110%

there are some patients on our unit who have been there for months; it must seem like lifetimes to them. some of those patients are a pleasure to care for; they are sick - but independent, kind, and fun to be around. and of course, sadly, there are some longterm patients that you just don't want to care for. they are SUPER sick, dependent on others for every and all tasks, and often emotionally draining.

on sunday night, before the worst schedule in my nursing career, (monday, tuesday, thursday, friday, monday, tuesday, wednesday - 12 hour shifts), i secretly hoped to myself that i would have a good assignment. "please, pretty please, don't let me have room 2." sometimes i feel like i just don't have it in me to work hard; i don't have the physical, but mostly the mental, capacity to give 110% - to give a very sick and needy patient all the care and kindness that they deserve.

sure enough, monday morning finds me with two longterm-ers. the first is E - a 32 year old female from canada. she has two children thousands of miles away. her first transplant failed. she has spent 50+ days in the hospital. celebrated a birthday. had multiple infections. and is now getting chemo AGAIN for transplant #2. she is a joy to care for. we're approximately the same age. she's sarcastic and fun. and although she is SICK, with no white blood cells (hence no immune system and highly susceptible to germs), she is independent - what we nurses call a walky-talky.

my second patient... well, not so walky-talky. my patient lives in room 2. literally. lives. he has been in the hospital for more than 2 months. his transplant didn't go as planned either. he developed severe mucositis which compromised his airway. he coded. they did chest compressions. they broke ribs. and he survived on a ventilator for weeks. he is now recooperating. breathing on his own. but that's about all he can do independently. he needs help turning in bed to prevent pressure ulcers. he needs help ordering food from the cafeteria and feeding himself once it has arrived. he has tubes in orifices. needs to be cleaned up frequently. has pain issues. and because of his complex course and stent in the ICU, he is not quite back to baseline. he is emotional and needy. he's 43. and sad. he cries all the time. and needs a nurse's very best - their 110%.

and to my surprise, despite my lack of faith in myself, that is what i gave. my very best. my 110%.

life has been everything but perfect for me in the last few months. sickness has plagued my family. i've spent more time at the hospital than residents in their first year. heartache has been a regular friend to me. but despite my exhaustion and emotional overload, i took good care of the patient in room 2. dare i say it, i even enjoyed my two days with mr. H. i'd like to say that i always give 110%. but to be honest, i don't. i can't. it's not sustainable. but it sure feels good to deliver.

leg

just thought i'd write an update about patient B, the orthopedic surgeon. he is now a "below the knee amputee."

(isn't that horrible? we often define people by their diagnoses or misfortunes. the diabetic in room 2. the schizophrenic lady in room 64. medicine is cruel.)

anyway, patient B's colleagues decided that saving his life was more important than saving his leg. his "stump" (again, not a very nice description or technical term) is still open, ravaged by infection. and sadly, he is still fighting for his life. on a ventilator, unaware of his loss, he is trying to survive.

patient B has already lost his leg; let's hope he does not lose his life too.

my patient and friend - jamie

i could have written this post on monday, after i learned that my patient passed away. but for some reason, i haven't been able to write. i don't know what to say.

i met jamie in november of last year. i began caring for her prior to her transplant and continued to care for her long after. she had several admissions to the hospital. her first visit was about a month long - chemo, transplant, mucositis, pain, infection. her transplant course was never uncomplicated. her subsequent visits were for more infections, for infusions of granulocytes, immunoglobulin. she returned with respiratory issues - lung nodules. sadly, her first transplant failed. her 29 year old feisty body did not accept her donor cells and hence, jamie never regained an immune system. infection after infection, complication after complication, riddled her weakened body. but never once did jamie lose her spirit, her optimism, or her sense of humor. she always had a smile to share. even on saturday, when i admitted her to uw one last time.

it's strange, almost every time jamie got re-admitted to the hospital, i was her nurse. it's like the powers above assigned me to her care. we enjoyed one another. it was easy to care for jamie - even when she was critically ill - because her pleasant demeanor and sarcasm made my shift enjoyable. i'd like to hope that jamie enjoyed my presence too; i'd like to think that she felt safe and cared for when i was her nurse.

jamie was sent via ambulance from seattle cancer care alliance to uw for low blood pressures and fevers. the report i received over the phone from the nurse made her sound sick, but not critical. i was not worried about the admission or her safety; instead, i was looking forward to catching up with what felt like an old friend. upon arrival though, i recognized that jamie was sick - very sick. her oxygen saturation was low. she was breathing rapidly, hungry for air. her blood pressures were low, despite fluid boluses. and her heart was racing. but even then, jamie smiled.

i settled jamie in to uw for a few hours, before my shift ended. we got more fluids ordered, antibiotics hung. she went down for a chest x-ray. an ekg was performed at the bedside. blood and platelets were ordered. potassium was being replaced. after just a few hours of work, i felt like i had done my best nursing care. i had thought of every last thing - even the little details. a commode chair by the bedside with toilet paper within reach (so that she wouldn't have to walk the extra steps to the bathroom). a stash of her favorite fruit punch gatorade. non-skid socks to prevent falls.

and despite my every effort (and the fantastic nursing care that followed me), jamie coded that evening. her young, tired body decided to stop working - it had been through TOO much. the team of nurses and doctors did all they could - they intubated her and got her heart to start beating again. amazing drugs increased her blood pressure. machines kept her alive. until her wonderful family was able to be at her bedside. on monday, with courage and bravery, jamie's family watched her take her last breaths. with borrowed strength from their daughter, they said goodbye. tears were shed. smiles upturned. stories and memories shared. it sounded beautiful - it was not all sadness. those that knew jamie could not mourn her loss without celebrating her beauty. aunt b (jamie's amazingly kind relative) says it best on jamie's caringbridge page:

I would like to take this opportunity to thank everyone for all your love and support of Jamie these last months as she has literally fought for her life. Your words of love and encouragement kept her strong. Unfortunately, the cancer prevailed. We lost our sweet Jamie on Monday March 21st with her family and friends surrounding her. To those who could not be there to say goodbye, she knew how much you cared.

Jamie amazed those around her (especially the medical staff) with her strength, stamina, and positive spirit to the end. I know I speak for all of us who love her when I say that she will be greatly missed.

We love you Jamie, you have truly touched many lives and we are better people because of you. Thank you for that. You will be in our hearts forever.

Goodbye sweet Jamie

Aunt B

leg or life?

in a twist of irony, an orthopedic surgeon was admitted to my unit this morning with necrotizing fasciitis. for those of you that do not know what that is, be brave, google it and check out some photos. ewwww!

necrotizing fasciitis is also known as the flesh eating bacteria. the patient admitted to my unit not only has this rare infection, but also, had a stem cell transplant several months ago for cancer - talk about a double whammy! the reason this is so ironic is because often, the "cure" for NF (if the patient does not die from infection first) is an amputation - a surgery an orthopedic surgeon is all too familiar with.

in the morning, patient B went to the OR for an extensive debridement (surgical removal of the infected tissue and muscle). strangely, the team of surgeons performing his surgery are his colleagues. they will do everything to save their friend's leg. let's hope that while they are being conservative in their treatment (in hopes of maintaining his ability to walk) that the infection is not too aggressive and takes his life. which is more important - saving a leg? or a life?

hours at UWMC

march 9th - 12.5 hour shift

march 10th - 12.5 hour shift

march 11th - 2 hours (take dad to UW for appointment with his cardiologist)

march 12th - day off

march 13th - 4.5 hour overtime shift as secretary

march 14th - 12.5 hour shift

march 15th - day off

march 16th - 2.5 hour shift (worked for friend who is getting IVF and has doctor appts every other day)
6 hours in the ER with my dad getting fluids for his dehydration related to gastroenteritis

marcth 17th - 12.5 hour shift
6.5 hours in the ER with my dad for low blood pressures (in the ER til 3:30am)

march 18th - 12 hours on 5NE with my dad (3:30am-3:00pm)
4.5 hour shift
1 hour visit with my dad
(at UW for 23.5 continuous hours)

march 19th - 8.5 hour shift
4 hours with my dad on 5NE

in the last 11 days, i have spent far too much time at the university of washington. 101.5 hours to be exact. in just the last 60+ hours, i have been at UW for 51 of them. i'm not a resident with hopes of becoming a well-renowned doctor, pulling all nighters and caring for dozens of patients. nor am i some surgeon who gets paid thousands of dollars to do heroic surgeries. i'm just a nurse and the daughter to a sick man. i spend my time outside of work at work. i eat, breathe, and sleep at the university of washington - the same institution where i work.

march 20th - my dad will likely be discharged (thank god!). and i hope not to make an appearance at uw. i don't HAVE to be there until tuesday, the 22nd. here's to hoping for UW-free days ahead.

sick of sick

i'm sitting on a miserable cot, leaning against a cold window, watching my dad sleep. he's wearing hospital pajamas and is all wrapped up in white, scratchy hospital sheets and blankets. five stickers and five wires on his chest monitor his heart rate; he's "televised" out in the hall, so someone can watch his every heart beat. occasionally he snores and wakes himself up, only to realize he's sick and in the hospital and might as well go back to sleep to make it all go away.

as if the congestive heart failure and arrhythmia issues weren't problem enough, my dad developed a flu bug two days ago. you wouldn't think that a flu bug would wind you up in the er two days in a row and eventually get you admitted. but it can. if you have heart failure. if the nausea prevents you from taking your cardiac meds. and the diarrhea gets you really dehydrated. for someone with medication induced hypotension (low blood pressure), dehydration can sink your already low blood pressures to dangerously low levels. nurses and doctors say "his blood pressure is in the toilet" or "he's circling the drain." i never want nurses and doctors to talk about my dad like that.

the ER is an interesting place, i must say. i did not like the care we received down there. the physicians there are generalists. they're good at little bits of everything. but, they're not exceptional in specialties. and congestive heart failure is a specialty. typically, if someone comes to the ER with low blood pressures, you give them a couple liters of fluid intravenously and send them home. but for someone with congestive heart failure, a couple liters of fluid may just lead to drowning - literally. a boggy, inefficient and tired heart can't handle extra fluid volume. so instead, the fluid goes straight to your lungs. you get short of breath. your lungs crackle. and you drown.

we'd already been in the ER for hours (and they'd done nothing for my dad but draw labs) when an attending walked into our room. he had white hair and wore hearing aids in both ears. he did not introduce himself. he did not listen to my dad's heart and lungs. he prescribed fluid based only on my dad's weight loss. he didn't ask for a history or take my insight into consideration. he was an old-school doctor, a pompous ass. i hated him - instantly. and i wasn't going to allow him to take care of my dad. bedside manner means everything and this man had none. i demanded that the cardiologist on-call be paged; my dad needed and deserved a thorough assessment from a specialist. finally, at 1:15 AM, a real doctor came. he spent 15 minutes with us. he acknowledged the challenge of low blood pressures AND congestive heart failure. he was comfortable with my dad's low blood pressures and proceeded cautiously. he ordered ONLY 500 cc of fluids. safe. thoughtful. confident. and we were satisfied.

so, i feel safer with my dad admitted to a cardiology unit. someone else is calling the shots today, instead of me (i was at work yesterday, talking to my mom and dad off and on, calling his nurse practitioner, getting advice, and telling him which meds to take and which meds to hold).

but i still hate this situation. i hate that my dad is sick. i hate that his situation is ever-changing and always tenuous. i hate seeing him afraid and weak. i hate watching my mom fall to pieces as she watches her husband (of 39 years - today - happy anniversary!) sleep. i dislike sleeping on linoleum floors in the ER. i dislike calling in sick for work - not because i am sick, but because my dad is sick (i'd take his flu bug in a heart beat - i have plenty of healthy heart beats to loan or share).

i'm sick of sick. and ready for something different. i'm not asking for healthy. my dad will never be "healthy." but back to baseline would be nice. his baseline is spunky and crazy. his baseline is walking around the mall to get exercise while staying warm. his baseline is going to work, making soups, working too hard, and bossing people around. we just want to get back to baseline.

blood cultures

yesterday was a busy day. and in some strange way, i needed a busy day. i needed a thousand little and strange tasks to keep my mind churning on work instead of my life.

i had a 30 year old patient yesterday; he is 8 days older than me. his transplant was two weeks ago and still, he has no white blood cells. by now, at least a few hundred little white blood cells should be present, circulating in his blood stream. his immune system should be on it's way back. he needs an immune system. his temperature was 104 ALL day long. and he was miserable. sweating. shaking. nauseated.

one of my jobs was to do blood cultures. typically that means, draw about 30mL of blood from a patient's permanent line - we call them Hickman's (after the doctor that invented that specific central line). i call it a faucet. it's an easy way to access the patient's blood; it's like a permanent IV that threads a catheter all the way to the entrance of the heart. anyway, a set of blood cultures requires lots of supplies - syringes, flushes, blood culture bottles, patient labels, a transfer device, plastic bags, a requisition slip with more identification labels. we draw the blood from the line and then, with aseptic technique, transfer the blood in three different bottles for the lab to watch and grow out bacteria. typically, it's a simple process. a good nurse can draw the blood in less than two minutes and be out of the room in less than five. i'm a good nurse.

but...

yesterday, i was to draw blood cultures from EVERY line the patient had coming out of his body. and the number of lines this patient had is inconceivable. a PICC line in his right arm. a large bore dialysis catheter in his right chest. a portacath in his left chest. and a peritoneal dialysis catheter in his abdomen. some of the catheters have two lumens, a white and a red side. so, in total, i drew six sets of blood cultures, each with three bottles (for those numerically challenged, that's 18 bottles!). i took so much blood that my patient's hematocrit dropped three points and he needed 2 units of blood.

the best part of my day was when the lab called me. it was only about 10 minutes after i had sent down ALL of the bottles, each delicately and meticulously labeled. often the lab calls to clarify a problem. sometimes it's an easy fix - "you forgot to note the time of the draw." but sometimes it's a horrible call. if the lab says, "the patient labels on the samples don't match the labels on the requisition. you need to redraw your sample," you're screwed. you messed up big time. we've all done it. but it's frustrating. and for just a second, i feared that i would have to RE-draw ALL the patient's blood cultures.

instead, the lab technician said, "ma'am, did you send down lots of blood cultures a few minutes ago?" why yes, yes i did. "well," he said, "you're hired. you did everything right. the labels are perfect. the requisitions are filled out 100% correctly. thank you for doing your job so well. you just made my job easier."

a simple compliment made my day. somebody appreciated my hard work. it's nice to be reminded every now and then that you're good at something - even if it's totally random and un-applicable to real life. i'm good at drawing and labeling blood cultures. what are you good at?

flexibility

i have a new recommendation as a nurse: don't be flexible. when you're flexible, you get screwed. my day yesterday sucked because i was flexible.

7:00 - 11:00 nurse to two straight forward patients. easy day ahead.

11:00 - 15:00 secretary extraordinaire, plus nurse to one of previous patients.

12:45 secretary/nurse who answered emergency light to find patient seizing. assisted the patient's real nurse with seizing patient. transfused platelets for this struggling nurse who was drowning and falling behind.

15:00 - 17:00 nurse to first patient, nurse to third patient of day (same one i found seizing earlier).

17:30 transfer seizing, spanish speaking only patient to different unit, after attending a care conference in which the medical team told the patient and family he was dying and there was nothing more they could do (patient is 35 years old and has terminal brain cancer with metastases all over. he had about 27 family members in the family room, of all ages, 2 of whom ended up in a fist fight the previous shift).

17:45 - 19:30 nurse to first patient/bitch to the rest of the nurses (as in assistant, not cranky). answered call lights. completed other nurses' end of the day tasks.

note to self: don't be flexible. my day would have been nice and smooth if i had just stuck with my original two patients. instead, i wore every hat possible in one twelve hour shift and found myself in just about every patient's room at least once during the day. by night time, i hardly knew my own name.

lucky to know her

cassie is one of my very best friends. she and i graduated from nursing school together five years ago this june. i think highly of her in general. she is a unique soul and one of the most phenomenal friends. i am so lucky to know her.

in terms of nursing, i know that cassie is a fantastic nurse too! she has had several different nursing jobs. she has worked in clinics for vulnerable popultations - women, children, refugees, and the homeless. she excels in crazy, unpredictable situations. and her patients love her because she cares about them - because she offers them something no one else has - a listening and empathetic ear, a thoughtful and professional assessment, and equal care and treatment. her patients are lucky to know her too.

tomorrow, cassie is embarking on a new nursing adventure. she is starting a new career as an advanced registered nurse practitioner (ARNP) in the emergency room at harborview medical center. for those of you who don't know what an ARNP is, think nurse with prescriptive authority. essentially, cassie will be like any other physician's assistant or medical doctor. she will work autonomously, seeing patients, making diagnoses, prescribing medications, and performing invasive medical procedures. she will work side by side with er docs, but because she is first and foremost a nurse, she will think of patients as humans, not diagnoses, and she will treat their comprehensive needs, not just their medical ones.

i see cassie as a confident and strong-willed person. she always shows up with a smile on her face and does her very best (we're both perfectionists, perhaps it's why we understand one another and are such good friends). but today, i know her in a different light. i know she is nervous. she is pacing around her darling home, picking up piles of things, re-arranging furniture, and baking banana bread. she is laying out her scrubs for tomorrow's first day, packing her lunch (although she'll be too nervous to eat the hummus and vegetables tomorrow), and studying note cards in case there is one last thing to learn to prepare her for the unknown.

of course, this new job will be challenging. cassie will see VERY sick patients, people in VERY vulnerable scenarios. but i have confidence that cassie will do her best. and as mentioned before, her patients will be healthier and happier once they have seen her. and they all will be lucky to know her!

tiddly

what started as a blog about nursing seems to have quickly transpired into a blog about caretaking - about being a caretaker to my dad (who, for some reason, my family calls tiddly).

last time i wrote, tiddly was getting his pacemaker/defibrillator placed. i was in the waiting room, typing away, wasting away hour upon hour, pretending not to worry as my mom and sister paced the halls, ate grilled cheese sandwiches (ok, i had one too), and shed a few tears.

of course, as if the morning wasn't "exciting" enough, a fire alarm went off mid-procedure. as an employee of the hospital, i am used to calls overhead, fire drills, and irritating alarms; we tend to ignore them, as most are not real. but, when the halls started to buzz with people evacuating the area, i couldn't help but wonder... what the hell?!? is this is a real fire? how do you evacuate operating rooms, when wires are laced delicately through veins and into heart muscle?

the surgery ended well, without the need to evacuate the area. thank god! the new leads (wires) were placed successfully, threaded to the most important organ in the body - the heart. and my dad was discharged the following morning (of course, not without one scare and threat to re-open him up to thread a wire a few millimeters closer to cardiac muscle, to get better capture, whatever that means!). one more scary procedure done. one step closer to feeling better. phew...

well, tiddly is not an easy man... never has been, never will. he found himself back in the hospital by friday, two days after his "release." a new problem developed. a new arrhythmia. it is the fault of no one. just a string of bad luck. STAT labs were drawn. multiple EKGs printed and read. a chest x-ray completed to verify placement of the leads. ultrasounds to ensure no bleeding around the heart. interrogation of the pacemaker to see what the "bleep" was going on. and visits by doctors. lots of doctors.

atrail tachycardia - the newest hiccup in the road to improved cardiac function and overall health! damn those erratic and excitable cardiac cells.

the cure - amiodarone. a new drug. one my dad has been on in the past. one that of course, comes with side effects and intolerance. amiodarone, after prolonged use, causes hypothyroidism in my dad. which in turn, leads to worsening congestive heart failure symptoms. blah! what a fine balance! a chemical art to get the perfect equation!

tiddly's current state of health...

he's ok. he continues to challenge the nurses and doctors. he makes us all laugh. he takes pills. he does more than we think he should. and he continues to beat the odds. as of march 5th, tiddly has lived 12 years more than he should have. it was 12 years ago that my dad suffered a massive heart attack and underwent seven bypasses.

as of now, my dad is 100% paced. that means, 100% of the time, his pacemaker is telling his heart to beat. 100% of the time, wires help my dad's ventricles pump blood to the body more efficiently than before.

right now, things are ok. we are going to lunch.