the incisions doing?"

Jo: "Well approximated still, no signs of infection, her white blood count is still within parameters, some moderate serous oozing from the groin, mild from the leg." (No, really, I sound like this.)

Dr. S: "And her pulses?"

Jo: "I can doppler the PT's intermittently, but can actually palp the DPs. That's a new finding from last night, days wasn't able to find the PTs and could only doppler DPs on their assessment."

Dr. S nods, and covers her feet back up without confirming my findings. I'm sure that his note will record what I said verbatim. I guess it's nice to be trusted? As he washes his hands, he asks, "What are your concerns?"

Jo: "We've been unable to titrate her oxygen much lower, and her rate is remaining 7 to 10 over the vent despite the 40 mic's of propofol. Also, I've been unable to get her off that point five of dopamine. Her pressures are stable, despite the fairly high blood flow on dialysis."

Dr. S cuts me off: "I'm just the surgeon."

I glare. Jo: "Also, though she's on the propofol, we have nothing for pain. Maybe a little Fentanyl? And I can back off on the propofol?"

Dr. S: "Well, she shouldn't be having any pain since the surgery was X date. Looks like that's healing fine."

My. jaw. drops. I make a wide gesture to the room, to the machines. "How about the REST of what we're doing to her?"

Dr. S is drying his hands, pitches the paper towels and shrugs. "I'm just the surgeon."

He walks out of the room, and there's Jo, still got her arm dangling pointlessly in the air.

If you haven't seen this, you need to:

This is how, in a pandemic, those who are treated medically and those who are not treated will be chosen: AP story.

Triage is tough. Medical professionals do it every day, and to the layperson it probably sounds horrifying.

Many decisions are hard to make. And some just aren't.

I'm not an uncaring person. When the pandemic finally comes, SARS or avian flu or whatever, I will work the overtime at the hospital. I've been one of the people who did the overtime through three blizzards, sleeping (or not) at the hospital during the days. I remember one day I took care of sixteen quad- and paraplegics for a sixteen hour shift, with my partner, who did the other sixteen.

I'm willing to do that when a crisis happens, like millions of other nurses are. We are caring people. I love the geriatric population; I knew I wanted to work with older people from the start of nursing school for me. I hated my ped's rotation. But in a triage situation, and all other things are equal? I'm gonna treat the 10 year old in respiratory distress before I get to the 70 year old in respiatory distress. I think we're hard-wired as a species for some decisions.

It might not be a bad idea for the public to know that, though.

I love MICU: reason #1

I realize the past few posts have been harsh and negative. But there are a lot of nights I do love my job, love the ICU. So I'm gonna tell you about when I love the ICU.

Reason #1 is The ICU means Intensive care...

We do have the classic drama like on tv, (only always in the ER...the ICU does not have its own tv show.) I was there for our last cracked chest in the ICU...which does not happen in the ER. A suture on the junction from the pt's aorta to her heart muscle tore. Blood. Everywhere. Liters and liters of it. God, it was bad.

And tell me why don't we have our own tv show? Not that the ED isn't interesting, it very much is. But. But. The ICU is cool, too.

They don't have situations like my patient the other night in the ER.

Margaret is not my patient's name, and she's a train wreck. She came in for a complex vascular surgical procedure, developed a bleed...and 36 hours later she's in multiple organ system failure. Yeah. That fast.

In ICU, you meet patients at a life-or-death time of their lives. Margaret has in her living will that she does not want to be on life support for more than seven days. Today is day five. Don't think that isn't at the forefront at my mind at all times. A week ago, she was living at home independently. Having cups of coffee with her friends. Visiting with her grandchildren, walking her poodle. This was a scheduled, planned, surgery.

On this particular patient, we don't have an intensivist or hospitalist, so there is no one single MD brain drivin this train. It leaves a lot of holes for the RN to fill. I'm not going to blog on the appropriateness of this (it isn't) right now. What it does mean is that the day RN with whom I'm swapping this patient every day (Douglas) and I are operating in a frustrating vacuum. And a clinically challenging one.

What I do love about taking care of this type of patient is that I was busy all night titrating drips, titrating the vent, titrating the CRRT, getting the next round of labs and futzing all over again. Dressing changes, lab values to interpret, arterial and central venous pressure line waveforms to futz with. Oh, and she has a paced rhythm, too.

...I can't seem to get Margaret off the dopamine, even with cutting her CRRT rate in half. Her central venous pressure is THIRTY, and I'm slurpin out fluid at almost hemodialysis rates. But I stop that, hold the whiff of dopamine I'm giving her, her pressure tanks. Her heart likes the inotrope. Weird. (Gee, I wish I had an intensivist here who might have some more ideas on what's up with that....)

Incremental success for this patient is decreasing her oxygen by 5% and having her tolerate it for an hour. Five percent is no piffle. It will be the difference between whether or not she can attempt to wean off the machine, i.e. recovering or not. I am continually testing how her body responds to the changes in the meds, changes in the amount of fluid I'm pulling off her body, in the vent settings.

Let me underline: We have two days left to fix her. Before the family draws the line because of Margaret's previously stated wishes. If we can't fix her, we will stop the kidney machine, take the tube out of her throat and she will essentially....drown. In her own body fluids. Of course we're gonna have pain and sedation meds on board, but I realize how horrible this is.

We have 48 hours. Where else but in the ICU do you have this kind of situation?

In the ER, some of their adrenaline comes from the chaos, the randomness, the wildness. 'Turn and burn' is what the ED nurses tell me. It's a different adrenaline in the ICU. Continuous dose adrenaline, maybe. Adrenaline for control freaks (wonder if the OR is like that, too?) I didn't sleep well today, because I was thinking about what I may have forgotten, what I could have altered or improved.

I don't know Margaret. I see the pictures of her in her room. But my head is totally wrapped up in what we need to do to help her body heal from the inside out. Why the drop in crit this morning? Where is the bleed? Do we need to give her platelets because the CRRT is chewing them up? Why can't we get her off that blasted dopamine? Why is it sometimes I can doppler that left post tib, and sometimes I get it on the right but not consistently? What's going on with those sutures in there? Why are her LFTs still high even after we've stabilized her pressures? I wish I had a PA cath to see what's really happening with her hemodynamically. Her lungs DO sound better, but when she turns to the left, her sats drop, I wonder if we don't have an infiltrate on the right? Her CRRT "arterial" pressure kept alarming negative pressures, which might imply that she's vasodilating...etiology? Sepsis? No, we have her on enough abx to sterilize a barn. What are my other types of shock: spinal, no, anaphylactic, no, cardiogenic shock? That's the only one left...? Why, in a paced patient? Is that why I can't get off the dopamine? What's gonna help her...well if we do levo, we completely nullify the surgery that she came in here for...

Round and round.

I love this. I really do.


But reason #1 might be the reason ICU is Intensive Care. We have a different definition of intense here. It's not better or worse than similar nursing areas....and this kind suits me. I'm glad they love the 'turn and burn' in the ER, I'm glad they have the extremely sedated almost-dead patients that they 'put down' and revive in the OR, and that's not even the people that do oncology, or scarier...pediatric oncology. Intense in different ways.

We have 36 hours left to get her off that vent. It's a proFOUNDly complex puzzle for the team of people working with her to disentangle.

And it means life or death for Margaret. I'm sitting in her room, surrounded by pictures of her family, her pooch. They're waiting on us to be smart enough to get her out of this.

Thirty-six hours.