The worst day by Chelsea Moore

My day started out pretty standard, checked in with my patients, did my assessments, did my med pass and assisted my patients with their AM care. One particular patient asked
me to stay behind because he wanted to talk to someone. We ended up chatting for almost an hour and he shared with me the pain (both physical and emotional) that he was in and what he was feeling vulnerable about. It was a lot to unpack and he was emotional. He begged to speak to someone, anyone, who could help him. I told him I would put him in touch with a social worker and would encourage his MRP to order a psych consult. He had my word, I had his back. He was calm, cracked a few jokes, and finally felt safe. Until his wife came back at about 3pm while the social worker was at his bedside, declared he didn't need any of this nonsense, he didn't know what he was talking about and just needed to come home. She was the only one who could look after him properly and we were just making things worse. I looked at "John" trying to convey with a look that "Don't worry, we've got this. You're safe". The MRP came and did his rounds while I was on my dinner break and when I came back, the wife triumphantly told me she had him cancel all that nonsense with Social Work and the Psychiatrist and "John" would be discharged the next morning. I asked her how "John", the actual patient felt about this and she said he wasn't present for the conversation and was in the bathroom for the duration. I saw red, but politely excused myself. I spoke with the MRP before he left the floor and asked him if he felt it was right to discuss these things without the patient present, and he responded that the patient's "greatest advocate" was there; the wife, and that he felt good about his decision, and where to go if I didn't agree. When the wife left in the evening at the end of my shift, I sat with "John" for a while. He cried and told me that he felt like he was in a prison of his own body since his Parkinson's had progressed, and felt infantilized and emasculated. I told him I was sorry that I couldn't make happen what I said I would. We sat quiet for a while. He told me I was the first person who bothered to listen to him. I thanked him for the privilege of him sharing his vulnerability with me. I excused myself, wished him strength and courage and made it to the staff restroom where I cried so hard I couldn't see. I splashed water on my face and fixed up my makeup the best I could and walked down the hall towards the ward exit, took the stairs down the 6 flights out onto the street, walked to my car, and wept. And then the next day I got up and started all over again.

Chelsea, LPN in BC, Canada

Nursing Student by Yasming Stallworth

Hello. My name is Yasming and I am a senior nursing student graduating in August 2017. Two months ago I was diagnosed with Bipolar Depression. I was embarrassed, thought that I was crazy, and did not think that I could finish nursing school. Today I am proud to share my story with hopes of creating a community for others to share their experiences with mental illnesses.

Yasming Stallworth, SN

MVA by Rebecca Mateiro

 Most of us try and avoid working on our birthdays, right? Maybe not, since we barter for Christmas and Thanksgiving off...so birthdays are just another day. I happened to be off my birthday and was watching TV with my two year old and his brother who was four at the time. My phone rings. Work. It's the radiology department. Weird. I'm a nurse but a close friend's voice speaks. 
Can you come in? The ER is crazy and they need help.
I can't. I have my kids. 
I'll watch them she says. They can hang out with me for awhile. Please.
What's going on?
A pediatric trauma. It's bad.
Five minutes
Juice boxes and crackers shoved into a backpack and a scrub top over my head. 
She's right. The ER is crazy. The ten beds are full and there is anticipation and urgency in the air. I find my charge nurse. She tells me to expedite discharges as fast as I can. As I go to get charts a nurse stops me. 
Please take care of this kid. I can't and you need to.
As an ICU nurse, I see trauma a lot. I haven't seen a peds trauma but I steel myself. My charge says I really wanted you to come and take care of the kid but didn't want to ask cause it's your birthday....and the patient is the same age as your son. 
It's OK. I'll do it. I walk in and a child of four is lying on a backboard. Normal saline bags taped bilaterally to his neck for c spine. Our small ER didn't have small c collars. He intubated and maxed on two pressors. He is bruised everywhere. Obvious broken arm and femur. OK Rebecca. Assess and stabilize I say to myself. I check the alarms, drips, tubing, ETT, IV sites, and ventilator. Finally, I look at him. He's fighting but doenst have much left I place my hand on his head to whisper it's 'OK baby, I got you,' but my hand trembles as I touch his head. He had so many skull fractures my hand slid his skull beneath my fingers. This is the point to which I think there is no hope for this child.
What other job do you get to see the end yet still push for a different outcome? Is there another occupation in which we use our sixth sense to see this is in vain yet still throw ourselves down to achieve one more month? One more minute? Can I say knowing this child was near the end made me work that much harder to give him the chance to hear his mother's voice? 
An urgency turned into controlled frenzy. The flight crew arrived and we worked for two hours more to make him stable for flight. He passed away 19 hours later. 
After six hours, I retrieve my children from the radiology department, they sat eating cheeseburgers and laughing. The trauma of this day so hidden. They remain innocent while I check and recheck their car seats.
I still think about that child on my birthday. How his mother is and his little brother, who survived the crash. I think about nursing and how my fellow comrades watched my kids so I could help. How seeing what we see makes birthdays so special but also, just another day.

 

Labor and delivery Nursing at its best by Tiffany Lorenzana

I start my shift and the charge nurse tells me to take room 10 because she's spanish speaking. I get report and am told she lost a baby six days after birth due to many congenital anomalies one year ago. The patient doesn't believe in abortion and carried her baby to term but the baby had too many anomalies to stay alive. She was back for baby #2. I enter the room and everyone turns silent. I somewhat recognize the patient but then her husband and sister give me a look. I recognize the husband. Then I realize I delivered the baby she lost one year ago. She was back this time for a baby boy which had no issues. The patient sees me and begins to tear. I ask if her if she wants me to be her nurse this time. I tell her I will understand if she doesn't because it's difficult. She told me in Spanish that she couldn't go through this experience again without me. And she wants me to remain her nurse. I said sure. I excused myself and cried outside the room because the way she said it was so heart felt. A few hours later we pushed and had a healthy baby boy. Which we placed upon her chest for skin to skin. I took the towel dried him off and then showed her his body. I said look at him he's yours and he's normal. Everything is okay. She kept crying and crying. "My baby. My baby." Everyone in that room cried. The attending, the resident, the family, the baby nurse and myself. It was the most amazing experience for me and was the epitome of labor and delivery nursing at its best.

Tiffany Lorenzana BSN, RNC-OB, C-EFM

Why I decided to be an RN by Rachael Bell

The decision came suddenly, albeit to took a while for me to act on it. I was 21, working as a financial consultant when finances were good and the housing market was on cloud 9. I was 7 months pregnant with my daughter and lived a mere 6 hour drive from my family, who resided in California. On a early Saturday afternoon, my father called and left a very casual message. "Your mother is having some trouble breathing and is in the hospital for a bit". I called back when I got off work and found out that his version of "trouble breathing" was her being intubated and in septic shock. She died 2 days after I arrived when we decided to end treatment. Her EEG had virtually no brain function, I would later learn this would be due to the fact she had long hours of such a low BP her end organs slowly died. 
On my second day in her ICU room, gowned from head to toe, a nurse in dark scrubs approached me and said "you must be the pregnant one from Arizona". I am a twin and can only assume my mother spoke to this nurse about her twins when she arrived at the hospital. I explained I had flown in from Az and I was pregnant with a girl. The nurse knew all this from a conversation she had with my mother before my mother was intubated. I learned this nurse came from the ER to check on my mom. It meant a lot to know that the nurse wanted to communicate with me that my mom had thought of me before she was sedated. This changed my life. 

Two months later, in June, I gave birth to my daughter. I was terrified and uneducated. At one point, they couldn't find my daughter's heartbeat on the monitor and had me move in various positions to try and find it. Explantions as to what was going on and what they were doing for my baby never happened. The birth of my daughter was a dark and lonely experience. Mainly because of the nurses. 
My mother's death was beautiful. The nurses and doctors were solemn, but open. My daughter's birth was frightening. The nurses hardly spoke, and never took the time to explain things. 
Both of these experiences lead to my decision to become a nurse. I had my daughter in June of 2005, and started part time classes in August of that year. I graduated a BSN program on 2013 and am an ER nurse now. 
Nursing is a calling. It is a desire to take care of the patient and the family. I hope that someday I can inspire patients and family members like that ER nurse inspired me.

What does a Nurse need to learn?

What does a Nurse need to learn by Justine zoeller
 

I push the button to silence the mechanical ventilator for two minutes. The loud "circuit disconnect" alarm makes parents and patients edgy. Besides, an unanswered ventilator alarm is a signal to other nurses - "I need help in here!"- and I know all the other nurses are busy with their patients. I don't want them to have to leave their rooms to check on me. Before suctioning, I usually push another button to give my patient 100% oxygen, but I don't for this baby. With his anatomy, too much oxygen can flood his lungs, decrease his blood pressures, and even cause myocardial ischemia- a heart attack. 

I turn my attention to the squirming infant in the bed. He is silently crying- face purple and screwed up, tears forming in the corner of his eyes. A quick glance at the monitor tells me that his heart rate and blood pressure are high. Not surprising, based on how upset he is at the moment. I disconnect the ventilator tubing from the endotracheal tube. This pencil sized tube is inserted through his mouth into his trachea so the mechanical ventilator can give breaths directly into his lungs. The external portion is secured to his face with tape. It's secure for now, but I'll keep a close eye on it throughout my shift- this is a drooly baby, and the difference of a centimeter in or out can have serious negative consequences. Across the crib from me, the baby's mom winces. "It's so hard to see him like this." "I know," I reply. "The good thing is, he won't remember any of it. You will though!" I try to strike a calm, upbeat and sympathetic tone. She smiles, reassured, but doesn't take her eyes off the baby. 

Carefully keeping my right hand sterile, I advance the suction catheter through the tube into his lungs. I anchor the tube with my other, un-sterile hand as I apply suction and withdraw the catheter. I can tell from the sound that I'm clearing a lot of secretions. "I think it was just the coughing making him upset. If he doesn't settle after I change his diaper, we'll definitely give him some extra pain medicine." She nods. It's good to have a plan. 

On the monitor, I see the baby's heart rate start to dip- 160, 120, 90, 70, 60. Using my unsterile hand, I connect the ambu bag to the endotracheal tube and quickly push breaths into his tiny lungs. His heart rate recovers right away, and his blood pressure was stable the whole time. I think it was just a sinus bradycardia- normal baby business in response to suctioning- but I'll take a closer look at the telemetry later. 

As I pass the suction catheter again, I hear a beeper go off outside the room. My charge nurse sticks her head in. "I'm going to an RRT on 5." RRT stands for rapid response team Any doctor or nurse can call an RRT for a patient outside of the ICU if they're concerned that the patient is quickly getting worse, and a critical care nurse and respiratory therapist will respond. We can perform assessments and interventions and offer recommendations. If we think the patient might need ICU care, or want a critical care doctor's input, we call the covering Pediatric ICU fellow. 

"Okay!" I reply, as I give the baby a few more breaths, satisfied I've cleared the majority of his secretions, and then reconnect to the ventilator. "Who do you have again?"

"I have bed 6. She should be fine, but can you keep an ear out for Christine? Her post-op is starting to get a little hypotensive. We have epinephrine in line and there's blood in the fridge if they want to give volume."

"Sure, no problem. Call me if you need a hand down there."

My vent beeps. Two minutes have passed. 

The baby is already starting to settle. His heart rate and blood pressure have normalized, his eyes are closed and face is calm, and he's sucking on his tube like it's a pacifier. I wash my hands, and make sure mom doesn't need anything right now. I do a quick scan of my room- alarms are on, emergency equipment is available, tubes and IV lines are secure, and I have enough of my continuous IV medication drips to last for a few hours. I go to check on Christine. It's her first unstable post op, and she's probably a little nervous. 

After 4 years in the pediatric cardiac ICU, these actions and conversations and thousands of quick decisions are second nature for me, but I remember a time when they were not. There is so much to learn, and it is all so important. These patients are small and sick. For nurses new to our unit, the things that have to be learned before they are independent clinicians are understandably daunting. 

First- the sheer volume of information. Nursing school doesn't prepare us for the complexity of critical care, or inherent degree of specialization of a unit like this. There are hundreds of diagnoses and accompanying medications and surgeries. There are EKGs, blood gasses, and x- rays. There's specialized ICU equipment- ventilators and monitors, but also pacemakers, and ventricular assist devices, and continuous dialysis, and even long term heart-lung bypass, or extracorporeal membrane oxygenation. I often remind new nurses coming off orientation how much they've already learned. What used to be alphabet soup- HLHS, TAPVR, SVT, RVOT, ECMO, EAT- has become a common language, a tool for sharing information about our patients. 

The psychomotor skills. Nursing is hands on. We touch to feel pulses, skin temperature, swelling, induration. We bathe, we suction, we secure, we insert, we remove, we change dressings, we change sheets. We do these things carefully- sometimes steriley- to prevent further harm or infection. New skills are slow and clumsy, and take time to become as quick and sure as they need to be. 

The culture. Some things are simple. Safety first. We answer each other's alarms. We help each other. We treat parents with kindness and respect, even if they're difficult, because they're always having a worse day than us. If there's a code, we drop what we're doing and go help. Some questions are less clear. What tasks are okay to leave for the next nurse? How do you handle a patient or family member who doesn't treat you with respect? If the patient needs more pain medication, or their blood pressure is low, or their most recent blood gas shows an increasing acidosis, who do we talk to? More difficult still- what do we do if we talk to a provider and disagree with their plan? How hard do we push? How quickly should we escalate?

New nurses have to synthesize all of his new knowledge and experience to make decisions in real time. Some decisions aren't time sensitive and can be debated- should I turn the baby to the other side or let them sleep? Is this endotracheal tube tape secure enough or should I re-tape it? Many decisions are more critical and cannot wait. Should I call the doctor about this low blood pressure, or do I need to do something right now? Will this heart rate come back up when I give a few breaths with an ambu bag- or do I need to start chest compressions?

Then, slowly, surely, they put it all together. They assess and intervene and make quick decisions and perform necessary skills confidently and correctly while calming anxious parents. While calling the doctor and the blood bank and the lab. When, unpredictability, things change. A very sick kid at a different hospital needs to come right now. A post-op won't stop bleeding, and his chest needs to be opened emergently at the bedside. They do it when there are not enough nurses, and there's hardly time to think before rushing off to the next task. These new nurses handle it, and with each new experience their skill and competence grows. They have learned so much, and they are not the same. 

They go home, and they wonder if they did enough, and their families ask how work was. "Fine." They say. “Busy, but fine.”

Nurse thoughts by Jacqueline Bliven

Something they didn't teach us in nursing school is that we would suffer some form of post-traumatic stress. Everyone tells you its emotional and stressful but no one can really prepare you for that. For me, it's not when I have a "circling the drain" patient. I have a sense going in that this patient may or may not survive, so I'm always prepared for it. You titrate the drip, you analyze blood gases, you add new pressors...It's what you expect for that day after receiving report. What you don't expect is when you have a "walkie-talkie" who just dies. 
No one tells you that for days and weeks after, you will analyze every single thing you did for that patient that day. Did I miss something critical on his labs? Should I have pushed the doc harder to intubate? If we had brought him into the ICU sooner, would it have helped? Even though we didn't know this person until that moment, no one tell us that we will grieve for them as well. 
The fact of the matter is, people die. Every day. We can only do so much. We can intubate, push for that central line, give the potassium, hang the levophed and the neo and then the vasopressin. But it won't change the fact that it has limits. Just like we as caregivers, have limits. So it's important for us to take the time to take care of ourselves. Take the mental health day if needed. Have the drink after work with your co-workers. They are the ones who totally understand what you are going thru and who ran to your room with the crash cart and started bagging while you were giving CPR. Nurses are vital to our society so we need to be our best to keep going with what the unit throws at us that day.