Confrontational Surgeons

When I was in the peds cardiac ICU, there was a surgeon who seemed to
have particular joy in making nurses tense and everyone jump when he
came storming into to room. Even when everything was fine he was really
aggressive at getting answers met. When things were bad, he was far
worse. Imagine already having really high adrenaline levels and
sweating to do everything you can to save this child's life and then
this tall man walks in yelling at you and everyone else in the room! I
remember him standing over me literally so close that I had to crane my
neck up to maintain eye contact while he fed me 20 questions and
feeling my heart in my throat. I tried to leave the room and he
followed right behind me continuing to talk at me.

Only one nurse seemed to know how to deal with him and that was because she was
much older than him, had many more years of experience and was very, very New
York - Brooklyn even. She talked right back to him as if he was being
ridiculous, while showing she was obviously on top of the situation, "so
why was he so stressed out?" He liked it. I took notes. I was not any of
the three things she was, but I could display confidence around him and
let him know I was on top of the situation he was emoting about.

Things changed after one of my patients coded and we saved him. The infant had only
a single ventricle and had had his chest open for several days after
his heart surgery - because the pressure would have been too much to
close right away (there is a sterile dressing covering it all, but
still weird to see). They had just closed his chest earlier that day
and the surgeon went home. He went asystolic (ie flat line) and we
rushed to revive him. These children are very tenuous and when they do
code, they typically have to be placed on a mini heart and lung bypass
machine of sorts (called a ventricular assist device) to support them
for a few days. But this baby did so well after our resuscitative
efforts, that was not needed. The surgeon came in long after it was all
over and seemed amazed. He still tried to bark orders by having me
increase the dosages on some of the inotropes (medications to support
the various heart functions and blood pressure) and I would call back
"So you want this much? That means X per min." As I dialed it on the IV
pumps, he tried to be condescending by asking How do you know that?!
And I looked back at him and smirked, saying "I calculated it." He's
been nice to me ever since. Even now when I run into him in the
cafeteria, he asks why I'm not still there and tells me his patients
need me.

Feb 2005 The Morgue

Some how I've lucked out and have always had someone
else take the body away after I've done post mortem
care. No one to do it last night. I carried my infant
patient in my arms, covered by a blanket, down to
security to get the key and then down to the basement
morgue where I placed her in a bag. There's something
so weird and final about zipping up that bag over the
face. I placed her next to another tiny body in a
refrigerated room.

I keep playing the moment of her death over and
over.... her parents holding her, crying out her name.
Wondering if I was supportive enough for them......

Not an easy aspect of my job.

Sept 2004 offer

This morning, driving Mike to Cal train, I get a phone
call from my boss. I think she's tryin to get me to
work extra this weekend and right away I'm forming
excuses in my mind, when she asks me..... if I'd be
interested in training in the Peds heart cath lab.
Didnt see that one coming!

The cath lab is a place where cardiac diagnostic and
other proceedures take place (angio grams,
angioplasty, Rashkind, stent placement, ect). Some of
these procedures are done to allow a newborn to grow a
bit and maybe get to go home for a few months until
their open heart surgery. Some fix the problem all
together and prevent a baby from having to go through
surgery.

It's temporary..... to fill in for nurses on maternity
leave. But it'll be really great experience!
Something new and different to learn! It'll be an
amazing adition to my resume! And it may mean a better
work schedual (not 100% sure on this one) But I do
know that most heart caths happen during normal
business hours mid week. ie, I may get a break from
the night shift and working weekends for a while!

Coping with Death

My boyfriend is the largest part of my
support network and I feel guilty for having to use
his sholder to cry on so often because of my work.
Thats why I've always focused on getting out of town
whenever possible. Roadtrips, camping, snowboarding,
etc helps keep me sane. But sometimes even thats not
enough.

When a child was expected to die, the situation is hard but a bit easier to deal with. The hard ones are the ones that surprise you; when they plummet and you fight hard for their life coding for hours and still dont get
them back. And the older the kid is, the harder it is
for everyone to accept.

2 infants died the week of October 17, 2004 . A little girl,
after caring for her for over a month post op, and a
little boy we cared for over 6 months of multiple
surgeries. Both deaths were hitting me very hard.
Especially after the numerous deaths we've had the
past 2 months in the ICU. Including an 18 yo we tried
to save through 2 hours of chest compressions and code
drugs. It pains me to watch the families mourn. I was
doing a lot of crying with them, and couldn't seem to stop once I go home.

No one ever said nursing was glamorous.

Emotional Wound Analogy

Let me tell ya what I know about wounds. The deeper
they are, the more problematic a bandaid becomes.
Sure, it seems like its protecting the wound, allowing
it to heal, protecting it from infection. But what if
the infection is already in there, and now its trapped
with a covering to keep things moist and warm for
further breeding. The sking starts to scar and heal
as skin does, but the wound still lies benieth, not
having the chance to properly heal from the inside
out. Sometimes it continues to grow deeper and deeper
in the tissue, while looking ok from the outside and
confusing the person who cant figure out where the
pain is comming from.

To really heal a deep wound, you have to get in there,
behind the bandages and clean it, regularly, to
prevent infection and keep the tissue healthy as it
heals. Sometimes a temporary bandage is useful. but
it cant stay on and the wound may need some debreeding
there after to get rid of the scar tissue and get back
to the healthy tissue needed for really good healing
from the inside out.

ICU Cookies Aug 2004

Working in a busy ICU, thats often understaffed, there
are days where I feel like I'm putting out fires right
and left. But this month, I'm on night shift.
Typically no fires. The pace is often slower. Slow
enough to bring in cookie dough to bake in the toaster
oven in the staff lounge.

It seemed like a good idea at the time.

The toaster oven, while used, seems to have been in
decent shape. We set the temp to the recommended 350
degrees and discovered with our first batch that in
less than 5 min, the top cooked much faster than the
middle and got a bit dark. Still tasty, just a bit
doughy in the middle. The second batch, we decided to
flatten and cook at a lower temp and watch closely.
These came out great! Only six more to go and it's
time to serve hot chocolate chip cookies to all my
co-workers at 5 am. Who wouldn't love that? With the
last batch in the toaster oven, I asked another nurse
Sarah (yeah there's 2 of us here) to watch them while
I take care of my patient.

Next thing I know Sarah and Jamie are yelling from the
lounge "Oh my god there's a fire! I'm not even
kidding you Sara!" I ran, grabbed a towel and soaked
it ran in to the lounge to find flames leaping out of
the toaster oven and licking the shelf above. I start
batting it with the wet towel with one hand while
removing items next to it with my left and yelling at
the other two (who are totally freaking out) to get
the extinguisher. But they only run around saying "I
don't know where it is! Arn't we supposed to call
someone? Who do we call?!!"

Take in to perspective that these are ICU nurses here.
We're used to high stress situations with patients
who drop their heart rate and blood pressure with in
seconds. This requires a personality who can hold it
together in times of crisis. We've been trained for
such. Except in cases of fire. Drills we've had.
Inservices on who to call and how to use and
extinguisher. All the info is even printed on the
back of our badges. But the situation has really
never come up.

So my two cohorts are running circles around each
other while I'm battling flames and trying to figure
out how I'm going to reach around the flames quick
enough to unplug the toaster. Finally someone got our
charge nurse from her break and she came in and
immediately closed the door of the toaster. Fire was
out. (Now why didn't I think of that?) But the smoke
thereafter was really incredible! The charge nurse and
I soaked the burnt cookies and threw all the
incriminating evidence in the trash. By now alarms
went off and several service men showed up to
investigate, followed by the sound of fire trucks
outside. As the front of our ICU was filled with
Firemen in full gear, my cohorts and I stood by,
giggling from embarrassment and competing for reddest
face (Tough competition! They're both redheads and
really good at such shades!)

So the toaster is, well, toast. The electrician
checked out the scene and came back to tell us the
good news: that the coffee maker was on a separate
circuit, so everything will be ok.

My throat feels like I just had a cigarette. My scrubs
and hair really stink. And my charge nurse has
nicknamed me "Pyro"

I think I'll leave the baking to conventional ovens
from now on.

moving to SF

I decided to move to SF. I got a job at UCSF in their PICU and the exciting thing is they do cardiac surgery, so I'm hopeful I will get some exposure to that as I think it's really interesting. It's a bit sad leaving Sacramento though. There are friends and memories that I'll be leaving behind. Not to mention awesome co-workers at UCD. There will be lots of adjustment but it's time for a change.

hair do's

One of the things I really loved about pediatrics was bringing play into the job. Stickers, blowing up gloves into balloons, glitter polish, and ponytails for the little girls. Even if the child was on a ventilator, I would take the time to fix up long hair into braids. The kids and their parents alike seemed to enjoy it.

my little man

One of my primary patients was this adorable little toddler with big brown eyes, dark curly hair and a trach. His family lived far away and was not able to be by him, so I felt it important to be super playful with him and take him on outings when things were slow on the weekend. We had a wagon to transport patients in and I filled it with soft pillows, blankets and stuffed animals and would wheel him about the hospital grounds. He loved it and would wave "hi" to everyone we passed. 

Drew

He was a patient of mine for a very long time. It took him years before he was able to go home. I was amazed by how dedicated his mom was to being by his side every day. 

Watching heart surgery for the first time

There was an amazing surgeon who

Skiing

Living so close to Tahoe had a huge advantage. Many of the nurses and doctors loved skiing and we had several ski trips going up to the snow together. Not only did we bond on the ski lifts and slopes, we had a great time in the bar afterward. Once one of our doctors even bought a round of jagermeister shots for everyone! (It's a gross drink but sharing it in the moment was really fun). I really felt like our bonding outside of work made a huge difference in how well we worked as a team in the PICU. It was special and seems unfortunately rare. I've never had an experience with a work team like that since. 

Noa

One of my patients the first year I was an RN in the PICU was a little girl named Noa. I became one of her primary care nurses. The experience with that family was powerful and still affects me to this day.

Noa and her family were visiting relatives in northern California from their home in Sydney, when she first became ill. She was 18 months old at the time. Her father was still in Australia due to business, so only she and her mother were present when she was first admitted to the pediatric intensive care unit (PICU). Noa had the flu. But it was not this illness, which brought her in to the PICU. It was in the course of having the flu that she became too weak to sit up. This weakness did not leave with her flu symptoms. Studies conducted in our PICU came back with a diagnosis of Spinal Muscular Atrophy (SMA). Few children with this genetic, neuro-muscular disease live to adolescence.

The diagnosis was provided just as the father had arrived from overseas. Having not seen his family in several weeks, he was in a complete state of shock to hear the news. His beautiful baby girl had just been diagnosed with a disease with a poor prognosis. Noa’s father was not coping well. He felt out of control and was frequently emotional and would sometimes lash out angrily, finding blame with any medical staff that came near. Because of his length of time away during the initial stage of this disease, he seemed to place a lot of blame on himself as well. Noa’s mother, while obviously upset, was more accepting and focused on researching all the facets of her daughter’s illness.

Due to the severity of Noa’s disease and the need for therapies not available in Sydney, the family made plans to move and completely change their lives. Noa’s mother and older brother stayed by her side while her father went back and forth to Australia. Noa was discharged with a whole host of therapies to strengthen her.

A month later, Noa came back due to an apneic event and continued difficulty breathing. The SMA was now affecting her intercostal muscles. She was intubated and placed on a ventilator. While upset about this change in events, the family as a whole seemed stronger and better able to cope with the disease. They were no longer grieving the loss of their perfect, healthy child and were now focused on giving Noa as much quality of life as possible. This hospitalization was especially long and the staff came to truly bond with all members of the family.

As staff, we did what we could toward giving Noa as much quality of life as possible while in her PICU room and connected to the ventilator. I often assisted the mother with her daily “spa treatment” where we’d sit Noa up on pillows and place her feet in a basin of warm bubbly water so she could kick and splash with her feet. We invited the family to decorate her ICU room and her mother filled the bed with pink boas. We dubbed them “Noa boas”. Child life was heavily involved and we all participated in each activity. Story time was every afternoon by a volunteer. Pet therapy was once a week, where a dog came and sat on her bed. Music therapy was twice a week. This allowed Noa to use what little arm strength she had to shake a plastic egg filled with sand along with the music.

Despite being intubated, Noa was very expressive. She learned to communicate with her eyes and eyebrows. Two eyebrow lifts were for “yes” and either closing her eyes or shaking her head was “no.” Her mother had even taught her a few hand signs. This made it all the more enjoyable to spend time with Noa. We could do silly things with her toys and make animal sounds that would get her laughing so hard that her ventilator would alarm, due to the changes in air pressure. The family was now in California full time living with relatives and the father had not yet found work. While the unemployment was a cause of stress, it allowed all family members to be at the bedside regularly to spend time with Noa.

The day Noa had a code blue, both parents were witnesses. Looking back, I am so glad they were there, as it truly made a difference in the days to come. At the time there was no set policy in the PICU on having parents around during such events. If they had already been outside the unit, they likely would not have been let in. Yet because they were there, they stood outside the room watching us all work fervently to bring their daughter back. They saw the respiratory therapist bag with one hand while holding her little fingers in the other and they heard our pleas to her while we infused various medications and IV fluids during the resuscitation. Noa made it through that episode and her mother rushed to her side as we walked out of the room. But her father remained outside in order to hug each one of us. Seeing our dedication to helping his child cemented our bond.

Noa was soon given a tracheotomy and a G-tube. With her airway stable, she was able to be weaned off the ventilator and only required routine suctioning and oxygen at night. Through much family education, Noa and her family were discharged to go home.

Many months later I received a call at home from my co-worker, that Noa was dying. Noa had come in that week with respiratory distress and was barely responsive. It became apparent that her condition was worsening. After multiple family conferences, the family had made the decision to go home. They had watched their daughter go through so much the past year and did not want to prolong her suffering. The mother later explained to me how they lay her between the two of them and held her all night until she died.

The funeral was held in their neighborhood church, a three hour drive away, and almost all the PICU staff were there, wearing pink “Noa boas”. The father said wonderful things about our unit and set up a fund in his daughter’s name. After the funeral, we went to their home where her mother showed me the garden she had made for Noa and the little cement “Noa angel” she had placed there in her memory.

The family thanked me for all I had done for Noa. But I felt the experience with them as a family had given me so much more. I had watched them from the beginning of their crisis period and saw them grow together and strengthen their coping skills. Their faith and strength helped them through each hospitalization and worsening stage of her disease. The rapport between the family members and hospital staff built trust and allowed family conferences to be more productive, as they knew we also wanted the best for Noa. Their love and strength as a family continued to support them as they had to face the very difficult decision to let their daughter die. It was a decision that I had seen few parents make and filled me with the utmost respect and honor for them.

Welcome to pediatrics

When I was a nursing student, my first day of my PICU rotation, I was cuddling a baby on my lap, feeding him a bottle and thinking how sweet he was. That was until I felt the really warm wetness soaking through my pant leg and looked down to see diarrhea exploding from the kid's diaper. The other nurses just laughed at me when I called for help and said "welcome to pediatrics!" There's been an awful lot of body fluids of various sorts on me since. Thank god for scrubs that are easy to wash in hot water and disposable gloves!

PICU Nostalgia

I'm starting this blog at a point in time when I am considering leaving hospital nursing all together. Just graduating with my MSN
in community and international health, I have new options before me to
explore
global health (see my blog on my international
adventures:Saz Sans Frontiers).

But I'm feeling a bit nostalgic for all my local adventures in PICU
nursing over the years. Some of these memories have already been
written about and I will post them here, along with those yet to be
written. Enjoy.