Two years in the ICU

A little background: I have spent the last 2 years working in a medical ICU working with a wide array of patients and their diagnoses from detoxing, diabetic ketoacidosis, congestive heart failure exacerbation, GI bleeds, terminal cancer, sepsis, respiratory failure, and even a couple of West Nile virus cases. I have learned so much about the human body and the journeys it is capable of surviving, but I have also learned so much about myself. I needed a place to write my thoughts and so I have returned to SageBrushRN to explore those ideas.

ICUs are able to combat and correct a lot of things. I am most proud of my moments when I've had a chance to feel like I made a real difference. I've had patients come back in a say thank you for getting them through a pneumonia, a heart attack, a freak infection that came out of no where, and various other maladies. 

However, what I was not prepared for in ICU was the torture care of terminal patients. When I say "torture care" I mean cares that are done to a patient that is very clearly not going to survive but we are still doing everything possible like we still have a chance to cure. 

I have cared for people for weeks with tubes coming out of every orifice that are unable to communicate but still grimace with every position change every 2 hours. I have lost a little of my soul to these patients that will spend the last hours of their precious lives being poked and prodded under fluorescent lights in the ICU. I have wept when we have coded the same person time after time because the family has no idea the violence of a code and would rather subject their love one to another Code Blue rather than hold their hand and savor what time is left. 

I have recently read Atul Gawande's book Being Mortal and it gave voice to all these feelings I have been grappling with over the last 24 months. Our medical culture is inept at dealing with mortality and we rather flail helplessly against certain death in an attempt to make ourselves, not our patients feel better. 

Gawande sites a study about palliative care where patients with Stage IV lung cancer  were randomly assigned to receive either usual oncology care or usual oncology care plus palliative care specialist care. The following is astounding,

"...those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experience less suffering at the end of their lives - and lived 25 percent longer (his emphasis, not mine). In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality (Gawande, Being Mortal, 2014)"

I got into ICU to save lives, but the longer I am there I realize the majority of what I do is prolong suffering of both patients and their families. I got into nursing to serve others, to relieve their suffering, to make the world a better place. I do not fear death, I fear suffering as a patient's last memory of this world. 

When I've worked with families and doctors wise enough to recognize and accept the end of life I have been honored to be death's midwife and remove the trappings of ICU and provide relief from pain and suffering to let someone pass. When I can remove the lines and let a mother hold her child one last time, or a spouse snuggle in for one last hug that is the comfort my patients deserve - to feel love and security from those who matter most to them.

It is with relief that I am now leaving CCU. It was an honor to work with such brilliant nurses and to be part of a such an efficient team. However, I have found that my nursing practice and my nursing soul need a change and will find that change in the new journey of PACU nursing...

One year - it's a wrap!

As of this month I have been working as a nurse for a full year for the same hospital system. It has been an incredible journey that has been peppered with challenges and jubilation in varying degrees. Here are the major brush strokes that I have learned:

1. You will never stop encountering something new. I kept thinking "I can't wait until I hit my one year of nursing" like it was going to be a panacea and suddenly I was going to get rid of the anxiety that creeps up in my stomach when some new disease process or new piece of equipment walks in the door. What I have found is that I have had enough 'firsts' this year that when something strange appears in my patient or patient's room I know enough to take a deep breath and start figuring out what needs to be done next. This is what experienced nurses know to do instinctively - they can synthesize what they know and compare and seek out the differences they need to learn and account for to give patient specific care.
2. Teamwork is the solution to all challenges great and small. I am fortunate that I work with fantastic people. They are my sounding board when reasoning through treatment options. They are the arms that help me reposition my patients every 2 hours so prevent skin breakdown. They are the people I look forward to spending 12 hours with at a time even when it's a full moon and Friday the 13th and the ER is shipping us 5 patients all at the same time. 
3. There will always be a bully lurking somewhere. It might be a fellow nurse. It might be a doctor. It could be anyone really. But the sooner you learn how to deflect these personalities the better. This has been a hard lesson for me as I tend to be a people pleaser and desperately want to make everyone around me happy. I have learned to retool these skills into purposely killing every bully with kindness and becoming more direct in my communication. This technique works for me and I feel that I have become a more skillful communicator overall. My most triumphant moment was asking a team leader who was notorious for mocking people who asked for help by stating, "Are you going to make fun of me for not knowing this or are you going to  use your experience to help me become a better nurse by teaching me how to do this right?" Suddenly this particular person became incredibly helpful to me. I wish I had figured this out months earlier as I dreaded working with them.
4. Getting involved beyond the floor. A particular rewarding experience for me has been to join the Performance Improvement (PI) Committee. We work with our coworkers to generate the coming year's competencies (education required for our job). This means working with the nurse educator to find out what new piece of equipment is coming down the pipe line. For example, we chose to high light education on the Stabber of Death this year as one of the new neurosurgeons uses that particular piece of equipment regularly in his practice. And yes, it is actually called the Stabber of Death. It's used to place intraventricular drains at the bedside for patients with high intracranial pressures.
5. Learning to disconnect appropriately. The first year has been hard for me to disconnect from my work when I'm not there. Thankfully the number of work related dreams has started to decrease. Transitioning from school where there is always homework hovering on the edge of your thoughts to a job that is demanding in physical and emotional ways has taken some time to balance. I have found that seeking out new hobbies - cooking being most prominent recently- has been therapeutic and helpful. I am a better nurse when I don't think about it 24/7. That does not mean I don't take education outside of my work very seriously. It just means I am learning to manipulate the on/off switch much better so that I am 100% present when I'm with my family and friends.

And with that my friends,family, and followers- I'm closing up SageBrushRN. It's been a wonderful place to write and share my thoughts during this first year of nursing. Your comments have definitely been appreciated and should other new nurses stumble across this blog I hope they find it helpful as well. I'll leave the pages up, but don't plan on adding any more at this time.

~Have a dynamite holiday~

Leaning In, Leadership, Ladies!

I just read Sheryl Sandberg's book Lean In about women in leadership positions. She is a very good author, but an equally articulate speaker. I found this TED Talk a powerful reminder of how social change is both an individual and societal act. Enjoy!

Thinking outside the box: Fighting Fire with Fire- using HIV to fight Cancer.

How to start a movement

Adrenaline

I knew I had an admit coming since midnight, but they did not roll in the door until 0200. That sort of delay always makes me nervous because I know a train wreck is coming my way. I assisted (by myself!) the MD to place a central line and hovered nearby as RT placed an arterial line. I hung and titrated dipervan by myself. I had lots of nurses helping me and I delegated away and took advantage of every offer while maintaining control of the situation.

I pretty much felt like this guy.



I came home humming and then promptly passed out at 0900 in a fit of adrenaline let down. What a satisfying night :)

Flying solo

It happened almost without my notice. Titrating IV drugs, handling alarming vents, and even drawing labs via needle sticks are becoming second nature. I have a long way to go before becoming comfortable in this job - actually if I ever become comfortable it will be time to change jobs.

However, the alarms and tasks that had a way of getting my adrenaline pumping are become less stressful and now I seem to have more mental focus to do what I enjoy - think about my patient and consider their disease process and how I can improve their outcomes. These last 2 weeks I took care of the same patient and having the band width to think about their situation was really great versus feeling like I was giving all my energy to complete each task as it arose.

In January I will rotate back to days and I know it will take time to construct a rhythm there as well. Nonetheless, the chance to rotate back and forth every 8 weeks or so will be welcome as a chance to stretch my skills as well as get the chance to work with all the doctors and nurses that roam our halls. Additionally, I have now floated to the Meridian ICU (in the same hospital system, 20 minutes out) and to the surgical ICU (down the hall). Although I feel like Dorothy in the Land of Oz when I leave my home unit it's nice to have those first floats out of the way!

Happy autumn.