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.
So, as we talked about last time, occupational therapy is a therapy focused on the specific aspects of what makes you, you—and we call those your “occupations”, the things you find important and spend your time doing.
When you come into occupational therapy with an impairment of some sort, OTs will take that and come up with a two-pronged approach to therapy:
First, we get an immediate, short-term solution to the problem. This is a modification, an adaptation. Second, we start figuring out how the patient can work, learn, or exercise in different ways to strengthen, stretch, or otherwise adapt their body to be able to do the thing they want to do long-term.
When one of my professors (an OT) was very young, she decided she wanted to be a physical therapist. Her mom wanted to encourage her, so she set her up with a volunteering gig at a local therapy place. Her job as a volunteer was to wheel elderly people in from the waiting room to their therapy, then wheel them back out. As she wheeled in one particular lady, who was recovering from a stroke, the physical therapist asked, “How are you doing today, Mrs. Smith?” Mrs. Smith admitted she was not doing very well. The PT responded something like “Well, no pain, no gain, right?” and continued on about therapy as usual. (Most PTs aren’t like that, hopefully!)
After the PT session was over, the volunteer was supposed to wheel her to OT which was just down the hall. When the occupational therapist asked, “How are you?” Mrs. Smith responded the same way. The OT stopped and pressed her for more information. Eventually Mrs. Smith reluctantly disclosed that she had been unable to put her bra on in order to leave the house, and she was embarrassed and upset at having to ask her husband for help with such a simple thing. The OT immediately reformulated the structure of her entire therapy session. First, they re-fitted her bra with Velcro in the front and adjusted it and practiced until Mrs. Smith could put it on herself. Then they began to address the issues of her limited shoulder mobility. There was a lot of work yet to do, but Mrs. Smith was wheeled out of the office with a smile because they had addressed what was specifically important to her.
So what do you do if the patient’s preferred occupation—their own personal goal, the thing they want to spend time doing—doesn’t have direct therapeutic value for addressing their impairment? That’s where artistic media can sometimes be brought in, like I mentioned briefly in part 1.
Let’s imagine an elderly woman who more or less goes around chatting with people at her assisted living facility all day long—all she wants to do is chat. But, since she’s having difficulty using her fingers for fine movements (like dressing herself, brushing her teeth, feeding herself), we want to do occupational therapy for strengthening her fingers. Sure, we could force her to do a boring activity that she doesn’t connect with: squeeze on a stress ball for 10 reps, practice picking up small items over and over again…or, we could incorporate an activity here. Have her make a pot out of clay that she has to pinch and shape. Have her make a mosaic by pressing tiles into air-dry clay. And while she’s doing that activity, she can chat, and when the project is done, she has something to tell other people about and show off!
Creative media are so useful when it comes to getting people engaged. Mr. Jones is a grumpy retired veteran who tends to be labeled noncompliant: you’ll get so much better results if you teach him how to make a leather wallet than if you try to force him to pick marbles out of some putty. Bobby is a little boy with Down syndrome who has a single mom and multiple siblings: get him interested in a therapeutic game on his iPad, and he’ll be much more likely to do therapy in his free time than if you prescribed an intervention that required hours of uninterrupted one-on-one time with his mom. Mrs. Miller has high anxiety about regaining full use of her arm: show her a soothing, repetitive craft like knitting or crocheting that will strengthen her hand and also help calm her down. Seriously, the possibilities are endless.
So hopefully you understand a little more about how OT is unique. It fits into every practice setting: there’s OT for acute care, home health, nursing homes, outpatient clinics, schools, pediatrics, geriatrics, and everything in between. I personally want to be a pediatric OT and work with children with special needs, which looks like gaining as much independence as possible for that child’s particular challenges: can they learn to feed themselves? Dress themselves? Communicate with an iPad? Maybe they can learn to walk with a walker; maybe they can learn to walk independently; maybe they can learn to use a wheelchair, maybe they can control the wheelchair with the movement of their eyes. How independent can this child possibly be? How empowered can we possibly get him/her?
It’s a fantastic profession, despite being little-known. If you’re interested in a medical profession, but you have no idea which one, consider occupational therapy when you’re making your decision! If you’re a medical provider already, hopefully this may give you some ideas of the use of prescribing OT for people. In many places, it’s considered an “emerging practice” and we’re trying to spread the word about how important OT can be, so keep an eye out at wherever you work or see how you can help drum up support for including OT in your profession!
Hi everybody! Occupational therapy first year second year student here to answer the question, “So, what is occupational therapy exactly?”
Many people in the medical field may have heard the name or have some vague concept about what occupational therapy (commonly abbreviated OT) is, but others may have not, and certainly there are a large number of people not in the medical field who have no idea what this is. In fact, it’s probably easier for me to start by explaining what OT is not:
Occupational therapy is not career counseling. (That’s the name of my blog!) Yes, the independent words seem like synonyms of one another, but they’re totally different things.
Occupational therapy is not physical therapy. A lot of times, they get prescribed together (OT/PT), to the point where medical providers act like “oh-tee-pee-tee” is one long, bizarre word meaning “please exercise this guy”.
Occupational therapy is not just group craft time, nor is it artistic busywork. Many OT providers do choose to use art as a component of their therapy (which I’ll explain more about later), myself included. Sometimes laypeople and even medical providers look at this and don’t think it can have any value because on the outside it looks fun and playful. Because everybody knows that in order for therapy to work, it has to be super boring, and the minute you start to have fun it ceases to be therapeutic!
Okay, so those are probably the most common misconceptions about what occupational therapy is not. So we’re back to our original question, what is occupational therapy? That’s a good question, and in fact, the American Occupational Therapy Association is currently in talks to agree upon a simple definition encompassing exactly what we do, which will be announced at the 100th Birthday of OT happening in 2017.
In the meantime, we’re having to get by with our own simple definitions, and here’s mine:
Occupational therapy is therapy that focuses on an individual’s ability to enjoy life the way they want to as a measure of success.
That means that, for an occupational therapist, the most important measure of whether they are succeeding in providing therapy is whether or not their patient is able to participate in the things they want to do. Right now, if you’re in the medical field (or even if you’re not), you might be scratching your head and saying “uh, isn’t that what every medical provider wants?” And the answer is, yes and no.
So let me break this down a little further.
The reason the name “occupational therapy” confuses people (see: not career counseling) is because in our society, our “occupation” specifically means our job. But in occupational therapy, an occupation is defined as any meaningful activity that a person does to occupytheir time. Under this definition, your job is definitely still your occupation, but so is being a parent, going to school, playing with your pet, engaging in your hobbies, participating in leisure activities, and so on.
It encompasses all the roles in your life (employee, parent, sibling, student, child, friend, volunteer). And, here’s the most important part: your occupations are totally different than somebody else’s occupations. You may be the same age, live in the same area, and have the same diagnosis as someone else, but your therapy will be totally different because it’s going to focus on the crucial aspects of what make you, you!
This is not at all to say that other medical professions don’t care about you as a person, or that they don’t know how to adjust their tactics to fit their patient’s personal needs. Not at all! Good medical professionals in every field will have elements of this holistic viewpoint in their practice. But at the end of the day, if a surgeon has a guy open on his operating table, it doesn’t matter whether this guy uses his knee to play basketball, to perform martial arts, or to dance at the grocery store and embarrass his kids; all that matters is that the surgeon needs to replace the knee. (Cue kneeologists correcting me in the comments.)
But when the guy is recovering from surgery and learning how to do things again, his occupational therapist will be the one taking that into consideration.
We’ll look more at how OTs do that in Part 2 of this series!
this is a graphic about what to expect if you’re sent to the ER by a therapist/psychiatrist/family member/etc trying to institutionalize you.
bare in mind this is just based on my experiences as an 18+ year old in the US, and compares notes with friends. it’s not applicable for adolescent ward or folks outside the US.
other factors that increase your likelihood (across the board) of being sent to the psych ward:
being trans: it willprobably increase the likelihood that you’ll be institutionalized, but to what degree varies hugely based on location, hospital, and even doctor.
having a history/dx: if you’ve been institutionalized before it’s much easier for them to do it again. also if you have a *bad* dx.
unsupportive family: if you fam wants you to institutionalized, the doctor is more likely to agree with them.
living alone: doctors get nervous if there’s no one to keep an eye on your/take care of you.
race: if you’re a person of color, especially for black folks, you’re more like to be medically labeled as psychotic/severely mentally ill (there’s actually stats to back this one up), and thus so more likely to be institutionalized.
anyway feel free to add! i’m sure folks have experiences that don’t aline with this!
If you’re neurodevelopmentally disabled and/or chronically ill, or have other debilitating conditions you’re more likely to be institutionalized to “help protect your physical health”
Artist and author Jenny Williams has hand-lettered quotes from this year’s Pep Talks! Check out her work at www.jennydwilliams.com, or follow her on Instagram @stateofwander. Read the rest of Alaya Dawn Johnson’s pep talk here.
Like the main event itself, NaNo Prep is always better with an incredible writing community around you. Luckily, our forums come with such a ready-made community. Inspired by the Plot Doctoring forum, we askedDerek Murphy, NaNoWriMo participant, to share his thoughts on plotting, and he outlined his 9-step plotting diagram:
Here’s a truth: you must write badly before you can write well.
Everybody’s first draft is rubbish. It’s part of the process, so don’t worry about it. The writing can be polished and fixed and improved later, after NaNoWriMo, during the editing stages.
What most writers get out of NaNoWriMo is a collection of great scenes that don’t necessarily fit into a cohesive story—and that’s a problem if you want to produce something publishable.
Nearly all fiction follows some version of the classical hero’s journey: a character has an experience, learns something, and is consequently improved. There are turning points and scenes that need to be included in your story—if they are missing it won’t connect with readers in an emotionally powerful way. And it’s a thousand times easier to map them out beforeyou write your book.
+$5-10 per extra character (it depends on lined or colored and bust/torso/full) speedpaint available for your commission for an extra $10 !
I’ll draw pretty much anything! Furries, dnd characters, ocs, any fandom tbh, i’m chillin However I won’t draw any nasty stuff but i dont think anyone will ask me to anyway slkdjf message me here (dms pls) or email me at [email protected] and if you have any questions feel free to ask!
i’m gonna try out google pay and not paypal bc paypal……. is a mess
+$5-10 per extra character (it depends on lined or colored and bust/torso/full) speedpaint available for your commission for an extra $10 !
I’ll draw pretty much anything! Furries, dnd characters, ocs, any fandom tbh, i’m chillin However I won’t draw any nasty stuff but i dont think anyone will ask me to anyway slkdjf message me here (dms pls) or email me at [email protected] and if you have any questions feel free to ask!
i’m gonna try out google pay and not paypal bc paypal……. is a mess
So I just applied for food stamps for like the sixth or seventh time this year, but while I’m waiting for that to process (and likely be denied again), would it be inappropriate to spread a post just to scrounge up some grocery money?
I know this site has helped me out with rent just last month, and I’m thankful for that, and I know like in an existential sense I haven’t earned that yet, much less earned anything more. But I’m also hungry and I’ve got a migraine I can’t shake. I asked my family for 15 dollars today and they just screamed at me.
Whenever I do this kind of thing I always try to pay it forward into the universe later on. So far I haven’t had the ability to do that, I’m still out of work and hanging onto my apartment by the skin of my teeth. Still, if I could just get some decent food, maybe even a fresh vegetable, that would be astronomicalfor me right now.
Hey guys what’s up, I have a very promising interview tomorrow! Downside: I have no money for public transportation. Or, like, eating beforehand. Click above to give me transit fare pretty pretty please I’m so stoked about this interview, I’ll be so depressed if I don’t make it there.
I want to be huge and round and pregnant, and walk around in public holding your hand so everyone stares at my huge belly and knows that you bred me. I want every woman who seems me to look at what you did to me and instantly get turned on imagining being bred. I want you to show me off as your sexy little pregnant fucktoy.
