In nursing, you learn to take the good with the bad. I’m starting to think there must be a lot of bad in this profession, because there sure is an awful lot of good. (Do I mean that the other way around?)

I’m talking about the best part of my job. The days when you know you made a difference. The weeks when the continuity of care is absolutely perfect and seamless, and you see a guy from start to finish, from sickness to health. The days when they look in your eyes and say, completely genuinely, “I just talked to Jesus and he said to tell me is an angel standing in front of me right now.”

I met a patient that I never, ever want to forget. Just yesterday, I cried because I feared the worst, and was ready to throw in the towel. Today I cried for a completely different reason. I knew I made a difference. To this patient, I got to be the nurse I had always dreamed of being: smart, compassionate, realistic, honest. The one with the answers, the one with the pain meds, the one with the time to listen, the one with the ability to go a little further. I was the one who sat down with him when he was terrified. I was the one who worked with the family. I took care of him on the worst day of his life. I was the one he will remember.

This is a lesson to student nurses everywhere who believe that the fun, caring, listening, counseling, relationship-building part of our job stops when we graduate and take on “real” responsibility. I admit that there are days (read my previous post) when I feel very unable or unqualified to provide good care. But then, there are the days when you know you were in the right spot at the right time, and were exactly what someone needed. And those days make all the other bad ones seem very insignificant.

We must never forget that we often see people on the worst day of their lives, and we can’t judge them for that. It’s an honor and a privilege to be part of their story. Sometimes I can’t believe they pay me for this.

It’s a damn good thing I didn’t post anything yesterday because it would have read something like this:

I think I might have killed my patient with a gigantic wad of rookie mistakes. Calling my boss in the morning to quit. Considering a career change.

Seriously. I was so overcome with the weight of this experience that I almost vomited on my way out of the hospital.  I then proceeded to sit in the parking lot and cry for 15 minutes. I then drove home, sat in the garage and cried some more, at which point I went upstairs to bed, cried some more, had my husband talk me down, went to sleep, woke up every hour with a horrible, sinking feeling, then got up the next morning, eyes very nearly swollen shut from crying, cried on the way into work, and sheepishly showed my face on the unit once more.

Did I overreact? I don’t really know. I didn’t kill my patient. Quite the opposite this time. In the end, I was labeled “conscientious” by the nurse I reported off to the previous night. But I will never, never forget that feeling of absolute, ultimate responsibility to my patient and my co-workers.

It was my first really sizeable, scary-as-shit type of event. My patient developed a pulmonary embolism with all the classic, very sudden, very extreme symptoms, including his own verbalization of the feeling of impending doom. In the process of figuring this out, all of the things I had not even realized I had forgotten, came to light. That’s what made me want to puke; the thought that had I done a few things differently, I could have prevent the outcome. Silly, huh?

I believe part of my hysterical reaction (which, I am proud to report, only took place AFTER I left the hospital) was due to being absolutely scared shitless, on top of being tired (end of my 3rd twelve hour shift,) on top of being new and stressed out and having a very sensitive nursing ego to begin with. Does the reaction get any easier? The longer I stay in ICU, the higher my chances of having another patient with a PE, right? Or any other type of life-threatening complication, for that matter. While I feel that I handled the immediate situation well, I will have to learn to quell my mind at the end of those types of days.

I’ve read lots of stories of new grads hating their jobs, feeling nauseated, being unable to sleep, and having relentless crying episodes. I never, ever thought I would get to that point. As a matter of fact, I love my job, but this was the worst day at work I have ever experienced. And it only took 1/2 an hour.

I (think I) write a lot about happy, touchy-feely, successful moments in the ICU. I do try to keep this blog mostly positive, because I generally hate, hate, HATE negativity. (Ha…?)

I made the mistake of going to work with a bad cold, thinking I could tough out a 12-hour shift. :::laughs hysterically::: I was keeping my fingers crossed that the Nursing Gods would have mercy on my soul. Here I was taking one for the team, knowing that they were understaffed already due to previous sick calls. You heard it here first, folks:

The ICU takes no prisoners!

I had the busiest assignment I’ve had since being off orientation.  (Read: not having a preceptor to correct my missing details, remind me what I’m forgetting, etc. etc.) Although I did manage to take a lunch,  I never left my end of the hallway. Okay, I peed once. I know there are some who would consider that a luxury. Maybe not so much when you’re simultaneously trying to diurese the sinus infection out of yourself…

Adding to my complete and utter lack of time management and attention to detail (I partially blame it on hypoxia related to blocked sinuses…my first mistake,) I also felt completely incompetant when it came to “big picture” stuff. Even when I thought I was seeing the big picture. I wasn’t.

To be frank, I’m used to being pretty good at most things that I do. If I’m not good to begin with, I enjoy being able to catch on quickly (or else I just drop it and move on…) I like to exceed expectations. A few months ago, my preceptor told me I was “right on track.” I actually got upset at myself for not being ahead of the game. Silly, huh? Just  to give you an idea of how my brain works. I think a lot of ICU nurses are like this, and I think that’s part of why orientation and especially coming off orientation can be so difficult. Nothing but time; lots and lots of time, will teach you to be good at this game. And sometimes, not even that will do it.

We’re a teaching hospital, and thus, every specialty and every person with a Master’s Degree has implemented some sort of “patient rounding.” (At least it sometimes seems that way.) Sometimes it feels masturbatory, but mostly, I really appreciate the input from the specialists. Really, I do. However, today, on the verge of tears basically all day, it was all I could do not to leave a Caroline-shaped-hole in the wall after the latest group of “rounds” came, examined my patient, then pointed out everything that hadn’t been addressed. I decided that because I couldn’t possibly impress them with my patient-care skills, I would instead impress them with my ability to accept criticism. Sigh.

Criticism is one thing, but I would so much prefer we do it behind closed doors. One of the topics I’ve been meaning to address on this blog is the fact that I’m one of the youngest nurses on our unit. The 2nd youngest, in fact. I believe the baby is 21, and I, personally, could never imagine being an ICU nurse at that age. (Frontal lobe aside, I was nowhere near emotionally ready…hell, I’m still not.) Anyway, being one of the youngest nurses treating mostly older patients has, at times,  really jacked with my confidence.

First of all, I struggle everyday to gain the confidence of my patients. I’m a small-framed person with a pretty young face. It’s not a huge leap for a 70-year-old to wonder if he’s getting the shaft with the infant nurse. I try to imagine how I would feel if some fresh-faced -whipper-snapper wanted to tell me about my lung sounds or my most recent bowel movement. It would be weird.

Not only that, but nearly everyone in the hospital has more hospital experience and more importantly, more life experience than I do. Thus, it becomes extremely difficult for me (sometimes) to question orders or actions. If it’s not medically appropriate, there’s always a small voice inside of me that thinks that sometime, in someone else’s vast life experieince, they know the best solution. My only saving grace is that many of the newest interns are approximately my age, but many times, they don’t know the answer. Anyway, I doubt myself like this all the time.

All this explains why it is very, very difficult for me to accept any kind of defeat in front of my patients and/or their family. I am very sensitive to losing their trust. I feel I have a lot to prove. Today I had to accept lots and lots and lots of defeat.

However, good nurses are humble.  When I can’t give when I consider exceptionally good patient care (and really, I don’t like to accept anything else, I can still be humble, open to feedback and suggestions, and always the one that admits when I’m wrong.

I knew a long time ago that this was the hardest job I’d ever had. Today kind of royally sucked but I can’t deny it was a learning experience, just  like every other moderately bad day. I’ll never underestimate my sinuses again, for starters, staffing be damned. It.was.not.worth.it. I will continue to learn from my mistakes, and even moreso, from the things I just plain forget. I will take full advantage of our patient rounds of all sorts, because I truly believe they aren’t trying to be rude. I will continue to take fewer things personally. And I will keep trying.

I know there will soon come a day when I feel righteously incompetent. Hell, there’s a piece of me that feels that way every day at work, but I also feel like the last few nights brought me a new confidence.

Brief recount: I was on orientation for 6 months, went on vacation for almost 3 weeks, and came back officially unleashed on night shift. I had been feel very ready.

The first 4 nights were slow. I basically had one, floor-status patient. One night I had a guy on Q6 vitals who slept. That means that in 12 hours, I checked his vitals twice. TWICE. Okay, due to my own insecurity, I still found it difficult to get too far from his room, and I checked his monitor visually about 10 times a minute (that equals 7,200 times I checked his vitals in a 12 hour shift, which is probably about right.) Still, even by my own account, it was slow for a couple days.

And I had kind of settled into a slow routine. :::insert hysterical laughter:::

Then all of the sudden, our unit got very, very sick. It was like, vent world. Every guy with a tube, or at the very least, bipap. Including mine! I got my first vented patient the other night. Having settled into a routine, I nearly shat when I realized who my patient was going to be (because I had watched him the night before, trying to self-extubate for two shifts straight.)

What’s the point of all this, say you?

New nurses: you can do it! My day has come. Never again will I have my “first” vented patient. Not only that, but I like to think I did a pretty damn good job with him. Turned him frequently enough to get rid of the ensuing redness on his butt. Deep and oral suction Q2. HOB at 30 degrees at all time. All his scheduled meds on time.

Sigh. I also felt like Nurse Ratched with my magical, ativan-giving carpujet.  Oh well. I’d want Nurse Ratched’s cocktail, too, if I had tube down my throat.

I emerged from the hospital 12 hours later feeling…exhausted, relieved, smarter, stupider, and ready for bed.

I did it!

I’ve been in Europe for 2 weeks. Just another bonus of being a nurse: paid vacation! (5 weeks of it, actually. Woot! Government perks.) We got home last night, and I had 15 hours of plane rides to do some thinking.

I’m coming off orientation on Tuesday night. It’s a nice little “welcome home from Europe!” and “happy 27th birthday!” present. The reason I hadn’t been blogging prior to vacay was, well, honestly, I had started to feel a little stagnant and frustrated, and was trying to just “get through” the rest of my precepted work days.

So, yes. It finally happened. I got tired of being on orientation, just like everyone said I would. Admittedly, 6 months ago I would have laughed in your face (and often times did) if you suggested that my day would come. However, sometime in July or August, I started to feel like an obstinate teenager. I felt irritated when my preceptors, just trying to help out, would do things like dump urine or do a fingerstick or just generally help me out,  in the same way I would help them if they were busy. I wanted to do everything. I got secretly pissed when they would communicate things to the doctors, instead of letting me have the conversation. I felt ready to do things “my way” and was tired of being told what to do all the time (not that that will ever completely stop.) Basically, before leaving for 2 weeks, I had been feeling very, very itchy to be “released.”

That’s not to say that I feel confident in every situation. I don’t. But I can handle basic care, some more emergent situations, communication, and most importantly, I have a much better idea of when I’m in over my head. I’m also starting to get a sense of when things just aren’t “right” although at this point, I’m not aware of my gut instinct until after it has already been confirmed. I’m just realizing that I have it, in hindsight only. It’s a start.

It basically happened on my last 2 shifts before vacation. On Thursday, my preceptor went home sick 8 hours early, so I went “on my own” (with backup) after that. On Friday, there was a staffing issue, so although I had floated to the medical ICU where I am much less comfortable, I took one patient on my own (again, with backup, but she had her own assignment) again. It was a simple, easy day, thank god, because I felt like a complete and utter fish out of water. However, at the end of the day, when other patients started crumbling, I was still in control of my own situation enough to help them out.

And yesterday, as I sat on a plane for 15 hours, I had some time to reflect on my orientation.

It’s been awesome, that’s for sure. Due to the acuity of our patients at the time, I was able to get a LOT of different experiences; in fact, I saw some stuff that a lot of experienced nurses hadn’t seen in years, and some never at all. I couldn’t have asked for more variety. Specifically, when I look back on the last 6 months, 3 experiences immediatly pop into mind as being moments that changed me.

The first experience was in June, about eight weeks after I started as a nurse when I was unexpectedly punched in the sternum by a paranoid schizophrenic. Only now, months later, am I beginning to realize what an impact that made on me. I was traumatized, plain and simple. Until then, nursing had been nicer. My patients had, for the most part, really liked me. Hell, this guy did, too; he was singing “Sweet Caroline” moments before the assault. Since then, I’ve been much more cautious around patients. I am constantly aware of their actions and my body positioning. I get unusually anxious when patients start to become anxious. I am still learning to deal with my own desire to medicate their anxiety and achieve results immediately, rather than use non-pharmacological (and generally more useful) methods, first. I also hold a bias against people with the same diagnosis, but I’m aware, working on it, and trying hard not to let it affect my actions. Interestingly enough, I realized that my co-workers care. There was an outcry of support from not only management but the rest of the unit, and even people working on different floors. I was supported from the beginning. In a way, being punched made me more a part of the “club” than ever before.I know I’m surrounded by people who will be there, and that idea alone gives me a little bit more confidence in myself.

The second experience was in August. My preceptor and I took care of the sickest patient I have ever seen in my life. I can’t think of a piece of medical technology that wasn’t used on this guy. From strictly a medical perspective, he was a textbook. The experience could have ended there. Amazingly enough, I was lucky enough to take care of him and only him for my entire 2 week rotation on nights. Also ironic was the fact that he was my first admit to the unit about a month before all this. I knew the family very well, and had just shown up for work the night they decided to withdraw care. I was the one the family wanted. I was the one who pushed the morphine, bolused the fentantyl and versed. I was the one who was with the family when he died. It took several weeks for me to come to terms with how it ended, and to finally allow myself to feel like I did all the right things. Now I see it as an amazing growth experience, and I often find myself thinking of him and his family and saying “thank you.” As I wrote in the post, it was the moment I went from being a new graduate to a nurse.

The third experience happened in late August, just before I went on vacation. Basically, it involved tangling (and I do mean tangling) with a surgeon about a patient’s wishes. In the end, the patient was allowed to die on his own terms. I wish I had been there during his final moments, but I feel like it was my conversation that allowed this man to achieve his peace so quickly.  I recall that by the end of the day, I felt more stressed out than I had ever felt. I couldn’t sleep for several days after this event. I hate conflict, but I learned that there is a time and place for it. I think it was the first “real test” after my emotional transition from new graduate to nurse. Although there are things I wish I would have said differently, in the end, I would not change much of how things were handled. Given a variety of situations, I wasn’t given a lot of choice. It all sounds very vague, I know, but the point is, I realized that as a nurse, our most important job is doing the right thing. This situation made me inherently more aware of morality and ethics, and just obscenely aware of the nurse’s job as patient advocate first.

I have learned many lessons, some not so nice or pleasant, and I haven’t always been right, either. Take, for example, the day I gave an 80 year-old a second degree burn after placing a homemade hotpack on his arm in order to find a vein. Shortly thereafter, I also gave him an enormous hematoma when I blew the vein that I couldn’t find in the first place. I gave a colace to a woman with a NG tube and had to spend the morning listening to her trying to gag it up when it got stuck on the plastic tubing. I very nearly gave a patient an embolus when two medications in his IV mysteriously precipitated into a million tiny pieces of cement. (Thank god for IV pump alarms.) I spilled almost the entire contents of a CVVH bag on my shoes, dropped a patient’s Starbucks coffee all over the floor, and gotten squirted in the nose by a plugged-up J tube, not to mention the shower of normal saline after I forgot to release the pressure on the a-line pressure bag when taking the set down. I’ve given enemas that went all over the bed, and dumped the contents of a foley on the floor while trying to measure the output. I’ve made lots of stupid phone calls and asked lots of stupid questions.

All this in just 6 months. Here’s to what the next 6 months hold! And the 6 months after that, and after that, and after that…

I can’t write to much about the incident that has inspired this blog post. To briefly sum things up, I have managed to piss off a lot of people over a decision I made for a patient who was finally able to die on his own terms.

Doing the right thing is rarely easy. The most important job we do is not chest compressions, ABG analysis, or vasoactive drip titration. (Admittedly, though, those are really important, too…) Nurses are patient advocates. End of story.

It’s rare for me to encounter direct conflict at work. For the few years in between my first college degree and nursing school, I floundered at a lot of jobs, and mostly tried to keep my head down while I figured out what I really wanted out of life. I can only think of one other real confrontation I’ve had in the past 5 years, and it was really stupid and pointless compared to this (just another reason I got out of Corporate America.)

For the past few months as a new nurse, I’ve also been trying to keep my head down, not cause waves, and do my job to the best of my ability. I’m one of the youngest nurses on my unit, and that combined with my lack of experience in nursing (let along the ICU) makes it difficult to have any confidence in my work, whatsoever. I’ve often thought that those who know me best (as painfully blunt, assertive, and somewhat rough around the edges) might be completely stunned at the Caroline they see at work, who is pretty much the opposite of all those things.

This incident has given me the first real boost of confidence I’ve had since I started working as an RN. There is no doubt, not a single, freaking doubt in my mind, that I did the right thing for my patient. I knew I was right from the beginning. I knew I was right when I heard that he had finally passed away.

So why can’t I stop thinking about it? I’m hoping for a little closure this week, but I’m also stressed out by all the anger over the incident. Doing the right thing is rarely easy.

Now that I’ve been a nurse for, I dunno, a few months give or take a few days, I admit that my scrubs are actually kind of wearing out. I only have a couple of pairs, and I try to rotate them equally, being the anal, obsessive-compulsive ICU nurse that I am. Some of them get blood on them and have to be completely pitched. Some have bleach wipe stains from whatever c-diff positive patient I took care of that day. Some are pilling with multiple washes. And don’t even get me started on my scrub pants. It’s a constant battle.

Enter scrubsgallery.com.

They really have evolved since they started advertising here on brainscramble o so many years ago (Ha.) The selection continues to increase, and they continue to add name-brand stuff that some of us are snobbish about. That’s in addition to shoes, lab coats, and other accessories. (And did I mention the whole “satisfaction guaranteed” and “free shipping on orders of $29 or more” thing?) In fact, they just started offering my favorite brand of scrubs: Cherokee Touch. I find this to be one of the more rare brands that doesn’t leave me looking like wrapping paper or a paper bag. And the pants somehow manage to be a good combination of not riding straigh up my leg when I sit, nor falling straight off my butt when I stand. I’m cool with that.

Please thank scrubsgallery.com for their continued support of this blog by checking out their immense selection of stuff!

At the beginning of my orientation as an ICU nurse, I was completely overwhelmed. By the time I got home after a 12 hour shift, I could scarely form a complete sentence. I never thought about work after I left; my brain wouldn’t tolerate it, and at that point, I hadn’t taken enough responsibility to feel the “real stress” quite yet.

My, how things have changed! This job has been full of amazing, difficult transitions. And I’m barely 6 months in! (There are times like this that I am thankful that I’ve actually had other jobs…I have a vague idea of what is “supposed” to happen in new job transitions.) Although I am technically still on orientation, my preceptors have backed way off. I’ll be on my own before I know it (within weeks, actually,) and everyone is trying to give me the fullest experience possible, I think. Therefore, I’m as close to taking patients entirely on my own as I can possibly be, without actually taking them on my own. Additionally, the unit has been very, very busy lately. We certainly go in phases, and at times it feels more like a step-down unit than an ICU. Now is not one of those times. Plenty of sick patients for all to experience and learn from. Lots of vents, lots of CRRT, lots of drips to titrate. A fun and stressful time for all.

I’ve had lots of fun titrating all kinds of drips this week (the first time I’ve done this without much supervision at all,) as well as my first experience with an emergent intubation. (I tried to jump in and get my hands dirty, which resulted in me missing my first ABG stick in front of God and everyone. Seriously. Love it.) It’s been a(nother) week of amazing learning experiences, and I absolutely love my job for this reason. The best part is, the team I work with has continually reinforced that I will never be alone, and that they will always make themselves available in any way when the sh** hits the fan. (So here’s a big shout out and a thank you to our awesome team: nurses, nurse interns, interns and residents, fellows, respiratory therapists, pharmacists, educators, ward clerks, managers…geeze, I hope I haven’t left anyone out because we could never do this job without each other.)

That being said, the more responsibility I take on, the more stress I tend to bring home. After a busy day, I spend the car ride home running through my day, deciding what I could have done better, what went really well, what questions I have. I mentally dissect the disease process and the pathophysiology, the drugs I gave, the alternatives, and the worse-case-scenarios. However, I get hung up on my limited knowledge base. I have millions of questions. I’m finally to the point that my desire to know more and my brain’s ability to handle it have actually coincided. At the beginning, I had no brainpower left when I got home, so there was no way I could have cracked open a book. These days, my brain is starting to crave more. There are times that I actually can’t fall asleep until I get out of bed and research some of my questions.

But I’ve never been one to want to bring my work home. I don’t like the way the stress is starting to invade my life. I don’t like that I can’t shut my brain off. I don’t like that I am now tempted to spend my free time doing work-related studying. I don’t know where the boundary is.

The only thing I know how to do is to find more hobbies that take my brain out of the ICU, and maybe add in a little bit of studying when it’s absolutely necessary. I downloaded some super cool Surgical ICU podcasts that I can listen to in my car, for example. I read a couple of articles here and there, especially on the surgical procedures we see in our unit. When I see something interesting at work (lately it’s been septic shock, ARDS, and a lot of pulmonary stuff) I read about it when I get home, without going completely overboard. I’m still limiting my study time, because I’ve never wanted to be the person that cannot talk about anything but nursing. Admittedly, I still have my days. It’s an ongoing process.

When I’m not studying, I’m working hard on finding activities that truly take me away from work. Exercising helps a lot, really intense, gut-wrenching exercise like Crossfit. I also like sewing, shooting guns, and today I wrote a motorcycle for the first time, which was an absolute blast. We camp during the warmer months, and I find it very easy to relax and sleep when I’m in a tent with my husband and my dog. We also love to travel. It’s hard to think about work when you’re literally thousands of miles away from it.

This whole ICU Nurse thing is a major process. Like I said, I’ve never wanted to be the nurse who can’t talk about anything but nursing. However, when I’m at work, I want to be as strong as I can, as confident as possible, with the best knowledge base. My goals are slowly becoming more clear, and I’m starting to have a better idea of where I might like to be in 5 or 10 years. Without being specific (because I’m  still mostly unsure) I think it will have something to do with having all those things: knowledge and confidence. I’m working on it, but I hope to not let my goals interfere with my life at home.

Some time has passed and now I can write about the experience. There are so many firsts as a new nurse. I’ve now scratched a big one off the list. I’m a different nurse, now. I feel as far from being a “new grad” as I’ve ever felt. I feel older, more mature. Yes, something definitely changed that night.

The family requested me.

It happened quickly. My shift had barely started before the tube was pulled, the pressors were off. Blood pressure immediately dumped, eyes wide open for just a few more minutes. There were immense amounts of tears, wailing. Family’s. Mine. Silence. Rock music. Pain meds, then some more pain meds, then a bolus, then some more pain meds. Then another bolus. Then peace for the patient. Achieved quickly, in less than an hour. Peace for the family, too. They told me they saw his personality, felt like they got to say goodbye, felt that he knew they loved him.

I did my job.

And the palliative care nurse, who had been a silent presence in the corner of the room, told me, as she walked out with the family, “Never allow yourself to stop feeling. What you did is an art.”

I did my job.

What a job it was. Now that I’m a little removed, and I’ve hashed it out a few times with my husband, other nurses, other friends, I can recognize it more for what it was, and I feel more at peace with how it went. It was one of the most difficult, transformative things I’ve ever done. But such an absolute honor to be included in the transition from life to death, to be requested by the family, to be there to support them, to be part of their story. Wow.

I guess I’m ready to come off orientation, for reals.

Last night I was chatting with a friend about all the things I’ll be doing on my 2 week trip to Europe. Canyoning, bungee jumping, possibly sky diving at some point in the near future. I also discussed my new love of extremely spicy food, my even lower tolerance for boredom, my need for at least an hour of extremely intense exercise every day or two, and a demonstrated increased and constant level of multi-tasking.

She suggested that being in an ICU has “flipped a switch” in terms of what activites are really stimulating to me these days. I thought about it…is she right? What do other nurses think of this?

I do know that my perspective has changed. “Sick” takes on a whole new meaning after you’ve had a patient with a pH of 7.1 for the entire 12 hour shift. The idea of “power” changes drastically after you’ve pushed a button and made someone’s heart beat a little faster with a powerful medication, or changed some numbers and decided exactly how much fluid is going to be removed from their body each hour. The ICU is a constant buzz, a constant stimulator, a constant power struggle. For someone like me, that’s a good thing. But I do wonder if it’s forcing me to find new ways of stimulating myself outside of work.

I have to get rid of the stress, somehow. Intense exercise (crossfit, which leaves me panting and gasping on the floor almost every time) seems to help a lot. I don’t quite understand the need for extreme sports. Perhaps now that I’ve seen death so close and so daily, I find myself willing to push the boundaries of my own life a little bit more?

Thoughts?