The Invisible Nurse

26 Feb

The invisible nurse that the supervisor insists exists.

The Invisible Nurse– is the Nurse that all House Supervisors think exist, except they do not exist.

I can tell by the way he says my name when I answer the charge nurse phone: he is thrilled! He hates me!

Supervisor: Send a nurse to PACU– there are 2 patients holding.

Me: The first PACU holding has a bed ready here, and the other PACU holding is not coming here.

Supervisor: Is the second PACU holding written out of ICU?

Me: Yes.

Supervisor: Send a nurse to ED– there are 2 patients holding.

Me: No— disposition to telemetry.

Supervisor: If they are not out of ICU census before 1900– you better send a nurse to the ED.

Me: We do not have a nurse to send. I wish that we did, but this is not possible.

Supervisor: Do not argue with me.

Me: I am not arguing with you.

Supervisor: Yes you are.

Me: We do not have an invisible nurse to send to the ED.

Supervisor: I am telling you what to do.

Me: The acuity is high here in this tower. We can not work short. It is not safe.

Me: If you would like to walk up here and take a tour I would love to give you unit report, and then we can walk together to the ED and confirm disposition. If you still want to pull a nurse from this unit, I will give you the rapid response luggage, and the rapid sequence intubation box because we will not be able to respond to the floor for emergencies.

Supervisor: (Hangs up on me.)

I Will Always Be ICU New

19 Feb

Lieutenant Diechler on 10 August on discharge from hospital after recovery from bullet wound to abdomen received at Hatcher’s Run in March. From Circular No.6, Surgeon General’s Office, Washington, 1 November, 1865. Tinted lithograph.

It is the three year marker walking the Avenues on the intensive care unit and opening the glass doors of these special Hospital rooms. It is a complex obsession of knowing the patient, untangling needs, and anticipating what will happen next. It is persistent vigilance at the bedside. It is the critical care thinking.

There is intuition: Something is wrong before the brain can process exactly what is wrong. The learning is built like bricks in the brain with a heavy foundation on the neck. It breaks the back, it ruptures emotions, and it creates confidence without arrogance.

Three years is maximized with learning and minimized by time: I will always be new.

Sleep All Day

18 Dec

This work is hard. It is harder to nurse a patient and see major improvement to come back the day and see a turn for the worse. This has to have an effect on our emotions. I slept all day. I was just tired.  The blanket over my head felt so good.

I know what the book tells us: eat right, exercise and care for the self.  I was never good at doing what the book reads.

Wet Your Eyes

10 Dec

The eyes are complicated things, I still don’t understand the anatomy and physiology. I don’t understand how a camera works either.

I do know that these shutter lids wet my eyes even with the dry eye. Apparently the glassy end of shift red dry eyes try to compensate with tears like lake reflections in the water of a busy shift– but they are still dry.

After years of suffering with the eye blur and hurt, I have accepted the diagnosis of dry eye. I broke down and complied with the medication regime of drops– The Restasis gtts.

After one month of the drops there came relief! Now, the bad news is that I ran out and am waiting for the mandatory mail-order that my prescription plan demands.

Your Head in My Hands

9 Dec

The frontal lobe assault! The diagnosis: Orbital skull fracture with Subdural Hematoma (SDH) secondary to flip over bike head first to the black top, and no helmet on.

The scene: Trauma patient holding in the Emergency Department waiting for ICU bed availability. The patient has intermittent periods of aggression and anger. The patient is not directable. The patient continues to rip off the cervical collar. Sedation is not possible because of the need for frequent neurological assessment. The patient is placed in 4 point locking restraints. Intravenous Tylenol is administered for pain. The Emergency Department is loud, bright, and full of action. The family hovers over the bed attempting to console the patient worsening the agitation. The patient screams and then falls back to sleep.

ICU Arrival: The TBI patient continues aggression and agitation while awake. The stretcher arrives followed by RN and security with the key for the 4 point restraints. The patient is safely transferred to the ICU bed. This is followed by a large family trying to visit the patient. The patient is attached to the monitor and the nurse tells everyone to leave the room. The family feels insulted as evidenced by crying, dirty looks and running out of the unit.

The Care: The nurse turns off the lights and closes the blinds. The nurse completes a full neurological assessment. The patient does not follow commands. There are no focal deficits. The patient knows his name and the name of his mother. The patient becomes calm. Two family members are retrieved from the waiting room. Detailed explanation and education is given to the family about decreasing external stimulus. The patient wakes up screaming and the Mother runs to the bedside. The aggression and agitation starts all over again.

The Mother: “He is not like this. He is a sweet boy, you can’t keep me from my son.’

The Nurse: “We are on the same team. I do not want to keep you away from your son. I understand that you are worried and sick, but at this time your son needs a quiet room. I will care for you and your son, but the priority is to decrease the pressure in his brain. When he gets up screaming the pressure in his brain will increase. This is not acceptable. I also understand that he is not acting like his usual self, and this is common. He has a head injury ”

The Mother begins crying and doesn’t believe that her presence will not comfort him at this time.  The nurse takes the Mother into the hallway and watches the patient fall back to sleep and rest calmly. The evidence of the care plan is witnessed.

It is that frontal lobe you know, the personality driver and the changes can be extreme and diverse. This is apparent during acute and after acute injury. We can’t predict the future of recovery. And to me as the primary nurse– I see good signs: the patient wakes up, the motor strength is strong enough to require restraints, his pupils are equal and brisk, he knows his mother’s name, and the bruise clot hematoma is not expanding on follow up repeat CT scan. There has been no surgery, no external ventricular drain, and I am happy as can be regarding this assessment. The orbital fractures will heal. To me personality changes are the least of his problems at this time.

For the Mother this is the worst scenario because she does not know the worst. It is not her fault.

Two Minutes Switch

5 Dec

The reality: Once upon a time in a busy intensive care unit a patient was dying. The severe bloodstream infection causing severe sepsis leading to the complicated pathophysiology associated with disseminated intravascular coagulation is difficult to understand and treat. There is bleeding and micro-clotting at the same time. The multi organ failure is already apparent.

It is a three on one nursing resuscitation. The hemoglobin is four and the pH is 6.8. This is not compatible with life. The blood bank delivers four coolers filled with: packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. It is called a massive transfusion protocol and the products are transfused in two minutes each. Two nurses check the blood products with unit number and patient identifiers, and the other nurse uses the rapid transfuser to push the product into the patient.

And in the middle of this we place the backboard under the patient, attach the defibrillator, drop the bed into CPR mode, and prepare the documentation papers for a code blue. Central pulses are located and marked with a permanent marker to ease the location of pulse in between chest compressor switch.

Two minutes: Switch.

Time of death =

The flame without love is just a wick.

3 Dec

This space for the case of the new nurse does not apply anymore: from telemetry to neuroscience to the trauma & medical intensive care units; I hardly know what to write about anymore. I read popular science to get away from nursing science. I wonder why it is so hard to prime the CCRT cartridge without getting air bubbles and alarms. There must be a missing step or maybe I didn’t snap the lines hard enough; maybe I didn’t tap the cartridge hard enough.

 

I might be back with a fire. A fire to extinguish the lonely flame in this world without lovers.

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