Lost on the Floor

Yes folks, Lost on the Floor is moving. I went over the reasons in a previous post, did some thinking and realized I wanted to spend more time with my family and actually writing, rather than playing with HTML and code. I'm a nurse, not a programmer. Everything I read seemed to point my way over to WordPress. So I've set up shop over there for good.

So update your bookmarks, adjust the feed in your reader and come on down!

Recently I had an 8 day stretch of time off. Yes folks, 8 days in a row. And staffing never called. Not even once. The first time in three months where I actually wanted to work extra and had said, "If they call I'll go in" and they don't call. I found out later that census had been low, nurses were being floated and even sent home early. Talk about poor timing to try to get overtime. Guess it was a good stretch to have off though.

But I paid for that time off the first night. In blood.

Not really, just a lot of miles and a ton of sweat.

I started with 4 patients and I knew I was going to be busy. Intractable nausea and vomiting, a small bowel obstruction on TPN, demented little old lady post-kyphoplasty who had been taking swings at the previous night shift and in the morning, who had a hypertensive episode post-intervention and was still goofy from anesthesia and the winner of the night: post-stent to the RCA with the arterial sheath still in place, Integrilin running and ACT still sky-high. It was going to be an interesting night. Oh yeah, did I forget to mention the load of empty beds and me not capped?

I had it all planned out. First, see all my patients. Second, pass meds. Third get everyone settled in. Fourth, pull the sheath. Yeah, like things ever go to plan on my floor. Intractable nausea wakes up, gets Zofran, and some IV Metoprolol for her elevated BP. Demented LOL, wakes up and starts asking where she is, why she's here and who she is. Get her relatively re-oriented. Small bowel guy is doing just fine. Hang new TPN, walk him and get him settled. Finally, at about 2200 go back to see stent guy. Have everything I need in the room. Ready to pull the sheath. Stick him for blood for the ACT. And miss. My sheath buddy S. gets him. Except the machine rejects the sample. Try again. No joy this time, ACT is in the 180's, order is to pull after ACT<160. Tell stent guy to chill for awhile longer.

As I walk back to the nurse's station, charge tells me I'm getting an admit and report is on the phone. Remember those empty beds? Yep, got to fill them somehow. Take report. Go back to stent guy and check a set of vitals and he tells me he's having pain. On the left side of his chest right by his armpit. I ask him if it's the same as it was before he came with chest pain, hoping he's going to tell me it's not. Nope, not that lucky. He tells me it is exactly the same. Shit.

Run down the hall, grab the EKG machine with a quick stop at the Pyxis for nitro. Grab a 12-Lead, throw some oxygen on him and give him a nitro. While I wait for the nitro to work, compare the new 12-lead against the previous one and breathe a small sigh of relief as I see no new changes. Double the relief as he tells me the nitro worked and he's pain free. About that time, my pager goes off. Intractable nausea is puking again. Head over and she tells me the Zofran didn't do much. And that's all she has. I page the house doc for phenergan, send the order to pharmacy and wait. Phenergan comes up and I give it. Look at the clock and it's nearly midnight. Time for rounds and midnight meds. Pager goes off: phone call. It's the ED who tells me that my admit is hurting, nauseous, on the way up and I'll want to medicate her when she gets to the floor. I can barely get a "WTF?" out as she hangs up on me. Great, my favorite way to admit someone: in pain and nauseated with nothing to give.

I'm in the middle of pushing Metoprolol on SBO guy and my pager goes off, again. Oh, the admit is here. Now I'm starting to get pissed. Nothing is going the way I thought it would. The night I tried so hard to keep organuzed is seeming to be coming apart at the seams. I've been up and down the hall enough times to wear a track in the rug and except when getting report from the ER I haven't stopped moving all night. Have I charted yet? Not a chance. Heck, I don't even know if I signed off on all my meds. But now is when my co-workers stepped up. They got the admit settled, hooked up to tele and orders started. They even sent the pain meds and anti-emetic orders off. Did I mention I love the people I work with?

I go in and grab an assessment and vitals. Admitted for chest pain, but now it's more like a shoulder pain, cardiac enzymes and EKG were both negative and she's relatively comfortable, but the pain is coming back. Out to check on the meds. Not in Pyxis yet. Try again. No luck. Go finish up seeing the rest of my folks. Look again. Nothing. Go in to stent guy to draw blood, the ACT machine tells me it is time to QC, which takes 10 minutes. Go back out and the meds are still not up. I'm pissed. I'm pissed at the ED who didn't medicate before they sent her. I'm pissed at stent guy's ACT and the order from the docs to pull at less than 160, when protocol is normally 180. I'm pissed that it takes pharmacy an eternity to get anything in. I'm pissed that the guy who arrived after my admit, already has meds in, even though the orders for my admit were sent first. So I get on the horn. I politely and gently persuade (without sounding like a sailor) the pharmacist to at least put in the oxycodone and phenergan. And then finally, as if by miracle, the meds are available. I medicate, get a history, orient my admit to the floor and what's going to happen tonight and head back to stent guy's room.

The ACT machine is ready. I'm ready. He's ready to have the sheath out of his leg. I poke him and get a good stick on the first shot. ACT comes up...and it's still >180. Shit. "Oh yeah, " he says, "I'm having some terrible heartburn too and was a little nauseous." Great. Look at the MAR, not a single thing for heartburn. Look to see who's on call for cards tonight: Dr. Complex. A quick word about him. He's a brilliantly gifted cardiologist,who is both incredibly young and smart, but whose bedside manner is, how you say, lacking? Once a day nurse remarked to me that he seems so uptight they wondered if he even poops. He's not exactly my favorite person to talk to in the middle of the night. But I start going through stent guy's chart and notice that he's had a sheath in for well over 18 hours, closer to 20 it appears. It needs to come out. So I call the answering service to have Dr. Complex paged. He calls me back and is actually polite and understanding. I give him the run down, mentioning the chest pain, the heartburn and the fact the sheath has been in for at least 18 hours and that the ACT has actually gone up since my shift started. "Is it OK to pull it now?" I ask, and sure enough it's coming out. He also gives me orders for something for heartburn which are sent to pharmacy. Somehow these come up quick. Give stent guy maalox and have him pee. Grab my buddy S. to help me out with the pull and get ready to rock.

Except this will be the first sheath I've pulled. Being the good little nurse I am, I had looked at the policy earlier in the night, and went over it with S. to make sure I didn't seem like an idiot in front of the patient. Things are in place and we're ready to go. We pull the dressing off from over the sheath and stent guy goes green, then like a scene from The Exorcist, starts vomiting. In large amounts. S. has the sheath in his hand, I'm holding a bucket for stent guy, praying S. can keep the sheath from coming out. Stent guy calms down and stops puking then tells us, "I feel better now." Murphy was working overtime this night. He's OK, we're OK, time to get this sheath out. Clamp on the Fem-o-Stop, I pull the sheath as S. pumps up the Fem-o-Stop. We barely get a little ooze. We spend the next hour checking vitals, pulses and the site until we take the Fem-o-Stop off, slap on a D-Stat and call it good. Knowing I still have to check him frequently, I pulled one of the computers down the end the hall and start charting.

By the time 0700 rolls around I think I'm caught up. I don't feel like I'm caught up. I don't even know where the last 12 hours have gone, but SBO guy is chillin', having had a couple of small bowel movements, intractable nausea is up, awake, taking clears and her BP is stabilized, my LOL is fast asleep having remembered who she was, but not where or when, but that's her normal, chest pain admit is just dandy and stent guy is chillin' too, the D-Stat looks great, no bruising, great pulses and no more nausea, heartburn or chest pain. I got home and was asleep 30 seconds after my head hit the pillow. It was one helluva' first night back.

See Part 1 and Part 2 for the backstory.

After losing one's child, the you have two choices. First, you can decide that this is not worth continuing and take on the final solution. Second, you can keep going and try to heal from the loss. Since you're reading this you can probably figure out which choice I made. It was not easy. There were times on the drive back to Flagstaff that I thought about jerking the wheel sending us sailing over a cliff Thelma and Louise style, but didn't. We had left Mia in Phoenix, the final arrangements worked out and completed. A second time we had to make that long, lonely drive up the mountain realizing we had left someone very special behind. Like the first it was not easy. I felt empty. The only solace I had was that my wife was OK. Her BP was finally under control, kind of, but at least enough for them to send us home. It was a very quiet drive home, neither of us said much, just sat in silence, overwhelmed by the last 10 days.

Back at home there were reminders of her everywhere. The day before everything had gone south was her baby shower. The gifts were out as was the stroller her aunt had brought back from Norway. The dirty dishes were still in the sink, our cats frantically waiting at the door. I ran in to move the gifts and stroller into the other room so as not to be completely obvious, but it didn't matter. The moment my wife walked through the door we both lost it, The finality of the situation was so complete now, She wasn't ever going to ride in the stroller, wear the clothes she had been given or hear her father read Dr. Seuss to her again. It was over. Life felt like it was over.

Having given our notice to both our jobs and our apartment in anticipation of moving to the NW, we had to pack up and get out of town. Soon. We had been planning to move to the NW, to move back home before this all happened. The last check-up was the day my wife was flown to Phoenix. We would have left 2 days after Mia passed away. Now everything was changing. So we packed our life (what was left of it) into a Penske truck, hooked the VW onto the trailer and left Flagstaff for good.

Luckily we both have supportive folks. Her's had spent days with us in Phoenix, her Mom being there at the end. My folks flew down from Seattle to help. Between us and her stepfather we got loaded up. My Mom flew back to Seattle with my wife leaving my Dad and I to drive up. As I stood in the now-empty apartment where we had lived for 3 years and had endured such heartache twice I wondered if it all had been worth it. My faith in the medical profession, the one I had spent 3 years trying to get into, my chosen career, was gone. I didn't know if I would ever be able to care, for myself much less for anyone else. The emptiness in the apartment was not just physical, but the memories,the emotional and psychological emptiness pervaded the space.

We learned about a week after Mia died that it had been Pseudomonas that had caused the sepsis that took her life. While I know that as a 26 weeker her chances were not good. The odds were stacked against her. But having something else on top of it made it even worse. My wife and I got thinking though. Several other babies in the unit had the same bug including the one in the room next to us, who routinely shared a nurse with Mia. Then we both remembered the night Mia's nurse swiped her fingers across her nose, like after a sneeze then went on without washing to play with her umbilical lines. We thought we couldn't be right? Had that really happened? As quickly as she had done, she looked up and realized she had done it in front of us. And we did nothing. I don't know why. I don't know why we didn't file a report with her boss, or did more than just sit there and stare. I kick myself to this day that I did nothing. And to this day I blame that nurse. Even if it wasn't her fault, I still can lay the blame, it at least makes me feel better as it provides a reason why this happened. We had lawyer look at the case. Not that I'm big on lawsuits, but I wanted to know if they saw anything negligent. Unfortunately, they said we didn't have a case. Mia's prematurity was the factor that swayed the case, she was too early. And the case with the nose wiping? It would be our word against theirs with no substantial proof. We dropped the idea. Let it go.

Since then our lives have been one challenge after another. I passed the NCLEX, but couldn't find work. I found work, but it was not even close to what I wanted to do, just took the job out of sheer desperation. Nearly lost our apartment once or twice. Had the cable and power shut off a couple of times. And medical bills? I think the cost is well near $250,000 for both of them, thankfully my wife had incredible insurance. We haven't seen much of that. But I remind myself that we're still alive. Now when people ask if I have children I can tell the story. They always say, "I'm sorry" or "It must be hard." I say, "Yes, it sucks. But we had her for 8 wonderful days." Would I have taken more? You better believe it. In a way, I'm glad it happened this way instead of having a year of more before losing her. But I wish it had never happened.

My relating the story came about by near cosmic chance. Ambulance Driver wrote a post that touched me and in a way made sense of all of this, or at least put it in perspective. In "Welcome to Holland" he quotes from a book(?) that relates having a baby to taking a trip to Italy. You plan and plan. Get the guidebooks, the travel guides, make plans. Everyone you know also is going and telling you how great it is, but your flight ends up in Holland. Just a little change in destination right? I figures our flight was diverted then canceled. I don't know why, but this analogy made sense to me. I can never understand why this happened. I can come to grips with it, accept it, celebrate her life and continue mine. In many ways while writing about Mia has brought up a lot of emotion, it is a good thing to get it out, maybe let go a little. Let go, but never forget.

As for me and the wife, we're doing OK now. She's been sick since the pre-eclampsia and the bed rest did her back in something fierce, but we seem to finally getting answers to both her health and her back. We have our good days and our bad, usually more good than bad. I have a job that I love, regardless of how it sounds in my usual posts. While we're not anywhere near even thinking about trying again, we know that we can. Mia will always be our little girl, even though she's gone. We will never forget.

Thanks for reading. Peace and love...

Read Part 1 here...

After 3 days and a helicopter ride the inevitable had finally happened. At 4:45 AM, they rushed my wife back to the OR to perform an emergent C-section.

At 5:05AM, Mia Rose was born.

I had accompanied my wife as far back to the OR as I could. I was left sitting in a lonely plastic chair at the entrance to the operating suites. Waiting. Alone. Every time I saw or heard movement behind the doors I sat up, hoping to catch a glimpse, or least a notice, something to let me know what was happening. I was worried about both of them. My wife has Factor V Leiden, which causes her body to not break down clots as fast as it should so I was considerably worried about bleeding especially since she had been on Lovenox the whole time she had been in-patient. But moreso, I was worried about Mia. She was early. Very early. As a nurse I knew the statistics, the possible outcomes, the frankly grim reality of our situation. But as a father I had so much hope. I believed in the strength of her spirit and that even though she was small and early with the help of the NICU she would pull through.

For an hour and a half I sat and waited. At this point I didn't even know if either were alive. Then she came back. They were wheeling my wife out of the OR area. She was still out cold for anesthesia. I pulled the attending aside and asked the question. "Is my daughter alive?" She replied, "She is, she's in the NICU, they're trying to stabilize her right now." Joy and despair raged through me. I had hope, but the word "stabilized" re-awakened the cold, gnawing pit of fear in my gut. We got my wife settled into recovery, hooked up to an A-Line and monitor, nurse on a 1:1 ratio. I asked the charge nurse if I could go to the NICU to check on my daughter. Phone calls were made and I was taken back. There, again, I sat, alone in the family room of the NICU, making phone calls to let family know what was happening. Alone and dozing, I sat and waited. Then waited some more. Finally I knew I had to check on my wife, so back to recovery I went. I knew Mia was alive, but didn't know how bad things were.

When I got back, the only thing my wife could ask was, "Is she alive?" In the dim haze of post-anesthesia, that's all she could say, over and over again. I sat there, stroking her hair and telling her that she was. Then a person in hospital scrubs came in. She introduced herself as one of the NNP's working in the NICU. She had consent forms for a PICC and blood with her and she gave us good news: Mia was alive. She had been stabilized, far from out of the woods, but stable for the moment. I asked, "Can I go see her?" And we were on the way.

I met my daughter for the first time 5 minutes later. There she lay in an incubator, lines from her umbilicus, and ET down her throat, leads all over, a tiny little diaper on. She was the most beautiful sight I had ever seen. All those emotions that had been pent up inside of me, the fear, the sadness, the pain from our son, the worry and the joy came streaming out. It was an incredible moment, one to treasure forever. The nurse and I talked, she gave me an update on things and a perspective on the next couple of days. She told me it was "going to be like a roller-coaster. There will be ups and down, good days and bad." At least so far it was a good day. The nurse gave me a picture they had taken so I could show my wife:

A little while later when my wife was feeling able she went back to meet her daughter. Again, only this time it was the neonatologist who gave us the run down, what to expect, what Mia's condition was, the gamut. Then we got to spend time together, as a family. Separated by the glass of the incubator, but a family.

They continued to stabilize my wife. Her BP's were all over the place, in constant pain from the section and generally a mess. That evening they moved her out of the L&D section and into post-partum. From the solitude of a single private room, they moved her to the madness of a 4 bed ward. And then the problems got worse. Each nurse would ask, "Where's your baby?" if they asked at all, and she would have to tell them our Mia was in the NICU. They rarely, if ever checked on her, left her to her own devices. Until they kicked me out for visiting hours, I was her nurse, afterwards though, she was forced to fend for herself in all the tasks of daily life, trying to walk to the bathroom after being on bedrest for 3 days and then having a c-section. Weak was too simple of a word to describe how she felt. Not to mention that her BP was still up. Had I had a patient with pressures like hers, I would have been on the phone to the doc in a hot second, but nothing. She was neglected and alone. She wanted nothing more than to see her child. The life she had grown inside of her for the last 6 months, but she couldn't.

The next morning began the ritual that would sustain us for the next 6 days. I would arrive at the hospital as soon as visiting hours started. We would go to see Mia. Spend time with her, think and plan about our future. Things were now totally changed from what they were 5 days previous. Now, instead of moving to Oregon, we were going to have to move to Phoenix. I needed a job. We needed a place to stay. Together we planned that. Every morning we would go see Mia. Then in the afternoon. Then at night. Every 2 hours she would pump and I would run it to the NICU, calling it, "meals on wheels." All this time they were still trying to get my wife feeling better. Finally after sending her back to L&D, they got an IM consult, but all they wanted to do was put her on an ACE inhibitor, which for breast feeding moms is totally contraindicated. So we had to fight for them to find something else. Which they did, but only at our urging. One thing the neonatologist had told us was the breast milk was the best nutrition for Mia and that while we couldn't do much, we could deliver that. It was important.

But it was night that we loved the most. We'd head to the NICU as visiting hours in post-partum ended, to have more time together. Lucky for us the NICU was open 24 hours a day, with the exception of report times. We spent time there, talking, letting our baby sleep. There in the glow of the bili lights we planned and celebrated.

We celebrated the good things. The day we heard her PDA had closed. The day she got a feeding tube and had her first meal of mother's milk. The day her ultrasound came back negative for intraventricular hemorrhage. How she responded to our voices. The day I changed her diaper. Even if she had been fussy before we got there, something about our presence calmed her down. Just us sitting there talking, like we had used to do when she was in the womb mellowed her out.

The last day she was alive started like any other. We got my wife moved to a private room, her BP was getting better. They were talking about discharge in the morning. Mia though, was having issues. She spit up milk, was fighting the vent, just not doing so hot. Come to find out later, her ET tube had gotten displaced and was resting on her carina, so she wasn't getting the best ventilation. But she was doing OK. We followed our ritual. That evening she was doing better, slightly, but at least resting. I went home the Ronald McDonald house thinking that it had been one of those down days we had been warned of. A bump in the road. That night my mother-in-law stayed at the house with me before she left town. I went to bed, tired and a little worried.

The phone rang at 6:45 the next morning. My wife was crying, freaked out, "I think some thing's wrong with Mia. There's hospital number on my phone. Can you call?" I called, the MD told me I needed to get over to the hospital, now. I called my wife back, told her I was on my way. Scared out of my wits, shaking I ran to where my mom-in-law was and told her I had to go to the hospital. Honestly, I don't remember the drive at all. I know I made record time and probably broke a couple of laws along the way, but this was an emergency. I ran up the stairs to the NICU, flew in, past the clerk who tried to tell me I couldn't go in. I didn't care. My baby was in trouble. I rounded the corner and saw her small little room in the back of the NICU jammed with people. My heart, already in my throat dropped out of my body. There they were performing CPR on her little body. I knew in that heart wrenching moment that she was gone. All that was there in the room, in that incubator she had called home for the last 7 days was a shell. The spirit and soul that made her Mia Rose was gone. My wife was there too, inconsolable, crying, shaking, looking like a lost little girl. The MD gave us the update. She was gone. Septic. Everything they did, all the miracles on modern medicine they had thrown at her couldn't stop the process. I looked at the team through a curtain of tears and agreed that they could stop. It was over.

That morning we got to hold our daughter for the first time. We got to see her face without the ET tube, see the eyes, still closed that she had tried so hard to open to see us during the last 7 days, touch her face and hold her close for the first and last time. They took us to the family room where we sat with her and the rest of the family for hours, saying good bye, holding our little girl. It felt like life was over, that there was no point in even going on. They dressed her in a little white dress, with a little white hat, wrapped in a little white blanket, looking like the angel that she was. After we said our good byes I took my wife back to her room. As she went to shower I once again had to make arrangements for the final disposition of my child. The previous November I had to do that with our son and now our daughter. Then we left that hellish place of a hospital, never to look back. Later that night, after all was done, we held each other close in bed, crying into each other's chests, hoping and praying that the day been only been the surreal dream it seemed like it was, but knowing that she would still be gone when we woke up in the morning.

Next...Part 3, the Aftermath.
I wanted to get the whole thing done tonight, but couldn't, there's just too much emotion. But I should finish Part 3 after this work week.

A year ago Friday was my daughter's 1st birthday. Unfortunately she was not there to share it with us physically, but in spirit she will always be with us.

A year ago at a routine OB appointment my wife was not doing so good. Protein in the urine, BP in the 180's over 110's, severe pre-eclampsia. Being in a small town without the facilities to handle the birth of a small child, nor the management of a very sick woman, she got the first and last helicopter ride she will ever take. No one in the Valley would take her except Maricopa County Medical Center. Not our first choice, by any means. Let me put it this way: if I got injured outside of it, I would have drug my bleeding body far enough away so I wouldn't have to go there. Yes, in my opinion, that bad. And it was worse for my wife. Thanks to the brutal summer Arizona heat and lack of functioning AC in our car, it took me another 6hours to get there to be at her side.

When I got there, she had been stabilized, somewhat. BP was down, they were much less concerned about her stroking out, but now the battle was with the clock and with how long we could keep little Mia in the womb. By date she was only 26 weeks. Small. Very small. But she was ours. She was the miracle that saved us after the loss of our son (and nearly my wife) due a placental abruption the year before. She brought us back from the brink. We would do whatever it took to keep her safe and sound. It meant changing our lives, our plans and our dreams. We had planned to move to Oregon not more than 2 weeks after this appointment, that was out. We had both turned in our notices at work. That too would change. But they were OK. That's all that mattered.

For 3 days we hung out, biding our time. Dealing with the endless stream of interns, residents and attendings, none of whom seemed to know how to handle either the situation or us. Maricopa county is not exactly in the best part of town and we weren't exactly the type of folks they were used to dealing with. In other words, we weren't the poor, uneducated and sometimes illegal folks they were used to practicing medicine with. We were involved. We asked questions. We wanted better answers than the stock answers they gave. In the meantime, we waited for the steroids to work to help mature Mia's lungs because we knew what the ultimate outcome was going to be. She was going to be early, but we wanted to do everything we could to keep her in and growing.

Until the morning of the 10th. The intern didn't like the situation, wasn't willing to try anything else so the decision was made to take Mia out. By C section in the middle of the night. We didn't even know what was happening until the anesthesiologist came in to ask my wife the standard anesthesia questions. Then we learned. But to this day, I still wonder why? There was no fetal distress (I could see the FHT tracings). Mom's BP was up, but I've since seen worse. We could have waited. We would have waited. They weren't going to wait.

A while ago GruntDoc had a great post about "The End of the Code" wherein he describes his actions as a team leader in the midst of a code. IT shows the true meaning of leadership. Luckily on my floor, the codes are usually quick, the patient well on their way to the Unit before most interventions can occur. One of the charge nurses said basically, "get a rhythm, get an airway and get off my floor." We neither equipped nor truly capable of handling complex interventions unless completely necessary. No thoracotomies, invasive monitoring lines, transvenous pacing (all of which have been done...) on our floor, the Unit is much more suitable for this kind of heroics. This is not to say that we won't in the emerging situation, but the reality is that we need them off the floor and down to the Unit quick.

The other night I had my first real code. Not a Rapid Response. A Code. Dude was dead. Wasn't my patient though. Here's how it went down:
We were all hanging around the nurse's station, in that twilight time of 0500, early AM vitals were done, folks were just starting to wake up. The monitor starts the high-pitched binging of a life-threatening alert. Look and see the patient in V-Fib. As we head down the hall, we hear that it's back in sinus rhythm and the pacer had taken back over. So the nurse heads in, starts checking the patient out. I'm almost back to the station when I hear frantic yelling from the end of the hall and that binging again. "I need the cart!" She hollered. I'm closest to the code cart and run for it. Mind you, our unit is big, it's nearly and quarter mile round trip from end to end. I've never made the trip so fast in my life. Hauling ass down the hallway to the very end (yep, it's always the room furtherest away) with the code cart. Into the room, the patient is laying in bed, back arched, mouth agape like a recently caught fish, "oh sit" I said to myself. Then my mind went blank. All that time in ACLS, all that time in previous situations. Nothing. It was like those moments in the Matrix where time s l o w e d to a crawl, my mind was trying to remember what to do next. The arrival of the next nurse behind me shocked me back to reality. He jumped in to start CPR, I went looking for the ambu bag to get an airway. But it wasn't there. I thought, "Isn't it supposed to hanging from the outside? Wait a sec, I checked the cart myself this evening...was it there?" By that time more people were flowing in the room, breaking open the cart (where the bloody ambu bag was...) and getting things going. At this point I got out of the way. Let the pros take over. They shocked twice, after the second the patient came back yelling and cursing. Which all things considered was a good thing. Not soon after, with a rhythm and a patent airway, they went off the floor to the Unit.

After this though, amny realized that we needed more training. In spite of the nature of the floor, we don't do many codes. This was the first I had been in since I started back in December. Sure, we've had them, but not anywhere near me. So we're going to get mock codes and a chance to see inside the cart so we(me) don't freeze trying to figure out where things are. At least I learned one thing: Ambu bags are inside the cart.

Oh yeah, the patient? Was a frequent flyer and this was not the first time they'd coded. Ends up they came back tot eh floor 2 days after the code and went home a week later. Guess it wasn't their time.

The other night was a first: first time to float. We had so many empty beds it wasn't even funny, so I got the short straw and went to med-surg. Not that it was a bad night, in fact I did more sitting doing nothing than anytime lately on my home floor. The thing that really chapped my hide is that I was at 4:1, with fairly non-acute patients. Sure between the poly-substance OD 3 days out of the Unit, the the homeless gent with DVTs and the lady on ETOH withdrawal protocol, not to mention the rather large lady in acute renal failure with a rectal tube, it was enough to keep me busy. Compared though to the previous night on my floor, it was nothing. They were stable. No one was detoxing actively. They all slept. All night. With minimal requests. I turned to the other nurses and offered my free time, but they were pretty well wrapped up as well. I'm not complaining, it could have been worse. It was just unusual.

In other news...
You always hear about "pucker factor", how your sphincter can slam shut in response to unexpected events. In the case of males, things like rectal exams or mentioning the Jewish custom of bris, can cause this. So can seeing V-Tach live and in person on the monitor. It kind of makes you stand up and pay attention. Right after that showed on the screen, we heard overhead, "Rapid Response to room xxx." By luck it wasn't one of mine. So like a good co-worker, I went to see if I could help, saw they had enough help, realized I would only be in the way and skedadled.

'Til later...

As I have grown slightly more confident in my ability to treat folks, you get a curve every now and then. I'm getting to the point where I'm a little more confident with cardiac problems. Things like chest pain. I've finally gotten my head around that kind of crisis and am starting to function better and quicker rather than standing there with a dumbstruck look on my face. So when something new comes along, I get that deer in headlights look and feeling.

Case in point:
Older woman had been admitted to the floor for pneumonia and possible UTI, accompanied by that wonderful AMS. When I saw her first in the evening, things were OK. She was alert and mostly oriented, not too far out of it. But she could not hear. If a bomb went off in her room she would not have heard it. Luckily she read lips. But I digress. Lungs sounded diminished, maybe a little crackly, nothing to be very concerned about. But she looked at me and asked, "Am I going to die tonight?" Taken aback I said to her, "Not tonight, we're going to get you through just fine." Yeah, I had to say it.

Then came midnight rounds. It sounded like she had transplanted an aquarium into her chest. Not good. O2 sats were OK, not great, but OK. Tried to get her to cough, not much luck there as the cough was as weak as a newborn kitten. Call the doc, now. Unfortunately she was a hospitalist patient and the house officers were not covering her, so it took a little bit to get a hold of him. Finally did, gave him the report thing, got an order for Lasix. OK, sounds good to me. Well that did nothing, except maybe make her pee a bit. Lungs still sounded like crap. Call RT, just to get an idea of what they thought. One look and listen said it all...she was literally drowning in her own secretions. Again, not good.

Down the nose goes suction, up comes gobs and gobs of creamy yellow/brown sputum. RT remarked that it kind of smelled like Pseudomonas. Not entirely, but not far off. After you clear someone's airway, they breathe much better. Now instead of wet, we had wheezes. At least she was moving air. Call the doc again. New orders, nebs, suction as needed and drop a Foley. I think I've got it locked for the moment. Wrong. Throws me another curve. Temp spikes to over 39C and BP is dropping Call the MD back. By this time I'm sure he is getting tired of hearing my voice. Blood and urine cultures, labs, culture the sputum, get a work-up going, bolus of saline and bump the rate of the fluids after. Keep an eye on her. So I did.

Finished the bolus about 45 minutes before shift change,the Tylenol I had given earlier had brought the temp down to the 37C range. So at least we were making progress. As I was leaving I went back again to check on her. Lungs sounded better,the nebs had helped, sats were back up and BP was improving, but I could see she was tired. Very tired. I looked over at here and said, "Told ya' we'd make it through the night didn't I?" A wan smile and a nod of the head was all I got.

That night when I came back in I looked on the census for her name. Nothing. A cold chill swept over me. Did she go? Did I miss something last night? The knot churned in my stomach until I got out of report and talked her nurse who I was getting report from anyways. "No, she's OK," she said, " we shipped her to the Unit." A little sigh of relief. I heard they tubed her almost immediately on arrival to the Unit, which didn't surprise me at all...let something else do her breathing, at least for the moment. She was stable for the moment.

Once again, I learned. Not a day goes by where something new doesn't come up, a new crisis, a new system to relearn in the crisis, but that's life right now. It made my bleeding patient last night not such a big deal. Perspective is a funny thing ain't it?

I've been having a bit of an almost existential crisis regarding work. There are days I feel like there is not way I can continue, that I chose the wrong profession, that I suck at my job and feel like there is no way on God's green Earth that I'm going in to work. I have yet to call out, just to call out, but there are days when I feel that it is what I have to do. But I go on. There are events that contribute to this feeling, then in a wonderful way, prove that I'm doing the right thing, the thing I was meant to do.

For some reason room #66 has it out for me. Of the patients that I've had go south on me to one extent or another have been in that room. Something abnormally high like 90%. I'm about ready to stop accepting assignments that include that room, it's got my number.

And that's where he was that night. Hanging out in his room with his wife. Came from an outside hospital for an angio due to increasing anginal symptoms. Cardiac history? Check, the thing was as long as I am old. Not pretty. CABG x4 last year, CHF, HTN, elevated lipids, smoker...at least he wasn't diabetic. Plus, he was young, at least relatively so. I got in report that it looked like 3 of the grafts had closed off completely and the fourth was pretty occluded. He was doing OK, his last bit of chest pain had been controlled with nitro paste and morphine. The docs didn't know what to do, really what can you do?

He was stable, blood pressure a little on the high side with a splitting headache from the nitro. So I did my nightly nursing thing. Kept my eye on his pressures all night, watched his heart rate and rhythm on the monitor at the nuurses station and let him sleep. I'm doing rounds at 0400 when his wife calls out to the nurses station that he's having severe chest pain, worse than before. I hit him with MONA, nothing. DOesn't even mae a dent in the pain. BP is way up, HR too. One of my colleagues gets a 12-Lead EKG, I'm calling the doc. One thing that sucks about nights is that a doc is a little harder to get hold of. Finally get hold of him, get new orders. I'm feeling a bit frantic now. I'm hoping this fear does not show on my face or through my actions. I'm already getting tired from having to run down the hallway from the med room and phones. His wife is really getting agitated now, she's questioning if coming to our hospital was the right thing, if I was the right nurse for the crisis.

Give him Metoprolol x3...maybe that will bring down the BP and rate, ease off the oxygen demand of the heart, maybe help to bring down the pain. Nope. Barely dents his BP or rate. I've got a nitro drip running now, it's helping a bit, but not much. Mind you he's also getting morphine and extra sublingual nitro, anything to get this pain under control. I keep upping the rate of the drip, anything at this point. His wife, well, she's very upset now. She doesn't see a doc around, wants to see one, even though it is 5am and any sane cardiologist is asleep at this point. I'm doing what I can to calm her down, calming myself at the same time. His BP and rate if coming down now, but the pain is still there, he's calling it 9/10, nothing seems to be working. I max him out at the level we can give on my floor. I'm calling the doc back saying, "We need to go to ICU." Luckily, he agreed. Thankfully, I had kept my charge in the loop to what was going on and as soon as the doc said to ship him, we were ready to go. After 3 hours of fighting on the floor, we shipped him to the Unit.

It wasn't what I did, or didn't do that shook me so hard, it was the things that his wife was saying. I know that it was a stress reaction and that I was doing everything I could do, but it still hurt. Here I was trying to save her husband's life and she was still calling me incompetent and that our hospital and floor was worthless. And those were the nice things she was syaing...it was not pretty. Looking back, I probably would have changed the sequence couple of things and tried to get him to the unit earlier, but I know I did my job right that night. Funny thing though, the 12-Lead we ran, didn't showed anything different from one previous in the day. When I got in the next night, I looked at his labs. There it was, jumping off the screen at me: Troponin I: 5.82ng/ml. His cardiac enzymes had literally gone through the roof. It wasn't a small infarct, it was the big one.

Lucky for me, I had a couple of nights off after that. Time to forget and forgive. "One day I will get the hang of this," I told myself. My shattered confidence was slowly coming back, I was feeling better about it all, not great, but OK. Then I the other night I saw a familiar figure. "No way," I thought to myself. Sure enough it was the very same guy. Up walking in the halls. Pink, warm, talking and walking. He had survived a serious infarct. He said the docs figured that night, the last of the open grafts shut off, leading to his pain and infarct. He told me he appreciated everything I had done for him that night and that he knew that I had done everything I could to help him. Talk about shock. I was amazed, in shock and nearly speechless. He thanked me again and we went back to our night.

Crisis not totally solved, but I do feel much better about work. I know I chose the right profession, it's just taking time to really feel like I'm actually getting it. I know I am and when I have a night like that, I feel it. But seeing the positive outcome afterwards made me realize why I chose this in the first place: to help people.

Sure I'm still Lost, but I'm finding my way. It's what I'm meant to do.

The other night started off like any other. Got my assignment, looked...OK, at least everyone is A & O and mostly independent. "So far so good." I thought to myself. It's funny, I no longer look to see what the actual reason they are admitted for anymore, just if they are going to either:

a. curse me out
b. try to get out of bed and go boom
c. yank at their lines
d. all of the above (usually the most popular.)

Good nursing practice? Maybe a little judgmental, yes, but this is tempered by experience. I figure, more than likely, I can deal with their admitting diagnosis, but if they are demented or delirious or just plain psychotic, that task just became a whole lot harder. But I digress.

So I was going along, and everything was actually OK. Then someone mentioned the "q" word. A chill swept over the nurses station as we all looked at them and in near unison said, "Did you just say the "q" word?" Mentioning the "q" word in the medical world is akin to mentioning "MacBeth" to a stage actor. Not sure what else we could say, for sure the alternative for the actor is far worse. Who really goes on a nursing unit and tells someone to "break a leg?" No one in their right mind. But it brought me back to the time that I had used it.

I was a senior nursing student doing my senior preceptorship in the ER of a smallish rural hospital. On the night shift. At the beginning of the month. During a full moon. Surrounded by black cats and broken mirrors ( OK the last part wasn't quite true.) But there I was. It had been a slow night, nothing too crazy. So I said it. the "q" word. No more than 30 seconds later we heard the tones come over the radio,

"Rural ER, this is unit 55, how do you copy?"

The nurse sitting there, "We copy, over:"

"55 y/o male, found down in apartment, in full arrest, we're coming code 3."

I looked over at my preceptor, she said, "You're on compressions, OK?"

As the thought ran through the back of my head that this was all my fault for saying that dreaded word, I said, "OK." Lead vest on, shoe covers, gown and mask, gloves and goggles. We had just barely gotten the trauma bay ready when we heard the sirens outside in the bay. They piled out of the unit, one in front, one in back, one surfing the gurney performing compressions. Rolled them into the trauma room, stopped compressions only to transfer to the table.

Now it was on me. I started, feeling the ribs grate under my hands, just keeping my mind on the rhythm, 80 a minute. I heard report in the background.

History of esophageal varices and alcoholism. Found down in apartment after wife had called it in after the patient had passed out while talking on the phone to her. 80 a minute.

1 and 2 and 3 and 4 and...keep the rhythm.

7 french ET tube, 21 at the lips. Left and right EJ IVs, got 3 liters in the field. RT is standing to my left bagging as I do compressions. The doc holds compressions for a moment to find the femoral vein. Then back at it. 1, 2, 3, 4,...

I'm hearing orders being given, rapid infuser, get 6 units of blood ready, continue NS until the blood's ready, get me an ultrasound machine. The doc calls out again to hold compressions. Has the femoral line. Compressions resumed.

I'm getting tired now, starting to look around for someone to spell me. Arms feel like lead. Now I look down and see with every compression fluid spurting out of the ET tube, a pink mix of blood and saline. But I keep going. As a student I can't do much, but I can do this.

The monitor shows asystole. The doc halts again, uses the ultrasound to see if the heart is doing anything. Nothing, just a little bit of movement. Finally, I switch out with another nurse. I can't feel my arms, sweat runs down my back and face. And then it is over. The doc calls it. I look at the clock, 7 minutes since they arrived in the ER. Then I nearly lose it. I run out the door to the ambulance bay, into the cold night air overwhelmed by the fact that we couldn't save him. Someone's father, husband, son. In spite of our best efforts, we couldn't save him.

That wasn't the worst. That came when his wife showed up. He came in covered in blood, I mean caked on. The police had said the scene looked like a murder scene there had been so much blood. So we cleaned him up as best we could. Cleaned his hands, his head, his hair. Made him presentable so that his wife could come and say good-bye. My nurse gave me the rest of the night only giving me the easiest cases. As we sat down and talked about it I asked,

"Does it ever get easier?" To which she replied, "Not really. You just forget to feel it anymore."

I knew she meant that you insulate yourself as you get exposed to it frequently, but it sounded a little cold, but I understand it much better now. Rationally, I know that even though I said, "quiet" that didn't cause this to happen, it was bound to happen regardless, sometime. It just happened when I was there. So I never say, "It's kind of quiet tonight." Not anymore.

Oh that other night? It went just fine.