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.
Inappropriate Comment of the Night
0 comments Published by Wanderer on Wednesday, October 10, 2007 at 11:34 PMI had finished getting report from the ER on the 30-something year old male who had experienced and episode of chest pain while "getting ready" (his words, not mine) with his wife - guess he self-edited due to the fact his young son was present. He later told me he was "getting some hot lovin' with the missus." After I calmed down from laughing, not because it was terribly funny, but because I could only imagine the embarrassment of the situation, especially in the size of the place they had come in by EMS from. Word travels quick in small towns. Let me put it this way: he was of the size that you didn't even want to think or associate with the phrase "hot-lovin'." Not something I wanted to end my shift with. I wasn't hungry when I got home that morning either.
If you listen closely you can hear several things...
You hear the charge nurse watching the monitor at the tele station go, "Oh shit!" Jump up, grab the code cart and go hauling ass down the hall. Then the nurse at the station right next to him calling the operator and the overhead announcing "Code 99 to XXX." Next you hear the page go live and pagers going off and nurses running down the hall with the COde Team hot on their heels.
He was down on the floor, half in, half out of the bathroom, all 300+lbs. of him. No time to move so they worked him on the floor, half in, half out of the bathroom. One nurse was standing on the toilet with their butt in the face of the one in the shower. The floor was covered in the miasma of body fluids and blood as the guy came to a little and started tearing out IVs. They shocked him once and got a rhythm back and like a bat out of hell, off to the unit. If memory serves, guy came back up to our floor about a week later, in pretty good shape all things considered.
Looking at the strip several things strike me. One is that this the last time I ever want to see a R-on-T phenomenon live and in person. Second, dude was damn lucky he was in the hospital, on a monitored unit with ACLS-certified nurses caring for him and a Code Team 30 seconds away. If he had been out in the regular world, things might not have turned up so rosy. I guess this could have been a case of Sudden Cardiac Death, but he was lucky. Third is that how quickly life can turn on you. One moment you're getting up to take a leak in the middle of the night and the next you're on the floor after having died for a couple of seconds. Kind of brings things into perspective. Finally, that tele tech who the charge nurse was covering for while they were away at the bathroom? Yeah, they don't get a bathroom break ever again. This was not the first time. No, this was the third or fourth time that they stepped away and something unfortunate goes down. It's just bad luck.
I wish I had saved my other favorite strip from a while ago. It was sinus with an 7 second pause. All you saw were these little P-waves, but you could call it asystole. Like above, they were dead, if only for about 7 seconds (isn't that the length of a champion bull ride?).
No offense to said MD...
NameThatDisease.com - Test your disease knowledge
Besides, Hawkeye was always my favorite.
I'm currently enjoying an 8 day stretch off from the floor. Talk about nice and relaxing. I actually am sleeping once again (thanks in part to my friend Ambien) and spending time with the family. Once I tear myself away from this whole mini-vacation thing there should be some new stories...
The other morning as the day shift was coming on, our unit manager (who was charge that day) pulled me aside. After the usual pleasantries she said, "Several of your colleagues have said to me that you seem like good charge nurse material. Interested?"
My first thought was, "Tell me who said this so I can go kick the crap out of them." Luckily, in spite of the shift being behind me, my social filter was still intact. Instead I replied, "Ain't ever going to happen." Not my most eloquent moment, but it conveyed the point well I thought.
She persisted, "Are you sure? It's a great opportunity, think it's something worth looking into, don't you?"
Me, "I've been in management once before, it chewed me up, spit me out. It's not going to happen anytime soon."
Her, "Well, at least keep it in mind."
It's not that being a charge nurse is all that unattractive. On our unit, charge doesn't take patients. But they're also the unit secretary after hours, the resource nurse, the go-to person, the decider of the fate of staffing and and patient assignments. I don't want that kind of burden on my shoulders. Would it look good on a resume? Probably. Thing is I don't want to do it. Not interested at all. At least for now. Let me get a couple of years under my belt, a little more comfortable with being a nurse before thrusting me into a leadership/management role.
This in many respects shows the fatal flaw however on our unit. Turnover. I know other units turnover nurses frequently, but I think ours does more than average. It seems like we're losing at least one a month. That means we use more system resource nurses to fill our staffing. It also means we are relatively short staffed often. The reason I think my manager would even think of bringing up the idea of me being charge is that most of the other people who have more seniority than me are already charge nurses. Most of the staff on any given night has less than 3 years of total experience (average here). If not less. We burn people out or they leave to bigger and better things. None of which helps morale any bit. Many of my friends on the unit feel overworked, under-supported and alone. Not a good way to feel. Many of us feel that we were misled to the type of patients we truly get. We used to a cardiac telemetry floor. Now many days it feels like a nursing home telemetry floor. Out true cardiac patients, the ones many of us signed on to care for, are far and few between. Because we are a big unit, we get admissions as an overflow unit. We get patients that do not need to be on telemetry, but get sent there for a "remote history of A-fib (currently in NSR, last a-fib was 20 years ago)" or "r/o CVA (while on ETOH withdrawal protocol)." The joke has become, "If they've got a heart, send them to us." It's like being told you're on a trip to Disneyland, but ending up at Wallyworld. I know that it is nursing. That is the deal I ultimately signed on for. Some days it's just harder than I ever expected, made worse by the deficiencies of the unit where I work. I'm trying very hard not to burn out already, but each day I get a little closer. My favorite telling fact about my shift: a great majority of us are either: a: In therapy. b: On meds. c: In physical therapy. or d: all of the above. We're about as dysfunctional as our patients some days...
Peace and love...
Inspired by of all things the "Blue Collar Comedy Tour", my version of "I Believe."
in no particular order:
I believe that at the start of every shift, you're issued a syringe with the intranasal topper-thingy and 2 mg of Ativan. You can use it on whoever you want; patients, families, colleagues, administrators, even JHACO.
I believe in the aerial spraying of Prozac and/or Ativan in large urban centers.
I believe life, like the movies needs a soundtrack. At least then you know when things are getting better, or worse and when you just shouldn't turn the corner.
I believe that if someone throws poop at you, it is perfectly OK to throw it back.
I believe that hospital administrators should have to work with above poop-throwing patients when considering cutting the budget for nurses, techs, aides etc.
I believe someone needs to invent insulin you can mix with Lantus, IV Tylenol and a medication that clears ammonia out of the system like Lactulose but without the messy side effects.
I believe that when admitted for chest pain, you would not be allowed to leave the floor to smoke, much less request pain medication after leaving the floor to smoke. (especially when you were just fine before you left...)
I believe that once a year you would be allowed to see your assignment for the shift and say, "Nope. Not this time. I'm out." Or at least ask for a couple of new cards patients.
Most of all:
I believe I'll have another beer.
Peace and love...
I had a ritual before nearly every exam in nursing school. It seemed to work, I have that magical "RN" after my name. I had so much faith in it that I even did some of it before taking my NCLEX. Usually, I'm not superstitious, but in this case it worked. It was simple. Breakfast and music. I think it was the music that helped clear my head before exams. I know that studies have shown that listening to Mozart during studying and before tests can raise your IQ, but I'm not sold. The music I listened to was mostly loud, fast and sometimes angry. If anything it pumped me up rather than mellowing me out. Call it a paradoxical effect or a placebo effect, but it worked. Music is good, but breakfast is the most important meal of the day.
Breakfast was the best way to prepare for an exam. Ever. There was a core group of about 4 of us who would drag themselves out of bed early to the greasy spoon down the street from school for last-minute cram sessions. Fueled by $3 breakfasts and bottomless coffee we would relentlessly go over the material on the exam. Our textbooks, the 180Lb behemoths that lived in our bags was just one tool. Usually between the group of us there would be a half-dozen different books there on the table, barely enough room for coffee. Between the huge tomes, there was the experience littered around the table. Between NCLEX review books, lab books, med-surg texts, OB texts, notes from the previous year's group and notes/powerpoint slides from class it was formidable amount of information to process. With dogged determination, fueled by the cheap food and the coffee we'd work through the material until someone quit (from overload) or it was time to go.
I have a lot of good memories sitting around that table though. Like crawling out of bed at 4:45 to be there by around 5am on a dark mountain morning. There were the mornings where the sun just was coming up, or that stillness right before first light. It was almost magical. I remember the brisk bitterly cold mornings up there on the mountain, where I spent 20 minutes scraping the outside windows then the 20 minutes of the drive scraping the inside windows, praying the little 12-volt heater would keep the windshield clear enough to see out of. Not to mention the 30 layers of clothes I had on to stay warm in that old VW I drove. (remember Ralphie's little bro in "A Christmas Story?) I used that car as my backpack, at any one time there was more dollar value in books than the car was worth. Usually roll up and see inside the diner, almost like that famous painting, with the warm inviting windows spilling light out into the darkness. Was never the first, rarely the last. It was like a rotating cast though. Some folks would come one week, others the next. Some would show at 5, others at 7, you never knew.
There was the morning where we were quizzing each other on STDs. Nothing says good morning like a conversation about STDs over your eggs, "Now is that grayish and fishy, or yeasty and cottage-cheese like?" Mmmmm. There was the ever present complaining about faculty, assignments, the incredible tediousness of our care plans and the general angst of nursing school. We learned from each other though, everyone had their niche. One guy was a RT, so he was our go to guy for all things respiratory. One gal was an EMT so she was on point for ER stuff. Another was a tele tech at the local hospital and therefore became our rhythm person. Between all of us there was at least one person that understood the material well enough to explain it to the rest. There were the times talking about clinical rotations, how we got to see "X" procedure, or do "Y" task, the crazy person we saw on the floor or the time the student from the other school in town asked the male patient if his diabetes was, "gestational." We laughed. A lot. Frequently.
We all made it through. They were there for me when my wife and I lost our son. We helped everyone through their unique set of problems. Celebrated achievements and commiserated the failures. In the end we all went out separate ways. I headed to the NW. Another went to Tucson, one to Cali. Many stayed in town. There are mornings getting off work where I wish I could go hang out and have breakfast with them again.
Thanks to the Breakfast Club for getting me through nursing school. Never could have done it without y'all.
Other things that helped me through nursing school though: my wife and family, caffeine, telemarketing, music, cheap breakfasts, good study buddies, not sleeping more than 4 hours a night, my VW (seen below), the scrub store in town that gave a discount to students, Strombolli's and Roma pizza, Dominican cigars, Henry Weinhard's Private Reserve, Wal-Mart, Robin Williams:Live on Broadway, that trip to Vegas, the NCLEX review book, Depends and many more...
Peace and love...
My "trusty" VW. Yes, it snows in AZ (esp. @ 7,000') To quote Keanu..."Whoa."
I posted Mia's story as nothing more than a chance to relive and remember and sort out a little in my head what happened to us last year. I never thought it would touch so many people. Thank you all so much for your kind words of support and condolence. Knowing that there are people out there who don't even know me and my wife to say such incredibly touching things reaffirms (at least a little bit) my faith in humanity.
Now back to regularly scheduled programming.
Peace and love...
Mia's Story, Part 3, The Aftermath
23 comments Published by Wanderer on Thursday, August 23, 2007 at 6:59 PMSee 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:
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.
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.
When we still had hope.As the gentleman wearing overalls, no drawers or shirt is settled in bed for after transport from ER:
Yes, Mr. COPD, I have to ask you all these questions over again. I am aware that you have gone over this approximately 15 times since you've been hanging out in our wonderful facility. But I have to do this. Again. No, the computers don't "just transfer" the information.
I know you waited 7 hours in the ER while in your so grateful words "the fat bitch just sat her fat ass behind the desk drinking Coke and eating chips." Not to mention the fact you couldn't see the drama unfolding across the ER from you where they were running a code to save someone's life, but they didn't look busy to you. I know that this was going on...you see us nurses kind of stick together every now and then, the nurse I got report from gave me the head's up all about your "displeasure" about your current situation. I guess I shouldn't point out that you called EMS to bring you in. For shortness of breath, cough and "coughing up yellow crap," that had been ongoing for 7 days. That would be rude of me to do and my verbal filter is still working. I know you want to sleep. I just have to get this history from you, take some vitals and look you over. How long's this cough been going on? Getting anything up? Not lately? If you do I want a sample, here's cup. I'm going to put you on some oxygen too. The amount of oxygen in your blood is kind of low and your lungs don't sound so good. No, I don't have a mask, but I'll try to track one down for you. Yes, I know your nose is stuffy, unfortunately this is all I have right now.
Guess what? They're going to come draw more blood from ya'. Do an EKG, try to give you a nebulizer treatment so that you aren't wheezing anymore, probably another chest X-Ray. That and the docs want you to be on telemetry. What? Oh yeah, the little sticky pads we put on your chest. We use them to watch your heart, make sure nothing bad is going on with it. Y'know, try to keep you alive at least one more night. And every time you tear those off, someone will be back in to re-attach them...it's our job. I know you would have left already if you had a way home, you've told me 3 times already and you've only been in the room 20 minutes. And yes, I think it is a little late at 0200 to call your daughter, but you dial "9" to get out.
So you have a list of meds? Great, that reduces the number of questions I have to ask you. But I have one more, when did you last take these? Oh, the only thing you've taken in the last month is your pain meds and stool softeners? What about that nice list of blood pressure meds? At least a month? Right, guess that's why your BP in the ER was 180's over 100's.
You know, we nurses hate it when you preference the question as "Don't freak out about this..." It's like hearing Jim Bob say "Hold my beer, this is going to be cool." So you want to take 100 Valium. OK, you have my complete attention. When? Not now? Later? Right, why? Oh, your life sucks? I guess I shouldn't tell you about the little old lady across the hall who may not last the night. Or the guy who had a massive heart attack last night and is lying in the ICU with a machine breathing for him. Yeah, you have some heavy-duty medical problems, but if you took care of yourself, y'know, be active in your health care, not expecting all of us to do everything for you, it might not be so bad. Death? No, in spite of everything I've been through in the last 18 months, I still have an allergy to pine boxes. So, do you feel like doing something about it now? No? OK. Do you want to talk to someone about it? No? Fair enough. Mental note, let still-wet-behind-the-ears intern know that we probably need a psych consult and I need to keep a close eye on him tonight.
OK, that's all for now. Yes, you can go back to sleep. But I'll probably be back in awhile.
A short while later at the nurse's station after RT came back and phlebotomy was waiting for me:
What? He refused the nebs? OK, I'll call to get them changed to PRN. He refused the lab draws? OK, I'll let house staff know, not much we can do right now.
And another short while later...
When do the docs come in the morning? Depends how many folks they have to see. Out by 9:30? Maybe, but I doubt it, they're a little worried about that nasty little pneumonia you're brewing, not to mention your lungs sound like a half-empty aquarium in a sandstorm. Again, I won't be so rude as to remind you, that you called EMS to bring you here though. I know, we keep waking you up, trying to do tests and whatnot, because after all, it is a hospital. It's kind of what we do, y'know, get you feeling better.
To the oncoming day shift nurse:
So that's about it. He refused AM labs, I already let the docs know. And yeah, he has a little SI, but he says he isn't going to act on it right now. Any questions for me? OH, almost forgot, he's going to try to leave, one way or another. My money's on going AMA. I put the form in the front of the MAR for you. Good luck and have a great morning.
Never found out how he left...unfortunately I don't particularly care.
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.
As I've gotten more and more comfortable calling docs, I've really began to learn what is needed in situations. Before I was simply tongue-tied even talking to the MDs, much less able to know what to ask for. In fact I was in awe of the nurse who could call and say, "So and so has this going on, I need orders for this, this, and a little of that." I know that in time it will come to me. Every new situation is a time to learn this and file it away.
The other morning, one of my folks, a sweet older lady fours days out from an AVR called me saying "I feel like I can't get my breath, having a hard time with it." Let me tell you, this is one tough broad. Here she was just recently undergoing a standard AVR with her chest cracked, and the only thing she has asked for is Tylenol. I've had grown macho men in the same situation crying for their Oxycodone every 3 hours, so I knew something was not right. Sat her up, put on some O2, listened to her. And there it was, widespread crackles and just that wet blanket kind of sound of too much fluid on board. Told her, "I'll be right back, gonna call the doc. Call me if it gets worse." Lucky for me it was 6 in the morning, not that I care about waking docs up in the middle of night, but I like having my docs awake when they talk to me (had a friend where the doc tried to give him orders for a Vitamin K drip, before correcting himself to an insulin drip - he then called back and asked my friend what he had said.) Asked for Lasix and duonebs and got a basic panel thrown in too for good measure.Gave her the Lasix and by the time I was wrapping up to go home she was right as rain. The next night she had scheduled Lasix and potassium...guess they figured her CHF hadn't quite totally improved, but yes, but not quite there.
The thing that took me aback, was that I didn't hesitate, just did and got the problem fixed. Guess I'm learning.
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 was cleaning this afternoon, I came across a journal I kept for nursing school. It was only a few short pages, I later realized it was easier to type it up and print out my "journal" to hand in with the infamous care plans we were required to submit after every clinical rotation. Reading those short passages brought back a flood of memories. Some good, some bad, some merely trivial. What struck me was the combination of awe, wonder and extreme trepidation expressed within those pages. Here I was embarking on an entirely new adventure, sailing into uncharted waters and it showed.
My first in-hospital clinical was the ER. As I wrote, "it was overwhelming, crazy and exciting." Or as my preceptor for the day summed it up, "go big, or go home." Crawling through the vault of memory I remember giving my first IV push, phennergan and morphine. I was shaking, hardly had my facts together as I approached the patient, clinical educator in tow, did the 5 rights, explained the medication I was giving, how it worked and why, then giving it. I was literally shaking in my scrubs. Compare that to current.
Last shift I gave IV antibiotics, IV push diltiazem, titrated a dilt drip, not to mention the regular cocktail of meds I pass on a near daily basis. All without giving much of a second thought past the required patient identifiers, reason, action and why. All of that was now internal, unless I had to explain to the patient (if they were able to understand me.) I had acquired the confidence to do this, automatically. Like many of things one does on a typical shift, assessments, line draws, manual BPs, dropping NGs and Foleys, starting IVs, the work of the registered nurse. While it is not automatic in a drone-like fashion, it is automatic in the technique. I can't really explain it without sounding like a robot or a dangerous nurse, but it is almost a Zen-like automaticity. I still have a looooong way to go though.
Confidence is a funny thing though. It comes and goes. Lately, I have had a string of great IV starts. Our facility has a dedicated IV team that will start a line when needed. This is a double edged sword. You have the resources tonot have to worry starting a line, but at the same time, your skills do not improve. It ain't like riding a bicycle. So I had a run of good starts, even on patients that were not easy. Then a runs of bad ones. I couldn't get a 20 guage in the healthy (albeit ETOH detoxing) guy who had great big veins, much less the geriatric renal patient. Then out of the blue, I had to get one of my patients ready for open heart. I figured, may as well have a look-see. And there it was, big juicy, right on top the of the forearm. Without a thought, the 18g went in, done. Confidence re-gained.
We'll see how long it lasts.
