When will I feel good enough?

I am certified, passed the CCRN.

As I studied and prepared for the exam which was harder than NCLEX I might add, I felt like I was so smart and getting smarter by the day.

My first night at work after passing the exam I thought I would feel more confident, instead I realized how much I do not know and doubting my own judgement.

I once heard somewhere "The most dangerous person is an incompetent person that does not know they are incompetent".

The more I learn and know the more I know there is so much more to learn. Perhaps I am just suffering from the "down" after feeling so high.

Courage does not always roar

Sometimes courage is the quiet voice

At the end of the day saying

"I will try again tomorrow"

Mary Anee Radmacher

Why did you come here?

I've never heard anyone say:

"I want to become a nurse so that I can help people who don't want my help."

"I want to become a nurse so that I can take verbal and physical abuse from people who are angry, confused, insane, drunk, high or just weren't raised better."

"I want to become a nurse so that I can see my tax dollars being spent to save people who don't care how much it cost because someone else will pay for their care."

"I want to become a nurse so that I can wrestle with +400 lbs of flesh so that owner of flesh doesn't get bed sores."

These thoughts were inspired by one patient. I guess this would be the ugly in:

I love this job; the good, the bad, the UGLY, and the stupid.

Who's running that place down there?

So I'm doing the charge thing the other night. It is kind of slow so about 1100 pm I start cruising the ED census looking for potential playmates also known as patients. I see 4 chest pains in the census, 2 been there since 630 not likely canidates and 2 that just rolled in at 1030 pm. Aha, these have potential.

The phone rings while I am looking at the stats on these two guys. Its bed control; Whatcha got for me? I ask. My friend tells me the name and I explain that this is not one of the potentials that I had been looking at. He says no its a Neuro ICU overflow. Okay I say, we can due a neuro case. Change in LOC he says. Okay I'm on it. And off I go to investigate this new case.

WHOA?! WTF, this change in LOC has been sitting in an ED bay since 1:30 in the afternoon. Upon further research I find that she has a history of UTI's that present with change in LOC. I call my friend in bed control and explain that this patient has been in the ED for a while and could we get a fresher patient. He assures me this one will probably be plenty fresh.

Upon further investigation the hospitalist has not ordered any neuro checks for this patient, her VS have remained stable since arrival at 1:30 in the afternoon, there are no IV drips, meds or even fluids ordered for this patient. I am seeing no indications of possible sepsis. Maybe she looks worse in person than she does on paper I think.

Ok so the patient arrives from the ED, she is in late stages of alzhiemer's with bilateral foot drop and upper extremity contractures. Her full time sitter will be staying with her. Skin looks great shes clean warm and dry. Again I ask myself "Why is she in the Cardiac ICU".

That was our only admission for the night. I wonder what ever happened to the CPs,wonder if they ended up on some med-surge floor infarcting.

Oh well, I love this job the good, the bad and the stupid.

Who wants a Cert?

Testing straight ahead. October 28, 2009. Oh no what have I done, if I don't pass everyone will know that I am not as smart as I think that I am. I will know that I am not as smart as I think that I am.

I kind of like living in the perceived reality of my own greatness. What it I do pass, will my perceived greatness improve, will my quality of life improve in some way. I certainly know that my paycheck will not reflect this proof of my greatness.

Calm down, this is only a test. If this were a real emergency you would be instructed...

Ahhh, I feel much better now. Well back to the books, Laura, David, and Denise are waiting, these are the CCRN exam gurus who have collected my money and promised that with their help I willl pass the CCRN. I will keep you posted on how that works out.

If you don't want swine flu don't eat the barbecue at the buffet!!

I am by no means a germ-a-phobe but here are a couple of things that I keep in mind:

I am a firm believer in good hand hygiene, not just antibacterial gel (although that is good too) but old fashioned hand washing with hot water scrubbing your hands while you sing "happy birthday" in your head and then drying off with a fresh paper towel and using that towel to open the bathroom door as you leave. I do this before I sit down to eat in a restaurant. If more people did this I would think that I would meet them in the bathroom but unfortunately I don't.

DO NOT EAT AT THE ALL YOU CAN EAT BUFFET!! My family finds it amusing that I balk each time they mention going to the local buffet. I gown up to enter the room of a patient that has MRSA but next week that same person may be dishing out their greens from the food bar right in front of me.

AVOID HANDLING CASH! Some women chose to carry it in their bra. It's used as tips at strip clubs, you don't know who's G-string that money came out of. Just think of all the cash only business and unfortunately money laundering does not mean germ free.

Do not go to the ED unless you are bleeding profusely, having crushing chest pain and/or guaranteed that you will be taken back to a bay immediately. I once had a pt's family member request a change in seating because the person next to them had a cough his statement went something like..."that person is sick, I don't want to catch it"...then go home what do you expect to find at the freaking hospital, the ED no less.

Keep your head out of your ass, use common sense, and keep it all in perspective. Remember most people will recover without complications, many will not even require hospitalization. In a couple of weeks there will be something else to capture the headlines and cause a new media frenzy that will send an already hyperventilating public into another panic.

Well I found the remote for the dish and there is still nothing on worth watching. I am sooooo bored. Nothing happened at work that is really blog worthy. I don't know if I am just cranky or bored. Thank God I work with such a great group of people, they make the shift entertaining but I can't write about them.

My patients were all extremely stable, I kept them entertained and amused during the shift at least until they all went to sleep by 2330. I am looking to move to an ICU that has more critical patients more of the time. Not that I want people to be sick I just want to feel challenged and stretched and be available for those who are really in need of ICU nursing care.

We got a flash pulmonary edema transferred from the floor no cardiac symptoms involved. Lasix and bipap and he was doing fine within an hour. The family arrived bringing with them the aroma of stale cigrettes-it was enough to send the staff into resp distress. One of the family members asked "When are you going to defibrillate". I have to admit I was speechless for a moment but I did think of some amusing responses. Thank goodness I have been practicing; stop and think before you speak. I began to explain the etiology, treatment plan and expected outcomes to the family. The family could not seem to understand why the patient had not or was not going to get 200 joules of electricity through the heart to help with the CHF. The physician tried to explain to the family what had happened and that the patient had already had a significant improvement. As the Dr left the unit he was shaking his head and wishing us good luck. Ever heard the saying "Nursing would be a great career if it weren't for the families"

Right now I will just bide my time, let the new grads get oriented and settled. In the fall when the leaves change hopefully so will I.

I'm a night shift girl living in a day shift world

I get soooo bored at night when I am not at work. I end up staying awake all night and there is nothing on TV to watch. It doesn't help that I can't find the dish remote and the channel is stuck on the cartoon network tonight. I am going to share some of my work sayings;

I don't do skin care on my patients I "Butter their buns".

My patients don't have stool smears they have "Farts gone wild".

My patients don't die they go on "Field trips" they are not allowed to go on the field trip without a signed permission slip (DNR).

When I get a walkie talkie admitted to my ICU my question to them is "What's a healthy guy/gal like you doing in a place like this".

My patients don't get discharged with discharge instructions they get paroled with parole papers. I don't do much discharging on the night shift.

I am known as the "psych whisperer" because I seem to calm the anxious and confused (often without haldol or ativan for them or for me) I explain that "It takes one to understand one"

I often hear from my colleagues (lovingly) "You ain't right" my response "But I'm rarely wrong"

I believe you hurt the one you love so I know that at 2:00 AM there are a few doctors who absolutely adore me.

Drs don't like you to be too perky at 2:00 AM so be sure to use your 1-900 voice until they are fully awake.

All men need an extra large external catheter the different colors on the package just indicate where they were manufactured.

We call our external catheters Texas Caths I once had a patient tell me he didn't need a Texas he needed a Rhode Island. I loved him, he kept me in stitches during his stay.

While wearing bright lipstick I kiss my patients on the forehead before they go to surgery so that everyone knows they belong to me and will treat them extra special. (after all I have set high standards).

I want to know if my patient brought me back a T-shirt from radiology, you know the one that reads "My patient went to radiology and all I got was this lousy T-shirt"

When I do an EKG at the bedside I make sure to tell my patient to smile for the camera.
I also try to increase sales by asking them if they would like a 5x7 or wallets to share with family and friends.

The transfer center nurses know that if my patient is admitted on an odd hour they go into an odd numbered room even hour admissions go into even numbered rooms. If only even or odd rooms are available then the ED must hold the patient until the appropriate hour. (ha, ha not even in my wildest fantasy).

When my patient is in trouble or really sick don't mess with me, I will tell you exactly what I want you to do. I am not Bi-polar, depressed, angry or unhappy I am just extremely focused. I am a DGN (Damn Good Nurse) and know when it is time to get serious putting fun and games aside because this is MY patient. The patients that are entrusted into my care get the best that I have to offer.

I work tomorrow night I hope I get some good blog material while I am there.

Why would I want to work from home?

In just one week I collected over 110 spams in my spam box. While checking to make sure it all needed to be deleted I had quite a few offers to work from home. My first thought is; "why on earth would I want to work from home". I work so that I can get away from home and be with people who seem to appreciate me and act as if they are glad that I am there.

I love my 2 boys, I think they are so cool and enjoy hanging out with them. I get to be the fun parent. I have also always been the disciplinarian. We get along pretty well most of the time. Occasionally we don't see eye to eye and I have to remind them that I am the adult in the relationship. So why wouldn't I want to stay at home?

I stayed at home full time until the boys where 5 and 6. Once they were both in elementary school I went back to school full time. I was able to arrange my schedule so that the boys did not have to spend too much time with a baby sitter or in childcare. The division of duties; my husband was responsible for the outdoor chores while I was responsible for the indoor chores including budget, shopping, housekeeping, laundry and so forth. He used to refer to staying with the boys when I had something to do as "baby sitting".

Hoping that he would become more supportive while I was in college I pointed out that when I graduated he could stay at home full time. The day came for him to take early retirement and stay at home full time, I thought he would then take over the "indoor" chores that I had been doing since we had been married. Come to find out according to him he could not "do it all" and expected me to continue to cook, clean, pay bills, homework and so forth. He has been a full time stay at home parent for almost 2 years now and we still struggle with the delegation of duties. If I'm at work I don't have to see the laundry that needs to be put away or the dust kangaroos (bigger than bunnies) that need to be taken care of.

My husband is not a happy person, he is often disappointed by life because circumstances or people fail to meet his standards. We are committed to remain in the same house to raise our boys to the best of our ability. I know that I am counting down the days until they will be 18 years old (1,934 days) when I can in good conscience leave in my very own land yacht and do travel nursing. (I plan to start in Alaska and work my way east).

Life should be embraced and each moment savored. People in the health care field are all to familiar with this idea. We know that every goodbye may be the last goodbye because we have witnessed lives that have ended without warning. I believe in eating dessert first, leave the dishes in the sink and go fly a kite when the wind is blowing, laugh often for laughter is the best medicine for whatever ails you and when life gets to be too much close your eyes and visit your happy place (mine is the beach).

I once had a patient tell me that he could see me coming to work even if I didn't get paid. He was probably right. I work with a wonderful group of people that accept me the way that I am, ADHD and all. My patients often want to know if I will be back to take care of them. I make a difference in peoples lives. Why on earth would I want to miss all of this and work from home.

I don't know it all but I thought I should

I do not know everything about my job as an ICU nurse. I know that I am not expected to. When I don't have the answers and can not find them instantly (impatience: adhd trait) I feel that I am not meeting expectations. These expectations I know are self imposed and unrealistic yet I still disappoint myself when I "fall short".

I had a really good weekend, I went back to work well rested after vacation and ready to spend time with those who seem to truly appreciate me and laugh at all of my jokes. All of my patients were fairly stable without any unexpected complications. Until night four:

On night three a patient had been admitted as a telemetry unit overflow patient, this patient had a significant medical history, the admitting diagnosis was SOB/CP. She was not my patient but I answered her call several times for the nurse who was caring for her. This patient seemed to be displaying typical drug/attention seeking types of behavior which included crying out, moaning loudly, speaking as if she were breathless (O2 sats were in the high 90's) demanding specific pain medications. She refused alternate meds due to ineffectiveness and made repeated demands that her doctor be called for orders for her pain med stating very loudly at 5:45 am "Call Dr. ... he knows that I need my...". We had already called and the very grouchy physician would not give an order for the med. At 7:00 am her husband rolls in the door and she very loudly and tearfully explains that "they are doing nothing to help me". Five nurses (including me) had taken turns trying to calm and assist her and 4 of the 5 sighed "I'm glad she was not my patient" (including me).

Night four: Hi ho Hi ho it's back to work I go. Oh NO! She's my patient, this nights gonna blow.

She was now intubated though. Late in the morning while the night shift were tucked in our beds, visions of vacation in our heads...her O2 sats dropped to the 50's and had to have rapid sequence intubation...needless to say she was very quiet during my shift. This is where the guilt begins, "Gee, I was in her room this morning, I looked at her and decided that she was a drug seeking drama queen". I did not make the statement out loud but the chant remained in my head during the entire night. I found myself trying figure out what I should have seen during my few encounters so that her decline could be anticipated.

I have a friend that lets me know when I am being too hard on myself. That night my friend threatened to take away the stick that I was beating myself up with. Last night Dr. Cox told JD that, "If you start blaming yourself for every patient that dies it is a slippery slope that you can not come back from" (or at least that is the way I remember hearing it). My very wonderful and wise friend and Dr. Cox are right. I must learn to accept that I do the best that I can with the tools that I have and sometimes even the best education, doctors, resources, equipment and prayers can not give you the outcomes that you want or expect.

I have decided to put the stick away.

I wonder if my patients and colleagues would still look at me with undying admiration, affection and awe (or at least that is the way it is in my happy place) if they knew the secret to my success is late night reruns of Scrubs.

miss the craziness that I can leave after 12 hours

Vacations are great, they make you appreciate your job. At least you can leave the people that annoy you at the end of the shift. While on vacation you can't leave them at the state line rest area after 12 hours.

I find myself saying things like:
"Stop whining!!", while at work I would say "What can I get to make it better, how-a-bout some ativan, morphine, haldol, valium...".

"What do you mean you are hungry again, we just ate 45 minutes ago!" at work it would be "Your hungry how wonderful, what can I get for you, a sandwich, pudding, a salad, jello, can I increase your tube feeding rate for you?"

"No we are not there yet! We just left 20 minutes ago." I say to a patient, "You are getting better, I know it is hard to believe right now but the better you get the faster you get better."

Apparently I leave my patience with my patients.

memo to self

Dear Self,

The next time you pack for vacation do not take only your skinny clothes. After the 12 roasted marshmallows by the fire, the barbecue, kettle corn, funnel cake and the $7.00 ice cream cone that you ate at the amusement park you will be trying to fit your "bloated" body into your skinny jeans. Not only is it hard on the ego it is not an attractive site to behold. There is a reason cruise wear includes lots of loose fitting dresses and elastic. It may be better to face the consequences of your vacation indulgence once you return home and mount the scales in the privacy of your own bathroom.

Love,
Self

permission slips and field trips

My patients don't die, they go on field trips. I don't let them go on the field trip without a signed permission slip (DNR). At least that is the way it is supposed to be.

The most draining, exhausting, burnout inducing cases are the ones in which the patient has had their permission slip signed yet the family refuses to let them go. A 90+ patient is admitted with ischemic bowel, there they lie in their bed intubated, TPN, Levo, Vassopressin, bicarb infusing into the central line, a-line pressure indicates a MAP barely above 60mmHg, CVP 4 urine output looks like over seeped tea and a DNR bracelet on their arm. Or the 80+ patient that signed a DDNR but the witness signature in not legible the family insisted that the EMTs do something when they were called to the home and now there the pt. lies in an ICU with the family refusing to accept the grim prognosis.

What keeps me going when I want to walk away and never look back? I'm not sure, I whisper in their ear that it will get better...one way or another it gets better. Scenario 1: The family will come to terms with the wishes of the patient and give them permission to go to the other side. Scenario 2: No matter how much or how many hormones, pressors, and fluids we pump into their system their heart no longer conducts the electrical impulses to keep it beating and life on this earth ceases for them. They are finally able to board their plane, train, car, boat, helicopter, UFO, wings of angels or what ever mode of transportation that is provided to the other side. Scenario 3: They may get well enough to leave our unit or hospital; but at what cost? None of them has ever come back and told me "thanks for keeping me alive"...then again none of them has ever come back and told me "thanks for staying with me till the end" either.

Since I have been a nurse (5 years) I have only had 2 of my OWN patients code (one lived on life support for a few days the other we were never able to revive). I do not know if it is luck, skill or because I let them know right up front that field trips are not allowed without a signed permission slip and their families permission; they are not to board the bus, train or plane. So far this has been an effective strategy for me along with a whole lot of prayer and diligence to keep them here until the next shift. Try it sometime and see how it works for you.

One is never prepared when a patient decides they are going on the field trip without your or anyone elses permission it can be devastating to one's confidence and moral. I personally still wonder if there is anything that I could have done better, diffrently, or faster to improve the outcomes for my patients.

Someday I will be on the other side and I will know the answer, but for today I have to have faith and courage to do what I do to the best of my ability.

what are my loud clothes saying about me

My nurse clothes are on the bright side. I like the vibrant colors and patterns, a lot of my patients seem to like it too. Many of them probably can't see that well due to glaucoma and other age related visual deficits; this way they can see me coming. I once had a Dr. ask me if I got dressed wearing sun glasses, I told him no but I do get dressed in the dark and what I can see is what I wear (this was when I worked the day shift and got up at 0'dark 30).

Today I had to go into the hospital to do some committee chores. My people clothes are actually very conservative with browns, blacks and blues. People are amazed when they see me and often find it necessary to comment on my appearance when not in nurse stuff. I was even asked where I was interviewing since I was dressed to impress.

As I contemplated this reaction from others realized that before I go to the bedside I prepare. I put on the costume, learn the lines, and play the part. I paste on my happy face while in the elevator. I enter the unit as a performer coming on stage gauging the mood of the audience. I receive my script from the previous shift. I take on the role of care provider when I enter the room with "Good evening, my name is Kim and I will be your nurse tonight". Will this act be a comedy, tragedy, horror story, a tear jerker or an on going saga.

When the shift is over I pass the script on to the next nurse. I take my final bow as I leave the unit. I enter the elevator attempt to work the stress out of my neck and shoulders and on the drive home I critique my performance. In the days to come I hope that the critics will give me a glowing review, expressing what a wonderful nurse I am and what good job I am doing.

Clothes; just a part of the costume. I sure am glad I don't have to wear white-if I did I would insist on wearing the nursing cap too.

Don't try this at work

Apparently I have too much time to think when I am not actually on the job. Today I was wondering what would happen if one morning while the physician were rounding respond to his entrance into the patients room with "Well hello Dr...., When did you get your license back." Even in my ADHD wired brain I realize this would be the fast track to unemployment but it sure is a funny picture in mind. It has given me hours of amusement today as I picture how each physician might spew and sputter in response, I imagine their faces turning purple with rage, shock and embarrassment.

at 2am he forgets what he learned in med school

I hate calling this surgeon after midnight; he seems to forget he ever went to med school. Night one pt. in CICU for afib post-op. Pt. has hypo-active BS, pt. reports no BM since pre-op(lobectomy) Now post-op day 3. I began tx with what I had; no results. In am Req. for more aggressive bowel regimen. Left a note for physician on the chart to address issue notifying him of lack of progress and abd changes each day. By my fourth night of doing SSEs, dulculax, fleets, miralax, mag citrate and so forth without results she vomits 100ml anti-emetic given; vomits again (200 ml) at 2 am. Now I know what I need to do and am required to notify him that I want to insert an NGT to LIS, change her amiodarone and lopressor to IV and make her NPO. When I call him he states "I know who she is, whats going on?" I have reminded him that she has not had a BM and it is now post-op day 7, and that she has vomitted twice therefore...and I state my request. His response is "Why is she nauseated and throwing up?" I again remind him that she has not had a BM in over 8 days. He asks if I gave her meds to make her nauseated and seems stumped as to why she is throwing up. I wish I had the nerve I would have stated "Because, Dr. ... she is FOS!! (In my fantasy I don't use the acronym). Do MD's appreciate the fact that we don't like calling them at 2am any more than they like being called?