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.


Emory Student Midwife said...

Sounds like it is tough seeing all these babies and children. I'm doing my peds/maternity rotation next semester, so I'm sure I will have some similar stories come January.

Erika said...

HLHS mama here. I would take that little boy on as my own in a heartbeat. It makes me so sad when parents just can't cope enough to make sure their little one knows he's loved.

I give you so much credit for what you're doing. I can't imagine what a hard job it must be - our nurses at Boston were simply amazing people. Good luck!

GingerJar said...

You know, crying isn't necessarily a bad destresses...and it proves that you still have empathy and sympathy. The little sick ones in NICU make you appreciate the really healthy one you have at home. So many of the nurses get so used to the pain and death that they don't seem to care at times. Please, continue to care! That's what makes you the best nurse material in the world.

that big girl said...

erika - wow - congrats on mr. monkey's words! We had a guest lecturer come and speak about her grandson's journey with HLHS. she said that one of the most supportive things that she heard was in the NICU from a nurse - "Some of these kids do really really well."

I had a chance to go visit my boyfriend in the PICU - he's still kicking around and charmin all the girls, but had a rash of some sort and they were a little worried.

It's a scary thought to consider how all that time in the PICU crib alone shapes a kid's development...

thank you so much for the comment - I was feeling like a loose kite when I wrote this and it's nice to have a contact.

that big girl said...

gingerjar - I guess that's the root of most of my fear; I would assume that most of the nurses that look to me like they don't care didn't start out trying to not care, and I don't know how it happens, or if there's warnings and I can clear the decks if it happens to me, or what. It's a mystery. A big scary mystery of how nurses become assholes. (and if I already act like an asshole a good 30% of the time now, am I predisposed to nursing asshole-ery?)

GingerJar said...

You probably will be a great nurse...sometimes need a little detachment to get the job done. I love spending a few extra minutes in each of my patient's rooms...just getting a feel for their personality ... you can figure out the ones that just want you to leave them the hell alone (give meds and scram) and the ones that are a bit more needy and need a little more reassurance. I still (even after 7 years) have trouble with the dying patient...but (unfortunately) have gotten better with practice...since I work a post Cardiac Step-down unit. I didn't finish nursing school until I was 43...and I love my career. You will love it body works as hard as you do for the grades and juggling their homelife for a job they won't love! Good luck