Wednesday, October 24, 2007

PICU + NICU + forgetting to pick the kid up from school = sobbing in shower

PICU kids were:
one month old boy with hypoplastic left heart, adorable smile, and hard swollen breasts (they were doing an MRI to find out if there was something on his pituitary?) Ventilator, central line in jugular vein, continuous infusion of fentanyl, methadone q6h. Mom and dad cannot come to visit often, and are a little checked out about this child. The nurse I was following (who I had really liked up to this point) described dad's tattoos and said "Some people should just be sterilized, you know."

five month old girl with metabolic disorder. ventilator, concern during the shift that her BP was rising, and that her end tidal volume of CO2 was getting too high. Continuous infusion of fentanyl. Attended a family meeting in which parents were informed that her problem was a mitochondrial defect, and that there was essentially no treatment available, and did they want to call and gather the family now or wait a day or two on the ventilator?

a boy with necrotic pneumonia in right lung, lots of staff in and out of his room all shift, trying to get a tube into his left lung to focus ventilation on that one. On an oscillating vent that was giving 400 breaths/minute.

a teenager who was paralyzed, wearing hand splints and Prafo boots, with a trach. She wanted to be moved up in bed, and so her nurse asked my nurse and me to help, and off we troop. Her nurse wanted our help to turn her, so that she could see her back and assess for skin breakdown. The nurse discovers stool in her brief and so we all help change her and clean her.
Then her nurse wants to change and clean the inner canula of her trach, and asks me to help. Sure, I say, desparately trying to remember the procedures from skills lab. That was the worst possible set-up for trach care I've ever experienced.
The bed was too low,
the patient didn't want us to take her pillow away, so her chin was down and resting on the vent tube,
the nurse didn't follow the inner to outer and throw away process that I'd been taught for cleaning around the stoma,
the patient is trying to communicate with me by eyeblinks and mouthing words,
there's clearish bloody stuff coming from around the stoma behind the trach, and
I can't get the velcro of the trach tie back in.

after the nurse puts the new inner canula in, the patient's sats start dropping after we get the vent tube back on. Like 98-to 87- to 74. She tells me to grab the bag behind me, and squeeze. Oh my god, I think. Squeeze. What am I doing, I think. Squeeze. Okay, back to 80, that's good. Squeeze. back to 94 and we put the vent tube back on, and she's looking at us again, and I'm not sure exactly what happened, but I feel like some sort of hero.

NICU: (nobody on pain meds here)
15 day old boy, 3180 gram born with sacral mengingocele, s/p repair. Two days ago, had a shunt placed from brain to belly to drain excess fluid. No IV access, foley cath from surgery that will be pulled later that day. He is the youngest of 6 kids, and has a 13yo brother who also has spina bifida. It was enough to make me want to take my folic acid right that second, even I never plan to get pregnant again. It wasn't until the end of the shift that I realized that his face really was all scrunched forward like that, it wasn't just because he was laying on his belly with his head turned to the right for the whole shift. Seven seconds into the shift, the nurse tells me to feel his head, and his fontanels. I'd call those full, but not bulging, she says. And here, these sutures, open wide is what I'd document for them. And when I say sutures, I mean the places where the bones of the skull should meet and knit together. I felt like I was touching his brain through his skin. He had never exhibited movement or tremors in lower extermities, no likelihood that he ever will. Mom is breastfeeding. Assisted nurse with cleaning and changing the stack of 4x4's under his butt that serve as diapers several times during the shift, positioning mom for feeding (which involves awareness of his foley tubing, ECG leads, incisions along his sacrum, incision on his head, no pressure on the shunt itself, no pressure on mom's c-section incision and 4x4s and pads under his anus to catch poop). He had a little plastic sheet (nurses called it a mud flap) stuck to his butt to prevent any feces from getting near incision site. I advocated for turning his head to the left, according to Neurosurgery's orders, because it seemed that his neck was starting to show some resistance and his opposite hand was cool and the pulse weak compared to the arm on the side he was facing.

33 week GA baby born 10 days ago, 1818 grams. She looked tiny, but so healthy. However, an echo had showed that she has no pulmonary artery, and the only way that blood is getting oxygenated is because the hole between her two atria hasn't closed yet. cardiology is deciding plan for surgical interventions. Currently on prostaglandin to keep ductus arteriosus patent. Some history of necrotizing enterocolitis. Pt has been NPO since last echo, and mom's questions are all focused on when she will be able to take a bottle again, without much insight into severity of cardiac condition. Observed bedside rounds while mom was present, holding baby, and realized how little of what was said would be comprehensible. Tried to translate after rounds were over. Even nurse greeted mom with news that she had only had 3 bradys overnight, so that was good. Mom indicated no understanding of what 'bradys' were, and I said to the nurse, Do you mean that her heart only dropped three times over night, and it was happening much more frequently? Nurse realized why I had asked when she looked at the relief on mom's face, and adjusted her language afterward. Come to think of it, though, her heart rate dropped to below 90 several times during our short shift and I don't remember seeing the nurse document. Fellow in rounds seemed to think that the apneic episodes and bradycardia were SE of the prostaglandin, and there was an order to cut the prostin in half by the time I left the unit.

Observed a PICC insertion performed on a 26 week premature infant. No pain meds on board, or any evidence of local anesthestic used. When needle was inserted, baby (who was completely covered by sterile towels except for her elbow) jerked and curled toward the arm. Nurse stated that she did have fentanyl PRN on her MAR, but that she's never had opioids before and you want to avoid them as long as possible because of her fragile state.

How do you care for a person that you don't think should be alive? How does it change your care to know that this person's lifespan will be only weeks long and contain no joy as you know it?
If you believe that some people shouldn't be alive, is it ethical for you to be a nurse?

So, yeah, sobbing while the kid did homework. I finally got in the shower so that I could feel like he couldn't hear me as loudly. He was all worried - I think he worries that I'm going to hurt myself and he's going to have to do something about it - and I just said that I had a really awful day, and that I needed to cry some of it out. I asked him if he would give me a hug in a minute when I caught my breath. I love that kid.

The situation with the dishes and the house is not funny and quirky anymore. It's not sexy-messy. It's rolled right into calling Oprah for an intervention. When the kid was a baby and after my dad died, my mom would come over on the weekends a couple times a month and we'd clean my house. I wish that she still did that. I wish that I didn't wish that at 33yo.

randomly surfing at

I Took The Handmade Pledge!

Sunday, October 21, 2007


Why is Blogger offering to type in Hindi for me? Did I select something or is this some sort of blog worm? ah, never mind. I can't be bothered.

  1. i have a headache. likely because it is in fact quarter til two and my ass is not yet in my ridiculously comfortable bed, with the window open to ridiculously cool air.
  2. my tonsils hurt. like i've been smoking american spirits, which i HAVEN'T and so this sucks super bad. i've had right tonsillar megaly for about two years now, and at some recent visit, hopefully not my annual pelvic, it was deemed 'no big deal'. But it hurts. it feels like the nasal passages are inflammed? is that anatomically possible? I just want to figure out a way to squirt some warm water somewhere that will make it feel better! Gargle? Snort? Mouthful of it and breathe through my nose? flark!
  3. i have my first clinical in peds on monday. I'm terrified. this won't surprise you. more details below.
  4. i am contemplating asking the principal for a transfer to the cooler 2nd grade teacher from the asshole 2nd grade teacher. the risk in asking? that she might say no, and then I'd have to resign myself to dealing with the asshole all goddamn year and I just don't know if I work myself up to ask for this, and then I don't get it, how badly will that actually suck?
  5. I. must. stop. signing. up. for. things. Run for election on state Board of Directors of Assoc of Nursing Students? Excellent! work with LGBTQ folks on my side of campus? Great! Read with kids at my kid's school twice a week for an hour? Super, thanks for asking! Work on the World AIDS week planning committee? Okay! Go to the Global Health Committee meeting because it might mean inroads with the community health folks at the SON? wellll... Meet with SON folks about gay stuff? good idea, but is this the semester for it? sigh.
  6. i got a haircut today. i'm growing out the crew. shaggy surfer boy chin length here I come. in the meantime, I'm working on how to make it less fuzzy looking. the stylist said that using scissors, not clippers, will help. and smoothing serum. and i'm driving home, thinking, yeah, having it be all one color instead of salt and cinnamon might help, too. Who AM I that I wash my face twice a day, pluck my eyebrows, purchase and actually wear kitten heels, apply nailpolish, and consider dying my hair again? it's like a remix of the 80s. I thought I was done with all these femmey trappings! (also planning the breast reduction I want with my signing bonus. eep!)
  7. my dishes still aren't done. yes, it's been at least 3 weeks since I updated. i still haven't washed that lasagna pan and i only recently ran out of clean gladware, so I actually will have to do it now.
Peds Clinical
Get this - Summer was my first clinical rotation, right? Med-surg, adult health, GI floor, lots of ostomy bags and wound vacs. Tube feedings and such. I only had a pt with a NG the last day of the rotation, and managed to fuck that up by removing the old nasty tubing to the canister and throwing it away, gettting distracted on my way to the supply closet to get new tubing and getting called back to the patient's room bc he was nauseous bc i had left him off suction too long. i still don't get NGs.
So, after that 11 weeks of patient care, I had a week of finals, three weeks off for break, and then the first half of the semester was my psych rotation, where it's simply not a good idea to touch the patients. I did vitals on the unit one morning, and I took a BP for a man who was having a hypotensive crisis (with a seated BP of 72/54 and a standing BP or 62/42, he was sent back to his room to wait for the physician - thank you for the excellent example of how to NOT provide patient-centered, competent care). No direct physiological patient care in about three months.

My first shift in peds rotation will be in the PICU. I'll be there for only one shift. I'll go in at 9a, get info on my patient. This is at a hospital where I've not worked yet, so I have the access codes for the computer, but have never used them. I'll come back at 1pm and work til 7pm with this patient and a preceptor, whom I've never met. I was thinking that this was fine, because it was just going to be observational, right? They won't let me touch really sick kids, will they?

Then I read this paragraph* in the syllabus, while looking up what to wear. It took me ten minutes to calm down and realize that I won't be in the Peds ED tomorrow, that's not for another two weeks. Then I started to freak out again when I realized that the only IV that I've ever started was on my lab partner, and the canula kept sliding out and I tried to shove it in with my finger... I'm all about the psychosocial support. I'm *very* supportive. Drawing blood? Fuck that. I gotta go.

Okay. Time for bed. I'll be up in a couple months, when it's winter break.

*Clinical Experience: The student will spend time in the Pediatric Acute Care in the Pediatric Emergency Room setting, where he/she will participate in caring for acutely ill children. Included will be nursing interventions such as triaging patients; assisting with procedures such as assessments, IV starts, blood drawing, teaching families; and providing psychosocial support to children and families.