Team ICU

ICU nursing is a team sport.  Some nurses don't get that.  They are too insecure to admit they need help, so they try to do everything themselves to prove their competence.  Offers of aid or advice can cause them to boil over with intense anger.  

Would you go into a basketball game and yell, "I got this!  Stay out!  I can do it myself!"

Your co-worker's eyes and ears and experience are like silver in a mine.  Use them.  A group is always stronger than an individual.  We are all learning and growing.  Policies, protocols and equipment change constantly.  Don't be afraid to say, "Will you take a look at this Arctic Sun and see if I've got it set up right?"  or, "I can't figure out why this balloon pump keeps alarming," or, "I'm concerned that I'm missing something here--got any ideas?"

And if a co-workers says, "Hey, that's not how this Swan is supposed to be hooked up," or, "Do you want your dopamine  running at this rate?" or "The heating coil should be on this return line," be strong and secure enough not to take it as a personal affront.  People who reach out with constructive criticism are trying to HELP YOU.  Getting angry and defensive and making stupid excuses will make you co-workers go silent, step back and let you fall. 

Take a deep breath and say, "Thanks for catching that!"

Together, we make a great team. 

Mos Def, be Les Dum

There's an online video showing the rapper Mos Def attempting to tolerate having a small-bore feeding tube placed.  I have to say this to his outraged audience:  you don't need to go all the way to Guantanamo Bay to see this.  Poke your head out your door and peer down the street at the nearest hospital.  There are dozens of patients right there with feeding tubes.  

Besides that, brides pay big bucks to have feeding tubes so they can lose weight before their horrific weddings and exercise fanatics proudly wear them to control every calorie.   

I have placed plenty of feeding tubes, mostly in frail, elderly people.  But I've NEVER seen a wild, sobbing breakdown like Mos Def's.  Only about 10 cm of his tube went down--but I guess that's more than this delicate flower can handle.  Where's his murderous public persona when it counts?  Man up, Mos Def!  Be Les Dum!   

I've also never seen handcuffs disappear like they do in this video, (although it allowed his hands to flail around desperately and then cover his eyes while he cried piteously).  And how did his head strap come loose from the chair where it was clearly shown in the first take?

Mos Def--you're a bad actor and you have a very bad film editor. 
.
About Mos Def's statement that this was the worst pain he's ever experienced--what a sheltered, petted life he must have!  What if he had to give birth or something that is actually uncomfortable?


Nurse's Note:  To the upset people posting comments about how "the doctors" were trying to get the feeding tube down:  doctors don't place small bore feeding tubes.  Nurses do.

Costume Faux Pas

What people wear makes a statement.  Our costume choices reveal a great deal about us.  We expect something different from a man in a tuxedo than from a guy with a Confederate flag wrapped around his head.

Here are some of my favorite--REAL LIFE--bad costuming choices:


The Cool Doctor with the black Vampira nails and trendy tattoos

The even Cooler Doctor with the greying ponytail

 

The exposed thong

Nurse's Note:  To save laundry costs, people should  just have their thongs tattooed on. 

What has the government done for me lately?

One afternoon as my daughter and I were trailering to a nearby park, and I heard a radio commentator criticizing the government.  I joined right in, complaining bitterly.   

My daughter protested mildly.

But, I retorted, "Really--what has the government done for me?"

She stared at me, shocked and appalled that I could be so ignorant  Then she said,  "How about:  the condition of this road,"

"The safety specs on this truck,"

 

"The ingredients in your can of soda,"

 

"the education in your head,"

 

"And the immunizations in your body."

"That's just a start."

Embarrassed, I shut up.




Nurse's Note:  When our youngest daughter was in third grade, she learned this poem in school:

"Services!  Services!  Our taxes pay for services!
Schools and pools, parks and roads.
Services are good as gold."

I try to keep that in mind when tempted to complain about the government.

The Attenders!

Nurses have superheroes just like Batman and Spiderman.  Here are some of them:



Nazalyzer has a supersensitve nose that can make many diagnoses.  She doesn't need lab tests, xrays or CT scans.  She can SMELL what is wrong with the patient!

Nasalyzer is famous for her superstrength!

Ultima  has been a nurse for many, many years.  She remembers when trepanning was done at the boulderside!  Ultima brings with her long and wide experience.  Her most famous line was to a physician who was arguing with her:  "Perhaps I am not being clear..."

When a patient is found pale and semi-conscious, with a rapid pulse and profuse perspiration, many experts are called in...

They offer different opinions...

Ultima sweeps in to save the day!!

Ultima devises an amazing, high-tech solution...

All ends well!!

Rez-Q-erz  can quickly assess any emergent situation and immediately predict what should be done and what the doctor will need.  By the time the doctor arrives, Rez-Q-erz  has all the supplies and equipment at the bedside, the labs drawn and the tests ordered.

Res-Q-erz is not afraid to take on drug reps in the parking lot!

Later, when this story is told to other staff members, some questions arise...
 

Solaci is a nurse with a magical soothing voice.  When patients are confused and climbing out of bed, when family members are argumentative or sarcastic, Solaci can walk into the room and de-escalate any stressful situation with his voice.  It works better than a warm blanket!

When a nurse yells for the code cart, if the wheels are locked, that doesn't stop Solaci!!

Solaci  doesn't know his own strength when it comes to the door latches...

But that doesn't prevent him from getting the code cart into the room!!

Solaci can leap large sewage floods with a single bound.

He can be turned into a toad by his nemesis, Dr. Duh Nyle.

EmpaSee has the unique ability to always see the world through other people's perspectives.  He wears Ryaban© eyeglasses, which can be adjusted to allow him to understand anyone's point of view.  

Empasee has the ability to contort his body into ANY SHAPE!!

Together they make up, THE ATTENDERS!

Nurse's Note:  Their shirts spell, "NURSE".  No one's seems to be getting that...I guess no genius is understood in their own time...*sniff*

In that sleep of death what dreams may come

Propofol is a milky-white drug that sedates patients beautifully.  I like propofol!  Its short half-life makes neuro assessments easy;  it controls hypertension and its soy base even provides some nutrition. 

But since Michael Jackson's death, I just gotta add this:

1.  Propofol is used ONLY IN A HOSPITAL'S ICU
2.  Propofol is used ONLY ON VENTILATED PATIENTS
3.  The only other exception is when it is used during conscious sedation BY A PHYSICIAN WITH DEEP SEDATION PRIVILEGES

Trust me--I'm right about this.

The Dating Game

There's a question that reveals immediately if a person will be a good partner.  I discovered this question quite by accident one night on a date with a surgeon.  I said, "Tell me about your ex-wife."

He rolled his eyes, took a deep breath and said: "God!  Those were the longest three months of my life!  I couldn't wait to get rid of that crazy bitch!  She was a huge bipolar disaster!"

Our appetizers had just arrived and they looked really good.  I wondered if it would be okay if I ate some before I suddenly remembered that I needed to take my hamster to the hairstylist.

When I met my present husband, I reached into my old bag of tricks and asked him about his first wife. 

He said, "Cindy and I were married for fourteen years.  We had a lot of good times together.  It didn't work out, but I have many great memories.  We both made mistakes and we recognize that we're better off apart now.  But we share two wonderful daughters and I wish her all the best."

I was so impressed, I married him.

Nurse's Note:  The question reveals nothing about your ex.  It reveals how you view your past and how you take responsibility for it.

The Name Game

The nurses in Labor and Delivery should be paid extra for keeping a straight face when they hear some of the names given to babies.   I've met babies named, "Knives", "Rumor" and, "Murder".  I'm still waiting for "Spoon", "Gossip" and "Manslaughter".

I also see names spelled in all kinds of strange ways.  Many Americans think if there is an accent mark, an umlaut or a circumflex thrown in randomly it proves they are erudite and cosmopolitan.

So, here's a combination of names that aren't really names AND creative spelling!

Can you read these names?

*Toenail, Carpet, Stripes, Leather Jacket, Fungus

The Doctor's Paw

The Monkey's Paw is a short story by W. W. Jacobs about a gruesome talisman that grants three wishes.  The moral to the story is, "Those who interfere with fate do so to their sorrow". 

Modern medicine has a lot of parallels with The Monkey's Paw.  All the elements are there:  meddling with natural order, unreasonable expectations and horrific consequences. 

Here's my medical version of The Monkey's Paw.  I'm calling it, The Doctor's Paw. 



Once upon a time, there was a man named, "Ernest".  He lived in a typical house in a typical town in a typical state.  He worked hard as a fireman, saving people and property.

Ernest married a wonderful woman and they had two adorable children.  He had a great life!

But Ernest grew older.

One day, Ernest couldn't get his breath.  Faint and gasping, he went to the hospital.

In the hospital, he met Dr. Duno Goode.

Dr. Goode told Ernest about a charmed amulet--the Doctor's Paw.  Dr. Goode explained that The Doctor's Paw could grant three wishes.  But the wishes would come true at a terrible price.

 Ernest was too scared to understand that.  He couldn't breathe!  He grabbed for the Doctor's Paw and made his first wish-- he wished that his breathing would be made easier.

He was placed on bipap at 15/8 with 100% bleed-in.  To provide nutrition, a stiff plastic nasogastric tube was poked down his nose into his stomach.  Sticky, smelly liquid was pumped into it.

 

Now, Ernest was very uncomfortable.  The bipap's strong air pressure felt like his head was hanging out of a space shuttle on its way to Jupiter.  The feeding tube down his nose made him gag constantly.

Once again, Ernest reached for the Doctor's Paw.

"I want this mask off my face and this tube out of my nose!"

Dr. Goode cut a tracheostomy into his throat.  A PEG tube was crammed into a hole sliced into Ernest's abdomen and stomach.

"I don't want to live like this!" he wrote in a shaky hand (he could no longer speak with the tracheostomy).  "Let me die!"

It was his last wish.

His code status was changed to "DNAR".   The hospital shipped him off to a nursing home where he lived for eleven years lying in bed on a ventilator, wearing a diaper, being turned every two hours and fed through a tube in his stomach.

The End

 

 

Nurse's Note:  evaluate your code status carefully

Public Service Announcement

Some countries have mandatory public service requirements like serving in the military or working with underprivileged children to graduate from high school or college.  Those are great ideas, but I'm gonna add one more:  countries should require every person to work in a nursing home for six months. 

 Let's educate our young citizens to know what they do and do not want from health care.

Restrain Me

Restraints are increasingly unpopular and politically incorrect.  There's a big nationwide push get rid of restraints in hospitals.

But, nurses don't tie down little old ladies for thrills.  For one thing, it's a lot of documentation--restraints have to be charted on by the nurse every two hours and reordered by the physician every 24 hours.  Patients don't like being restrained and the family members are stressed to see their loved one tied down.  

So, why do nurses do this legally risky, unpopular thing?  The most common reason restraints are used is that the patient is on a ventilator.  The ventilator is a breathing machine that is SAVING THE PATIENT'S LIFE EVERY MINUTE. 

 

Every minute.

 

Imagine having a tube the size of your little finger shoved all the way down your throat.  It makes you gag; you feel like you're choking; you can't talk.  Your immediate impulse is to pull the damned thing out.   That's why ventilated patients are restrained.  We're not punishing them.  We're keeping them safe.

I have heard of hospitals that don't restrain or sedate ventilated patients.  Frankly, I just don't believe that.  Unless every one of their intubated patients has a sitter or is chemically or physically paralyzed they are going to self-extubate.  It's a normal response when something obstructs your airway to want to remove it. 

If a patient pulls out their breathing tube they can die.  We would have FAILED to keep the patient safe.  

What will you say to the judge?  (Because the wrongful death lawsuit WILL go to a judge)  

 

"I didn't restrain them because of the political climate"? 

 

Reporting for Duty

Nurses give report twice a day, every day.  The day shift gives report to the night shift; the night shift gives report to the day shift.  Report is the time when very important information is passed from one nurse to another. 

Information like:

*What drips are running and how they are being titrated

*Lab values, trends and when the next labs are due

*Whether we are wedging the Swan-Ganz catheter threaded into the patient's heart, or whether the physician thinks there is too big a risk of pulmonary artery rupture

*EKG's, upcoming tests and procedures


This information is being relayed by a nurse who is exhausted; they have halitosis and their hair looks like it was combed with an eggbeater. They're trying to keep their speech clear and comprehensible so they don't end up in the CT scanner.

Interrupting report is dangerous. Things get missed; errors increase. Distractions should be minimized. This includes family members walking up to ask for soda, a washcloth or to have their parking pass stamped.


If you work at McDonald's and you make a mistake, someone might get a hamburger rather than a cheeseburger.  If you work in a hospital and you make a mistake, someone could die.  The stress level is titanic.

 

I've Got the Floor

Floor nurses have the largest nurse-to-patient ratio of any area of the hospital.  Depending on the hospital, floor nurses can have four, five, six, seven or even eight patients. 

When I first became a nurse, I started on a 22 bed unit, and at night I split it with another nurse. 

That was not a typo.  Me and one other nurse split a 22 bed unit. 

Things like giving baths, helping with meals, explaining medications, treatments and goals of care were like dreams from another reality.  We ran in the patient's room, did the most cursory of assessments, threw their meds at them and ran out.  A patient who wasn't on the call light and had no frequent medications usually didn't get seen more than once.  Medical students, family members and respiratory therapists found patients cold and dead in their beds in those days.

It was all paper charting back then.  The night shift had to do the 24 hour chart checks, the MAR reconciliations, put in all our own orders and start the next day's flow sheets.  Just managing that avalanche of paperwork alone was a full time job.

In theory, floor patients are supposed to be very stable.  But they can also be very sick and getting chemotherapy, blood transfusions, heparin or insulin drips. 

Floor nursing is like  rehearsing Shakespeare in a mall parking lot.  The constant chaos and distractions makes progress difficult.

Tele Vision

Tele nurses have challenges.  A typical patient assignment on a tele floor is four patients to one nurse.  That's more patients than on an ICU but less than on a med/surg floor.  If one patient becomes needy and dominates the nurse's time, the other three can be neglected. 

Some tele patients are walking around sipping cranberry juice and telling inappropriate jokes.  But some are fresh out of the ICU.  The "tipping point" on these patients can be razor-thin.  Tele floors take patients with intravenous drips like heparin, nitroglycerin, lasix, insulin, dopamine, dobutamine, milrinone, cardizem and cardene and all the labs and vital signs that come with them. 

Working on a tele floor is like teaching four caffeinated ADHD guys to use power tools.

I See You Nurses

ICU nurses frequently suffer from a slightly different version of Being Fabulous than ED nurses.

Many ICU nurses have never worked even one day on the floor, so they don't understand a floor nurse's job.   It's easy for ICU nurses to develop a superior attitude and not realize that one kind of nursing is not better or worse than another, they're just different.  Like apples and kumquats. 

ICU nursing is like trying to organize, prepare and serve an endless course dinner to two gourmets at a four-star restaurant.  You  may only have two customers, but they're so discerning there's no room for error.

EMERGENCY!!! EMERGENCY!!!

Nurses in the Emergency Department get a lot of publicity.  More movies and television shows are set in the ED than all the other areas of the hospital combined.  When was the last time you saw a television show set in a dialysis clinic?

88% of ED patients walk out the front door. 

I'm gonna say that again:   88% WALK OUT THE FRONT DOOR. 

What that means is that patients on the quietest med/surg floor are still sicker than most ED patients.

I've worked some in the ED.  I got to see a lot of vaginal discharge, nauseous kids, drunk prostitutes, whiny men with back aches and drug seekers.  There were some broken arms set and fluids given, but mostly I saw folks patted on their fuzzy heads and sent home.

The ED is like a big wall of graffiti.  The majority of it is just crap.  But mixed in are a few things you better not miss.

Nurse's Note:  If a patient comes in to the ED with a heart attack, a nurse from the Cardiac ICU responds. If a trauma patient comes in, a nurse from the Surgical ICU responds. If a patient is brought in with a stroke, a nurse from the Neuro ICU responds. If a burned patient comes in, a nurse from the Burn ICU responds. I have never seen any of those nurse responders portrayed on television. The televison ED nurse somehow specializes in every diagnoses.

The Sugar Diabetes

Some of my older patients tell me they have, "The sugar diabetes".  This always confuses me...is there another kind of diabetes?*  

Diabetes seems benign.  The patient feels pretty normal, so it's easy to ignore.  But consider a diagnosis of diabetes comparable to a diagnosis of cancer.  It's an illness that should be taken VERY seriously. 

If you have diabetes and you aren't controlling your blood sugars religiously, YOU'RE JUST NOT SCARED ENOUGH.

In the USA, diabetes is the #1 cause of blindness, kidney failure and amputation.  Diabetics are two and a half times more likely to have a stroke, and 75% of diabetics die of heart attacks.   

Nurse's Note: I'd take HIV over diabetes.

*Another Nurse's Note:  I am aware of diabetes insipidus and gestational diabetes.