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 etsy.com

ouch.

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.

research, addiction and other things I am angry about today.

My friend told me that I was very distractable today. I didn't really listen to her because I was trying to figure out how to get one of those cute little KEEN shoe keyrings... I also wasn't listening because I'm jealous that she gets to take her Master's degree in Research and roll out at noon on Fridays, whereas I have to remain on campus for at least three more hours, and possibly as many as four more hours. It's just horrible.

I turned into that back of the room asshole today in Research. After one prof read the damned slides verbatim to us, and offered nary a word of additional information or real explanation, another prof flashed a list of journal article titles on the screen and asked us to tell whether they were primary or secondary sources, and if they were empirical or theoretical. From the title alone.

I get that if it says review, it's secondary and if it says exploring or study, it's primary. But for one example, she said that it was not theoretical although SoandSo's Theory of Anywho was in the journal article title. We murmured and buzzed like the courtroom of Matlock when Andy Griffith makes his startling revelation, and she said, yes, it's empirical, because SoandSo didn't deal with these other subjects when she developed her Theory of Anywho, and so this article is actually creating a theoretical model, but not dealing solely with the theory.

Um. Prof? I have a question. Since we haven't studied SoandSo, nor her Theory of Anywho, we would not have been able to reach that same conclusion. I personally am still not clear by what you are using as the definition of theoretical framework and theoretical model. Will this sort of question appear on the midterm that you keep alluding to in such vague and threatening ways each week?

sigh.

We had a guest lecturer in Psych today, talking through Psychopharm and fucking it all up.

Five minutes into the lecture, she said, in essence, that if someone becomes tolerant to a medication, they are addicted to it, and that addiction and physiological dependence are one and the same*. When several of us in succession raised our hands and explained that that was directly contradictory to what we had learned in Pharm and Adult Health and Fundamentals, that the bigger concern for the general population was untreated pain due to a fear of addiction, that addiction is a pattern of behavior motivated by craving the euphoria effects of a substance, not the physiological tolerance that most people develop to drugs like narcotics.
She responded that we should challenge our professors and question that teaching (and I'm thinking that is a ridiculous statement to make, when although a Guest Lecturer, she is still a lecturer and should have some concept of the rest of the curriculum of the program, especially before she rolls in and starts talking shit).

To add insult to injury, this class is a combination of second semester accelerated students, third semester traditional 24 month students, and last semester traditional students. So, the seniors are just so over our questions, and one of them eventually raised her hand and said, all snotty, Can we just move on? It seems that we're not getting anywhere with this. I cannot imagine saying such a thing to a professor. It's really amazing to see entitlement in action at 10am on a weekday.

Ridiculous Guest Lecturer also told us that she is more likely as a nurse practitioner to adjust someone's lithium levels based on their experience than based on their levels. Sure, sure, know the levels for the boards, she says, and yeah, yeah, hydration and I&O's are important. but I think that a tremor is a better indicator of toxicity than a level over 1.2.

In good news, I got a voicemail from the lady with the testing company that administers the Nurse Aide Certification test that I took and failed on Saturday, and I think that she hinted that upon review, I did, in fact, pass it. I don't believe shit until I see the score report. I dare them to tell me that I have to spend $22 and an entire morning answering scenario questions about what to do when you find a patient masturbating and how to properly handle a patient who doesn't want to eat breakfast and throws it at you, whether to abandon the patient you are transporting when a fire alarm sounds and my very very personal favorite (I actually laughed out loud when I read it!), whether it's a good idea to respond to a patient touching you inappropriately by touching him appropriately and asking him how he likes it?

A busy day tomorrow:

• eggs from the happy chicken guy at the farmers market at the crack of dawn before he sells out, because they really do look and taste sooo different and better and because he has a photo album for the love of pete, a photo album, of his chickens and the Great Pyrennes who herd and protect them from predators.
  
• Pride parade with the kid, bouncing between the gay parenting folks and the gay students from the university.
• haircut for the kid, because school pictures are Tuesday and he's a tad shaggy. Incidentally, I'm thinking of growing out the crew cut and going for the chin length shaggy surfer cut that the boys are sporting these days. I love it.
  
• museum to see them feed the bears and give Kongs to the lemurs
• home to remove the clutter that has accumulated, and police the house for shoes, trash, and stray tumbleweeds of cat fur.
  
• spend AT LEAST an hour on notecards for peds, since there's an exam next week, and another hour reading the material for research, which may enhance my experience in the course a bit.
  
• make brownies and watch the disk of Scrubs that Blockbuster so thoughtfully mailed me today.
  

*I thought this phrase was - one in the same - for many many years.

still thinking...

Minority Midwifery Student's got me thinking again.

Our Research prof was talking last week about how she had this radical discovery after her first focus group in the Latino church. She wants to know if cardiovascular interventions for Latino folks like education on risk factors and exercise and whatnot are more effective if they are sponsored by the church. The church members interviewed said - We are glad that you are here and wanted to ask us questions and listen to what we say. And so we really feel that we have to tell you that we don't have time to talk to you about cardiovascular health and diet and exercise. We have enough other things to worry about - like when to buy food, keeping the car running or enough money for bus fare, and making sure that someone can always be home with the baby."

I'm getting all these messages lately that I'm not listening to what I am hearing. from newFNP, MMS, and my own District Health Action Committee that does not in fact want to talk about health disparities in the schools of my district, but would rather continue to advocate for compostable lunchtrays. I love the idea of corn-plastic cups, and composting lunch, and organic food for all school children. Get that Fast Food Nation guy in here right now for a sound bite. But also, there's shit going down that I would like to be working on, and instead I'm real busy jacking around.

I've been writing scholarship and election essays about how I want to work community health after I get my MSN, and after I spend a couple of semesters taking more conversational and health-care focused Spanish. But the more I edit those essays and really pay attention to what I'm saying, I realize that they are not reflected in my current day-to-day. In fact, I could be practicing my Spanish at the store up the street instead of driving past it to go the big chain store. I could be listening to Spanish on my mp3 player on the bus.

I wonder if I'm putting off the idea of working at the clinic until I am an FNP because I'm really scared to do that. Part of it is that I haven't had Community Health yet, but since when do I wait for the nursing school to come bring me the shit that I want to learn? I've trotted out to the workshops at the Pharmacy school on Plan B and over the library to meet up with the gay folks.

I guess I have this idea that once I go into the clinic as a practitioner, that I'll only be able to stay so long before my motivation/energy will be used up. Seems like that was my experience as a patient or the parent of a patient at the clinic - after a few visits, when I knew that being treated like shit was the norm, not the exception, I would go in with these high hopes, trying to muscle through as much bureaucracy before my momentum wore off, like that slow motion football player throwing off tackles left and right, and finally leaping over the goal line by inches... She finally... gets... the prescription... and she's clear.

Workshops on incontinence are important, yes. Seminars on the IRB process for the survey/honors project I want to do on nurses' cultural competency w/r/t LGBTQI folks, good. But following up on the shit that I said I was doing is also critical. And it's bugging me that I say I'm doing it for the people who will give me money, but I'm not doing it yet.

maybe that's why I'm still awake at 2am?