I’m an RN in a 18-bed Med/Surg ICU. Intensive Care units are for the sickest patients in the hospital. You get sicker than we can handle the only step up is to meet your Maker or have said Maker do a miracle.
This is our Mantra:
We care for people in Septic Shock, with CVAs, DKA, decompensated heart failure, post cardiac arrest, COPD exacerbation, ARDS, drug overdose, and the post-ops of every discipline (except the open hearts who have their own CVICU). We manage treatment modalities like CRRT (continuous dialysis), hypothermia protocol, and LV assist devices like the Impella and balloon pump. Highly technical and lots of variety, which is what attracted me here.
I originally was going to write about an entire shift in the ICU but found that the first hour of a recent shift gave a decent representation of what we do. Not terribly eventful or comprehensive, just typical.
Hour One went as follows:
I walk on the unit for the first of my three 12 hours shifts. Check the board for my two assigned patients, find the nurse who had them for the day and plop down next to her. Yes, only three shifts, and yes, only two patients. Trust me, it’s enough.
The “Day Babe,” as we night shift nurses affectionately call day nurses (do they have a name for us? The walking dead……) fills me in on each patient: history, hospital course, treatments, status of each body system. I fill out all the little boxes on my report sheet in an attempt to grasp an entire patient’s health and plan of care in less than five minutes in a way that somehow qualifies me to be responsible for them. It’s always astounded me how short, random, and unregulated this process is.
Hemodynamic monitors placed around the unit display heart rhythms and vital signs on each patient. They alarm and flash with increasing levels of dismay when something is out of range. This varies from little peeps and flashes for something minor (O2 sat probe is off) to the From Hell noise that awakens your hindbrain to mortal danger (your patient’s heart has stopped beating.)
Both of my patients have heart rhythms that are compatible with life and no alarms. Yay. I fill out a quick little schedule for myself for each patient and then go to see the sicker one first.
Patient One: Small bowel obstruction status post Exploratory Lap, went into respiratory failure on the hospital floor after developing pneumonia. Came up to us to be intubated, diuresed, and get IV antibiotics until the invading organisms are killed to death. She’s in septic shock on several pressors, Cardizem and heparin drips for AFib, fentanyl for sedation.
I assess her, making the million little observations that tell me if she is really doing as well as the monitor might lead me to believe. Vital signs can be very deceiving, nowhere more than ICU. Lung/heart/bowel sounds, ET/OG tubes, pupils, hand grips, pulses, skin integrity, IV access.
She’s severely edematous. Her flesh puckers under my finger like that green brick material flowers are arranged in. I wonder what she does for a living, if she has kids, pets, if she’s married? Read any good books lately? Details of personal life are UTA (Unable to Assess) when the person is I&S (Intubated and Sedated) and there’s no family around.
I ensure all her drips are running correctly and calibrate the arterial line, which tells me her MAP is 68. Beautiful. Only as much Levophed as she needs, no necrotic fingers and toes for her. She looks good. Stable-ly unstable, we call them, when their vitals are normalized on medicated drips.
Patient Two: Older gentlemen, VFib arrest, visited the Cath lab for a variety of stents then hypothermia protocol. He’s past all that now and has just been extubated. The day nurse told me he looked good respiratory-wise. I don’t agree.
He’s tachypnic taking shallow breaths. Weak cough that isn’t getting the job done. He’ll be reintubated within 12 hours if he keeps this up. I call my friends in Respiratory Therapy for ENT suction. It helps, but he HATES it. He asks me why I like to torture him. I tell him that I don’t, that I’m trying to get him better. He scowls. He’s over it. I don’t blame him.
The rest of his assessment is WNL, and that’s not “We Never Looked,” it’s “Within Normal Limits.” Because I looked. Except…….I can’t help but notice that he doesn’t move his left side as much as his right, and his hand grip on that side is just a tiny bit weaker. Am I imagining it? His pupils both react to light but don’t look exactly the same…..and he’s not really answering my questions. He’s probably just being difficult….right?
Come on man, don’t do that. Let’s not take an emergent trip to CT and do TPA protocol right now. Fast as I can, track down the NP. He has a history of right CVA with residual left-sided weakness. The day nurse didn’t tell me that in report.
I push some IV hydralazine for his BP of 180/70. He asks for a beer. I feel foolish for worrying about him so much a few minutes ago.
The hydralazine helps for only a few minutes so I chase it with 5mg of metoprolol, pushed over two minutes because I don’t want to stop his heart, just slow it down. I make peace with the fact that I’m going to be chasing his BP with IV meds all night long.
I set the bed alarm. Dude’s awake now and I don’t trust him, even as weak as he looks. You know how 100 lb. moms can lift cars when their kids are in danger? Elderly patients can do astounding things when the delerium sets in.
Overall a pretty easy ICU assignment.
I leave his room and hear a plea for help from a nurse at the end of the hall.
I know this patient, Heroin OD. Tattoos everywhere. When I say everywhere I mean it. Many of the nurses had speculated about whether or not certain tattoos look differently when certain body parts were in certain anatomical configurations. If you know what I mean. If you don’t, don’t think about it too much.
We don’t mean to belittle people or treat them as objects. We can’t help but think these things.
The nurse called for help because he’s been on tube feeding for over a week and his Dignicare fell out. You can imagine the consequences. If you can’t imagine them because you don’t know what a Dignicare is don’t worry about it, innocence being bliss and all. I help her get things straightened out. She grateful. I promise to help her with his bath later. He’s a big dude.
Quick stop at the Accudose, grab my meds and waste Versed and Fentanyl for another nurse. We chat and make fun of the NP who’s working on the other side of the glass, not noticing us. We’ll tell him about it later.
I give Patient One’s meds after deciding that they’re all safe and appropriate for her. A few IV pushes, hang an IV antibiotic, crush up the pills, mix them in some water, flush down the OG tube.
I most definitely neverpretend I’m a wizard making a magic healing potion when I do this. That would be childish and I’m a professional.
Her MAP is 64. Borderline but I’ll ride that out another 10 minutes before titrating her Levophed; you learn after a while not to micromanage your pressors……
Then the monitor starts alarming THAT alarm, the hindbrain one. Bed 24, and judging from the trace on the monitor it’s legit VTach. I start to run to the room but two steps in the alarm stops. Just a run of VT, not sustained, 20 beats or so.
I grab the rhythm strip that’s printing out and go to the room to give it to the nurse, a friend of mine who just got back from maternity leave. She turns to me and takes the strip.
I don’t know this patient. Septic on CRRT, came in yesterday.
“She looks like shit, ” my friend says. She does indeed.
Now that’s not some random or insensitive insult. It’s a thing we ICU nurses say when we get that vague unsettling feeling in our perceptive gut that even though this patient looks okay on paper or computer screen they’re going to go downhill, soon. And now here she comes with the increasingly-long runs of VT.
“I told them,” she says, shaking her head. I tell her to let me know if she needs anything, I have my unit phone.
Then I go get a unit phone and sign into it since I forgot to do it earlier. My manager runs a report every week that tells her when we forget to sign into a phone within five minutes of starting our shift. I’ll get a strongly-worded email.
Check the monitor, Patient One, MAP 72. Hah! Peek in on Patient Two. Still in bed. BP 200/103. Awesome. Bust out the IV labetalol. Take THAT. Back down to around 180/70. Sigh. NP says to give it a half hour.
Grab the aide, both patients get repositioned. Sit down to chart. Barely get logged on.
Good buddy nurse sticks her head outside the curtain and gives me The Smile. She’s helped me so many times, she knows I’ll do anything for her. Not that I want to go into that patient’s room. I do not. But we’re nurses, and we do what needs to be done.
I enter the room of the patient who solidified my belief that ultimately ICU nursing is not for me.
Now, I love intensive care. I love helping someone right in the moment they need it most. I’m good at my job and I love using my head and my heart to do it. But I can’t stay here. I’m willing to walk with a patient through difficult and painful treatments to get them better but I didn’t sacrifice my time with my family and go to nursing school to put people through hell for no meaningful recovery. I have an ethical aversion to a good 40% of what I do at my job now and that percentage only seems to be growing.
Her history is too long to recount. Her body had lost the ability to heal a long time ago. Every organ failing, even her skin. Her skin would break under our hands no matter how gently we would move her.
Her BKA stump has been infected for months. The flavor of this month was Pseudomonas. The nurse was asking for help changing the dressing. We remove the old dressing to find her stump disintegrating into the telltale light green of raging Pseudomonas infection. It looked like pea soup. We were keeping this woman alive so she could turn into pea soup before our eyes.
I couldn’t look at her face anymore. When I had first taken care of her I had paid very close attention to her face, trying to read her expression for anything I was doing that she found painful since she was nonverbal at baseline after massive stroke. Eventually I figured out everything we did caused her pain.
We still warned her of what we were going to do, still apologized. The family had instructed that no pain medicine be given “because it makes her less interactive with us.” The family wasn’t even here. Sorry she can’t entertain you like you want because of the tremendous pain she’s in. I try so hard no to judge them as I’m sure they’re are suffering too. But I fail every time and every time I get angry.
Ethics consult was “pending.” Meaningless, we have no teeth, no real influence. If the family says treat, we treat. What does “treat” even mean, then? If all we do is…..
I stop myself from going down that mental road, again. It simply isn’t up to me. What is in my power to do for this woman, right now, that will help her? I can think of nothing but to treat her gently and say a prayer for her relief.
I don’t know if it helped.
Dressing done, I leave the room with ice in my gut and go back to charting.
A few clicks done before Bed 24 alarms again.
VTach, really fast and not stopping this time. Everybody runs for the room. I’m first so I go to grab the cart with the Resus meds and Life Pack but it’s not there because my friend with the bad feeling already has it in the room. She’s been feeling for a pulse while we ran to her.
“No pulse,” she says as I walk in. I start CPR while she digs out the defibrillator pads. She puts them on around my hands and starts charging the Life Pack. “Clear!,“ I back off, she discharges the shock.
(Ahhhhh sorry. I can’t help it, it’s exactly what we’re doing when we shock someone.)
Sinus rhythm restored.
“Maternity leave didn’t slow you down, did it?” I say to her. She shrugs. Intensivist walks in and starts barking orders about STAT labs and electrolyte replacements. “Need something, call me,” I say as I walk out.
Check the monitor. Patient Two’s BP is 190/90. *sigh*
All things considered, not a bad hour. My scrubs aren’t covered in anything. I didn’t get any indecent proposals. Nobody tried that hard to die.
A quiet day so far for anniversaries, so I have to dig deep and create something from next to nothing,
May 12th each year is International Nurses Day.
Until the mid-nineteenth century, nursing was not an activity, which was thought to demand either skill or training. Nor did it command respect. As the English heroine of nursing, Florence Nightingale, said, nursing was left to ‘those who were too old, too weak, too drunken, too dirty, too stupid or too bad to do anything else’
The intimate body services to be done for the patient were considered to be unseemly or immodest for young unmarried or well-bred females, especially if not a family member. Cleaning and feeding of another person were regarded as domestic tasks performed by servants.
Also, before 1880, the hospital treatment of illness was fairly rare. Where home services were adequate, a sick person was attended by the family doctor and nursed either by female family members or servants. However, from the middle of the nineteenth century, the discovery and application of anaesthetics and antiseptic surgery advanced medical technique and allowed all classes to seek treatment in hospitals. From the 1860s onwards, a series of nurses’ training schools began to produce fairly large numbers of educated women who were eagerly accepted by hospital authorities whose medical officers, patients and public opinion in general were demanding higher levels of nursing skill in the wards.
In Scotland, a series of nursing schools began to produce large numbers of educated women who were then accepted to work in hospitals. This resulted in demand for higher levels of nursing skill in the wards. For Queen Victoria’s Jubilee in 1887 fund-raising efforts led to the creation of an institution that would nurse the sick poor. In Scotland, this resulted in the formation of the Queen’s Nursing Institute Scotland in 1889, based in Edinburgh. After training, nurses could be sent to work anywhere, from as far north as Shetland or down south to the Scottish Borders. This could mean serving a densely populated urban area or a rural one with vast distances between patients, such as that covered by the East Lothian Benefit Nursing Association.
Over time, nurses have been involved in wars, pandemics, daily emergencies, regular check-ups, and palliative care. There have also been numerous developments in all branches of nursing but what remains at the heart of it all is the commitment towards the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Where would we be without these wonderful nurses!
Pics are from the Queen’s Nursing website, first is District nurse Elizabeth McPhee in 1926 astride her BSA motorcycle on the ferry slipway at Dornie, and yes that’s an unrestored Eilean Donan Castle in the background! Annie Mackinnon, a nurse from Roag, Skye, she went to France during ww1 and was awarded a Croix de Guerre: “for conspicuous bravery in continuing to care for the sick and wounded under enemy fire’. Queen’s Nurse (QN) Katy Shearer, Loch Fyne, 1950. Midwife Catriona MacAskill weighing a baby in North Uist, 1959 and Maryhill war nurse Louisa Jordan, made famous recently due to her name being used for the temporary hospital and vaccine centre at Glasgow’s SEC during the pandemic.
You can find more pics a history about Scottish nursing on the QNI web site here https://www.qnis.org.uk/
#Thankyou to our #frontlineworkers who are fighting for us
Beauty can be found in so many ugly places because our frontline workers are at the forefront of most them.
Thankyou for taking care of me I need to be . Thankyou because I have so much more to live and so much more to give. Thankyou for being their for me I didn’t ever want to die. Thankyou because I know you have sacrificed so much for me. Thankyou because without you there, their would be no me or us . Thankyou for working such long hours And caring like you do . All I want to say to you Is that I’m thankful that is true and that everyday that passes I thank you for all that you do! I hope that every wish upon a star is answered just for you, because i am so grateful this so far is true ! Today my heart beats ❤just for you as my heart was fading fast you kept waiting , hating Covid-19. But as time went on you sang a song and before to long I came along and I had awoken life’s not a token . I too can enjoy life’s treats you’re kindness is for keeps , in my #heart and #mind forever and one day I hope and I pray for our frontline workers to stay while we lay with us today #Thankyou #doctors #nurses
Movie Review: The Vampire (1957) directed by Paul Landre
Dr. Paul Beecher (John Beal) is a typical small-town doctor of the 1950s. He has an office in his house staffed by new pretty nurse Carol Butler (Coleen Gray), and also makes house calls. A widower, he lives with his young (11-12) daughter Betsy (Lydia Reed), who cooks for him when not taking ballet and piano lessons (the teachers can’t…
My union has been making some ads about violence against nurses and this one felt so many levels of too real.
I love how someone always has to hop on and say something about nurses deserving it etc lol.
This post is about awareness for violence AGAINST nurses, I get that our unions aren’t perfect and that there are some nurses out there who are bad seeds. Just like in most professions. Please make your own post for that instead of jumping on this one to share that tidbit with me when I was scared a pt was going to beat the shit out of me earlier this week.
Have you ever stroked a stranger’s hair when they’re sick and told them it’s going to be okay even though you know what the numbers on the screen mean? Holding someone’s hand while they’re crying and telling you they’re scared runs a chill down your spine. Have you ever called someone by a name on a armband but wondered if that’s what their family calls them? Have you ever seen someone close their eyes and wonder if they’ll ever open them again? Have you ever forgotten what color someone’s eyes are? Have you ever been the place holder for their wife, husband, children, mother, or father? Have you ever cried telling that stranger that their family says they love them and that they’re praying for them even when they can’t be there with them? You ever tell that stranger that you’re praying for them too?
Nurses everywhere are tired. Emotionally. Mentally. Physically. We’re all tired.
Stop getting caught up in the social media of people who think it’s a hoax. Don’t give in to the ignorant bullshit that people are saying. One percent of the population of the United States, alone, is 3.2 million people. That one percent is worth fighting for.
They’ve stopped calling you a hero but that doesn’t mean you aren’t one. You’re a hero every single day you’ve shown up to work in this pandemic. You’re underpaid and under appreciated and yet there you are, every day, helping your patients fight. YOU are the reason your patients get to go home.
Do something for yourself on your day off. Wholeheartedly just for yourself. Not something your kids will enjoy, not something for your partner or parents or siblings or friends. You do you. Take care of yourself.
You are so important to your patients and your coworkers. Don’t give up. These vaccines are a light at the end of the tunnel. We’re almost there.
You got this.
(**I didn’t make this artwork, if anyone knows where it’s from, please message me so I can give credit)
Nobody signs up for emergency medicine because they have a death wish. We are here because we want to help. We don’t fear stressful situations, we thrive in them. In times like these, when there are so many unknowns, we may question why. Why are we risking our lives for this? Why are we showing up every day when everyone else is home?
We are trained for this. We remain calm when everyone else is panicking. We can help.
Be there for your friends who are scared, your family members who are uninformed. Do your own research and understand the changes happening everyday. Protect yourself at work. Wear PPE. Change your clothes at work before you go home. Turn off the news and social media for a while.
It’s okay to be scared. It’s okay if you panic bought toilet paper. You’re human. We are in this together. We’re all scared. But we’re also all superheroes.
Do you ever take care of a mentally unstable person who happens to be your age and then realize what if you had matched with them on Tinder/Bumble/match/eharmony/farmersonlydotcom?
What if you had swiped right unknowingly? What if that was you sitting next to them while they LOSE THEIR SHIT because the nurse dare ask why they’re in the ER for the leg pain they’ve had for THREE MONTHS?
