Constantly learning

A little while back, while I was still a STICU nurse, I decided to start a little notebook where I would right down new diseases/diagnoses/medications I came across during my shifts so I could look them up and learn about them. I was afraid when I transitioned into an imaging nurse I was not going to really be “learning” anything new. I’m just going to start IV’s and monitor for contrast reactions.

I was wrong.

People get MRI’s for all kinds of reasons. I have probably come across more diseases that I have never heard of in this position than I had the whole time I was in the ICU.

It’s been a constant learning experience. I start looking up the disease the patient is diagnosed with (which is the reason they are coming to MRI in the first place), and that leads me to another related disease, which leads to a new study, which leads to a med I have never heard of, and so on.

I’d never heard of MGUS, plastic bronchitis, or a syrinx. Came across all of those in MRI. I assumed that I need to be bedside to learn anything new in nursing. That’s not the case at all. As long as you are providing patient care you never really stop learning…

Nursing and mental health

Nursing and mental health go hand and hand. Nursing is hard. Nursing is hard not just physically but emotionally. We hold everything in because we are the ones that are supposed to help. We heal. We often forget that we can sometimes be the ones that need healing.

I was diagnosed with depression years ago, years before I became a nurse. I was placed on meds that I no longer take, I’ll explain why later on. Nursing school didn’t help, it just kept me so busy that I couldn’t take a moment to acknowledge the depression. Nursing, especially in a hospital that I hated, added anxiety attacks to the picture. I would wake up at night in a panic without being able to pinpoint why. That made me feel worse. I felt like an idiot for panicking over nothing, which made me hate myself even more. It was a downward spiral.

Before nursing school, when I first voiced suicidal ideation, my parents sent me to therapy. That is when I first received the diagnosis of depression (my mother died when I was 16, I watched her take her last breaths, I shut down big time). I was placed on trazodone and Zoloft. I hated it. I went from feeling depressed to feeling nothing at all. So I stopped taking both of them (don’t be like me) and instead stuck to therapy. It worked for me. She helped me come up with other ways to manage my mental illness. It worked for quite a while. Then enter nursing school and full-time nursing. I ended up back in therapy but due to my schedule I just couldn’t keep up with it. Hey, I’m a nurse, I can figure this out on my own. I’m tough. I’m a fixer. I’m a healer. I help everyone else so why can’t I help myself?

I am my own worst enemy.

I wear a smile for my patients and my coworkers. I am happy Fred the nurse. I’ve got a smile and a joke. My patients love me. My coworkers love me. Everyone believes I am ok. I look like I’m ok. I also spend most of my off days sleeping, I’m talking 12-13 hours. I don’t want to leave the house unless it’s to get food. I isolate myself from my friends, my brother is my roommate and he may not see me the whole day. I have dark thoughts that I know I should not be having. I wake up with my heart pounding feeling like some unknown thing is wrong and if I don’t fix it the world will implode. I am Fred the nurse and I have depression. I am Fred the nurse and I am not strong enough to battle this alone. I am Fred the nurse and I am strong enough to know that I need therapy again. I am Fred the nurse and I will get out of my own way. I am Fred the nurse and I will be ok.

 

Go pee!

Hey… Hey you, busy nurse, go pee!

I know you have a blood sugar to grab. I know your other patient wants his 250th cup of ice. Yes, someone has labs due as well. Go pee. Seriously. It’s OK. All those things that you need to do will be there when to get back. I’m sure there is someone you can delegate some of your tasks to. You have to take a moment for yourself.

Go pee. Your bladder will thank you.

Bad news

Yay, she is eating more today!

(We have some bad news)

She managed to walk from the room to the nurses’ station!

(We have some bad news)

Her labs look a whole lot better today. I think the bleeding has stopped.

(We have some bad news)

I think we may be able to move her out of the ICU today.

(We have some bad news)

She looks like she might be able to be discharged today!

(We have some bad news)

The cervical cancer is back. It’s stage four and its’ metastasized to the liver. There is nothing we can do. We can give her palliative chemo which may give her another 3-6 months or she can go palliative.

She chose to go palliative. She came home and passed away months later in her bed. I was 16. She was 41. She was my mother. October 18th will make 18 years since she passed away. It still hurts just as bad now as it did then. Fuck cancer. Fuck how it destroys people. Fuck how it destroys families. Fuck the pain it causes people. Fuck how it attacks old and young. Fuck cancer.

 

Self-care and nursing

You are a nurse. Your job is to take care of everyone else. When do you take care of you? As nurses, we are so conditioned to take care of others that we may feel guilty focusing on ourselves. That’s not fair to you.

At some point, you run out of steam. If you keep giving and giving but receiving nothing in return, you will become empty. An empty nurse is a dangerous nurse. An empty nurse can barely take care of themselves much less anyone else.

An empty nurse lacks empathy. An empty nurse stops caring. An empty nurse has nothing left of themselves to give.

THIS IS WHY SELF-CARE IS SO IMPORTANT! You cannot take care of others if you aren’t taking care of yourself. You have to practice self-care. You need to take moments to do things that you like to do. Like to shop? There is a lovely flea market on Saturday, go check it out. Like to cook? Well, whip it up chef! Like to sleep? You enjoy that nap like you’re still in kindergarten. Do whatever it is that makes you happy. You have to. You are just as important as anyone else. Your sanity matters. Imagine how much better you will feel. Imagine how much happier you will be. Imagine how much energy you will have to be the best nurse you can be. You are worth the time.

giphy

 

DNR vs Comfort Care

I have heard DNR and comfort care used interchangeably, especially by doctors. One is not the other!

DNR: Do not resuscitate. It is exactly what it says, you do not try life-saving measures in the event of a code situation. This does not imply that you stop caring for a patient. DNR does not mean “do not treat”! You will continue to provide patient care. You will hang medications for their blood pressure if it is dangerously low. You will more than likely continue to draw labs as well. You will still treat this patient pretty much like any other unless the patient, or their medical POA (power of attorney), tells you otherwise. One thing you must be aware of is whether or not the patient has exceptions to their DNR. Some may say that in the event of a code they want code medications but no chest compressions or intubation. Some people may say meds and intubation are fine but no chest compressions. I have even seen meds and compressions but no intubation (which leaves you wondering but hey, it’s what they want.)

Comfort Care: This is what most people think a DNR is. Just keep them comfortable until they pass on their own. At this point, you are no longer going to escalate care. In fact, you will more than likely begin to scale back dramatically the amount of care you provide. Typically the only medications you will give will be pain medications like morphine and maybe a few breathing treatments to help ease their work of breathing. For the most part, you are there as support for the family if needed, and to assure that your patient dies with dignity.

Please, for the sake of your patient, understand the difference. If you need to clarify with the patient or POA then do so. You don’t want to wait until the patient is near death to try and figure out what the patient actually wants.

The end isn’t always the end

I learned a lesson not too long ago. The end is not always the end. I got to see this first hand more than once.

A few months ago we had a trauma, pedestrian-vs-motor vehicle, that came to our unit with severe head trauma. The patient had a head bleed along with swelling. The CT scans did not look good. The MRI didn’t look any better. The patient and family were refugees from a war torn country, they spoke little English. The team began having “the talk” with his family. You know that talk, the one where they are pushing for the DNR because the patient is not expected to have any quality of life. Yeah, that talk.

The family would have none of it. We managed to stabilize the patient. They got the standard trach/peg combo. The doctors continued to speak with the family about the quality of life and the family continued to hold out hope. The patient ultimately managed to be transferred out of the hospital into a long term care facility. We were pretty much under the impression that they would just waste away in a nursing home, with no improvement in neuro status.

The patient came back to visit us, along with the family. The patient still has noticeable deficits but was able to fully communicate and even thanked us for our care. We had given up but they didn’t.

dont give up

More recently, our unit had a very sick vascular patient that coded during their surgery. The OR team got them back and immediately brought them to our unit (STICU). They coded again, the second code was worked for an extended period of time and then the team called it. They died. And then they decided death wasn’t really for them and their heart started beating again… spontaneously… after the code was called… while the team were having a moment of silence for the patient.

The medical team spoke with the family and let them know that even though the heart is beating, the patient has been “down” for an extended period of time and neurologically there is probably nothing there. The family decides it’s in the patient’s best interest to make the patient a DNR. The family begins saying their goodbyes and leave in expectation that the patient would probably code again within the next few days. Everyone is pretty much preparing for this patient’s end of life…

gointothelight

Except the patient…

That night, they opened their eyes to painful stimuli. Then it turned into opening eyes to name but no purposeful movement by the next day. By the third day or so they just woke the fuck up and tried to self extubate! All of us were pretty much like:

heart attack

They were completely alert, oriented, and by the end of the shift able to write questions on a piece of paper. Needless to say we were all kinds of confused, surprised, and impressed. We ended up nicknaming the patient “Lazarus”. Are we going to Hell? Yes. We are all well aware. I have a time share there.

The patient had a rough course. They were intubated, extubated, and reintubated multiple times before finally being trached and pegged. However, as I am typing this they are alive and are being prepped for long term acute care out on the floor. That’s right, the patient that we basically pronounced dead is instead going to LTACH soon.

These moments have taught me that it is not over until the patient decides it’s over. It has also taught me that maybe I shouldn’t give up so easily. My miracle patients are showing me there are still some things that we in medicine don’t understand. We don’t know it all. I am glad for that.