Death

Death is something that has or will touch all of our lives at one time or another. As nurses our lives are touched by death more often than most. It is a hard experience no matter how many times you go through it, and as a brand spankin new grad it is especially hard (I think). I saw my share of death as a tech/extern on my unit, but it never hit me the way it did last week. We have had a run of patients that have done very poorly postoperatively, and therefore have ended up staying in our unit for more than the typical 2-3 days. One patient in particular had been on the unit since the week of my hospital orientation. This patient was a poor surgical candidate to begin with, and had multiple issues post op (unstable rhythms, unstable respiratory status with multiple intubations, and acute renal failure). The patient was a candidate for a LVAD (basically a short term artificialy pump to take the workload off of the heart), but the surgeons decided against it. Anyways...suffice it to say that after many years of noncompliance with medications and health issues, this patient was not doing well after surgery. In the 3 weeks that I have been orienting on the floor, I was in and out of this patients room for manny different reasons, but I was never assigned directly to this patient. The patient had sustained runs of Vtach my first night on orientation, so we spent a bunch of time in there trying to get a more stable rhythm (pt was extubated and communicating that first night). The patient was on SLED (a form of continuous dialysis) by my second night of orientation, so we spent time in the room learning about the concepts of SLED and how to run the machine (pt was reintubated by this time, but could still respond to commands). On my 3rd night of orientation, the patient coded and we had to do compressions. I arrived at work on my 4th night of orientation, and took report on my patient. I noticed a bunch of family around the room of the patient I had spent so much time with. I wondered what was going on, but had my own patient to deal with, so I did not wander down to investigate. As the evening wore on, the family came and went, and hospital coordinators, doctors, and nurses were all milling around outside of the room. Finally when my patient was resting, I wandered down to see what was going on. Turns out the family had decided to make the patient a DNR and to terminally extubate the following morning. Apparently a terminal extubation is a big deal and requires lots of doctor consults, and a crazy number of signatures. Now as an aside, the nurse caring for this particular patient was not at the top of the list of caring and compassionate people. He is a very knowledgable and thorough nurse, but not the type that holds the patients hand. After the family made the decision, and went home for the night, the nurse spent probably 90 minutes spit shining the patient. When I went in to help him turn, I asked him what he was doing in there for so long, and he said that he wanted to make sure that the patient spent their last moments clean and comfortable. That really touched me coming form someone that I looked at as a very thorough nurse, but not the touchy feely type. He was talking to the patient and saying how everything was going to be ok soom and that there would be no more pain. he explained how we would be sure to make the patient comfortable. I was touched that he made the extra effort to talk to the patient and make sure they they knew everything was going to be ok. We hadn't been out of the room for more than 10 minutes when the monitors started alarming...the patient had a heart rate of 44 and dropping. We went into the room, the nurse took the patients hand and said it is all going to be ok now...it is ok to go. Within 3 minutes, the patient was gone. This was a first for me in many ways. It was the first patient that I had previously interacted with that I spent the last minutes of their life with (we see a fair amount of death, but usually the ones that don't make it never recover consciousness after surgery and we never really interact with them). It was the first time I saw that even nurses that are not the touchy feely type have compassion...they just show it in different ways. It was the first time I put my stethescope to a patients chest and did not hear heart tones. It was the first time I was the one to say "they are gone". Life is full of firsts, and I will always remember the patients who's last moments gave me so many firsts.

Decision making

Today I want to talk about decision making. It is not an area in which I thought I was hugely lacking skill, but when the rubber meets the road, it turns out that I royally SUCK at it :-). OK, maybe not royally suck, but I could use some brushing up in that area. I have been on unit orientation for a total of 3 shifts now (we have 2 -12 hour shifts a week and one day of classroom stuff). I have taken one patient each shift, and lucky for me, it was the same patient for the first 2 shifts (Yippee for consistency). Anyways, middle of my third shift comes around, and the notion strikes me that I have not made one decision on my own. Everything that I do I ask my preceptor...should I do this, should I chart this, should I time this lab for 4:00 since we need it by 5:30? About the time I had asked her the 800th question for the night, I had the revelation that I need to start making some decisions on my own. Orientation is a time for learning, but it is also a time for taking control of and responsibility for your actions. I apparently am sooo darn scared of the consequences if I screw something up that I am not even willing to decide if a lab can be timed for 4 or 5 am...what the hell is that???? I have been through more school than most people I know combined, and I consider myself to be a fairly intelligent individual. I don't seem to have a problem making decisions in day to day life, or in training my dogs or horses. I didn't really have a problem with decision making in the clinical setting, so now why am I all of a sudden a decision making retard? This has been the topic of my thoughts for the past 48 hours or so. I have pretty much decided that I don't feel like I have enough knowledge to be able to make the correct decision for my patient population. I am scared of the consequences of a wrong decision, and therefore I have resprted to turning to my preceptor for EVERYTHING (i.e I am going to clear the pumps at 6:10 instead of 6:00...is that OK? I was running a little late and forgot...jeez...what was I thinking). I posed my problem to my preceptor, and she laughed. In my head I was thinking...yeah...ha ha ha really funny. I am glad that I could be your joke for the night, ad then she said the magic words that changed my mind about the whole thing. She said..."You are asking me tons of questions, but you are not asking me to make the decisions. You are asking me if it is ok if you do A instead of B. If you were asking me what should I do, A or B, I would be worried, but since you are coming to me with your decision made, and you are just checking the answer, I am not worried. A few more days of making the correct decisions, and you will have a bit more confidence." A little light went off in my head, and I felt sooo much better. I am not really a decision making retard, I am just cautious, and cautious is good :-). Sooo, for those of you out there that are having issues with decision making, just make sure you decide what course of action you think is best, and then go to your preceptor. That way it is really YOU that has made the decision, and your preceptor is just your double check so no one dies (or gets hurt).

I have made a decision reguarding this blog (baby steps ya know). Instead of painfully rehashing everything that I do on every shift, I will take the main points I came home with, and the main things I learned and make them nice little bullet points, so for this week this is what we had:

- chest tube leaks show up as bubbling in the water seal chamber and sound like ping pong balls in the patient's chest...I know they taught us this in school, but it sticks so much better when you see it in action!!! I had a thoracotomy pt this week that had a crazy air leak ( and a heart that was deviated to the opposite side of the chest due to lung collapse...it was really cool).
- IV amiodarone should be run centrally whenever possible. Small boluses can go peripherally, but if you are gonna hang it for any length of time, get a central line...it is not pretty if it infiltrates (did not get first hand experience, but saw pictures)
- Levophed increases SVR, has a positive inotropic action, and somewhat dilates the coronaries. It is a good drug for hypotension, but make sure your patient has enough volume before you go jacking up the rate. At our institution, the docs only like to go to about 20-30mcg/min with the Levo before they switch to Vasopressin (which apparently does a better job of clamping down the peripheral vasculature)
- Low cortisol levels can cause low BP because of cortisols action in the renin-angiotensin-aldosterone cycle. My patient's SBP was hovering in the 60-70 range on 2 of Levo, so the docs wanted a cortisol level drawn to see if that was the cause of the hypotension. Cortisol levels came back fine, and we upped th Levo to 4 and the SBP went up to about 90. Pt was non symptomatic with SBP of 90, and got up to the chair with ease. My guess is thet their norm was low to begin with (but that is just my not yet very experienced opinion!!)
-Time management is everything!! I need to devise a cheat sheet or something now that I have a better idea of the daily flows. All of the "stuff" that needs to get done in an ICU setting is overwhelming, and I really need a vidual so I can be sure I finish everything i need to get done.
- Everyone makes mistakes, or forgets things...even the seasoned super nurses, so at the end of the day if your patient is still alive not much else matters (for now anyway) :-). They are not going to remember if you forgot to do the 24 hour chart check, or if you forgot to order that lab and had to leave it for the next shift. Treat each patient as you would want your family to be treated, smile, and do everything you can to make them comfortable...the rest will fall into place!!!