Babies Teaching Babies

Our first collaborative post! A dear friend of mine, who would like to remain anonymous as Freya, RN, contributed the below post. I’ll be posting another of hers tomorrow as well. Keep a look out!

I find it hard to organize my thoughts regarding this topic. It’s been the bane of my existence for the last year, and I’m running thin on my patience and my understanding at the moment.

I am by no means an experienced nurse. I’ve been a nurse in the ICU for four years and I’m getting tired of babies teaching babies. I was a new graduate in the ICU. I’ve been there. I should be more empathetic. The thing is, I was raised by nurses who had 5-20 years of experience in the ICU alone. I always had someone with more experience than I do to rely on. Someone who could help me with my critical thinking and decision-making process. Now, with my few measly years of experience, I’m a top dog at many of the hospitals I’ve worked at.

I have worked in situations now where I am one of the most experienced nurses on a busy unit. These new nurses are so intimidated by working in the ICU that some of them don’t ask questions. If they do ask questions, they feel more comfortable asking their peers and it becomes and issue of the blind leading the blind.

I’ve overheard some conversations that I’ve interjected myself into, just to be able to guide these nurses in the correct direction. Recently I heard a nurse of less than 6 months ask another nurse of only a year if she had to call the doctor back to clarify whether the doctor wanted a heparin drip with or without boluses (HUGE difference). The nurse she had asked said “I know what I would do, I’d just order it this way.” I couldn’t help myself (and probably looked like the biggest jackass in the world) – I walked over and I sad, “I would 100% call the doctor and clarify. It sucks that you didn’t think to ask the first time about the boluses, but really he should be putting in the orders anyways. Think of it this way, after paging and talking to him a second time because of this, you’ll never forget to do that again.”

I’ve heard some scary things out of these new nurses mouths, and I honestly believe it is because the person training them has only been out of nursing school for six months to a year. I’ve offered to train new graduates while in a permanent position and I’ve not had a student for the last five or so months while these babies are training babies. I believe it has been due to my complete honesty and my expectation that if you have a question for me, you’ve thought about the patient, the problem and have thought about what you would want to do. I do not give out answers for free, I train nurses to THINK. You cannot be an ICU nurse without thinking. 

 The scariest part of this whole thing is that management doesn’t seem to find an issue with nurses that have 6 month of experience, training new graduates in the ICU. There are always better nurses than others at any level of experience in the hospital, but I feel we aren’t setting up our new graduate nurses to succeed when the people training them have barely had time to be nurses themselves. The blame isn’t all on management and the higher ups though. The issue is that more and more bedside nurses don’t stay at the bedside. Bedside nursing is no longer a career – it’s a stepping stone. It’s a starting place for CRNA, NP and other advanced nursing careers. Many new graduates start out in the ICU with the plans of being a nurse practitioner by the end of 3 years. I can understand the appeal, a lot less physical labor, less time with the patients, more knowledge, and (what it’s ALL about) better pay.

The more these stepping stone nurses come into the work field, the more older nurses begin to leave the bedside. They leave because staffing becomes difficult and patient to nurse ratios become unsafe when turnover becomes so high. They leave because the people they work with are inexperienced and a danger to their patients. They leave because they can’t physically bear turning a 300 lb+ patient with only the assistance of one other person (and that is the only person they could find after ten minutes of searching.) To be honest, I LOVE bedside nursing, but I don’t blame these nurses. I’ve experienced the issues, I’ve heard the excuse of “It’s been worse before,” and I keep coming back. I’m not sure if that just makes me a glutton for punishment, a martyr, or more likely, a silly gal with a heart for helping others.

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The Fight for the Code Cart

I love circulating and scrubbing liver transplants. Kidneys/pancs at great too, but the livers are fascinating. The organ does so much for our bodies and when it fails or is damaged, the multi system consequences are disastrously….fascinating? Yeah, that’s the word. I’ve learned my sickenly morbid enthrallment with pathophys is almost an industry standard. At least, most other RNs and MDs don’t give the sketchy side-eye when I mention how much I love things like HIV and liver failure.

I’m on call over night for the transplant team with my favorite scrub tech, and really my favorite team from anesthetist to residents to surgeons. Notified at 9pm, set up at 3am, roll back at 5am. Of course we’re delayed. Most are, due to either the donor liver transport if it’s out of house, or the recipient arrival, cooperation, or labs.

The week prior, this same team had run the smoothest code I’ve ever seen in any situation. It was beautiful, a work of healthcare art. And we were proud of it. The experience had brought the whole tam together in a way unparalleled throughout the unit. The transplant room is also one of the trauma rooms, so it houses a code cart 24/7. We check all code carts every 24 hours, regardless of use. Prior to a transplant, I double check the daily check. Another reason the OR allowed me to release all OCD tendencies I might have ever had.

At 6am, my patient rolls back. This guy has active LBBB and lives in afib. Regardless of heart history, the most dangerous part of most surgeries is intubation and extubation. With livers, repurfusion beats them out, but only barely. Anesthesia resident, propofol given, blade in hand to intubate, is disrupted as the OR door flies open. One of the night nurses, an overweight woman who will pay cash to other nurses to take her surgeries so she can continue sitting in the lounge, walks in and begins to unplug the code cart. She says nothing, makes no eye contact.

“Tom,” I said, holding my hand up to pause the confused resident. “Hold on and bag him for a minute.” He breaths for my completely sedated patient. I ask The nurse what she needs from the cart and inform her of the obvious, our impending intubation. She ignores me and begins to wheel the code cart out of the room.

I run across the room, intercepting her and stand between the cart and the door.

“Sandy (our manager), wanted the cart brought into the core.” I point out the three other carts we keep in the OR and relay my patient’s heart history. She seems unphased and repeats the managers request, pushing the cart past me. At this point, the phrase, “pry it from my cold, dead hands” might have exited my mouth, but it all became a haze. I ended up physically removing her hands from the cart, plugging it back in to the wall, adding an emphatic, “it stays. If the manager has a problem with that, she can come speak to me herself.”

She left. We intubated.

Shortly after, while anesthesia placed lines, I was inserting the catheter. Doing so left handed, I left my back to the door. So when I hear the door open, I make eyes toward my scrub and he interprets it correctly to keep an eye on the code cart. My manager walks up behind me.

Sandy always wears hospital scrubs, but I’ve never seen her scrub or circulate a case. Rumor has it she did open hearts about 15 years ago. Since then, she has suffered from the middle-management curse of forgettting all knowledge one learned at the bedside  but being forced by upper management to act as if they hadn’t.

“Are you ok?” Sandy asks. I pick up my patient’s penis in my right hand, holding it upright and refusing to make eye contac. The last thing this patient needs is a UTI from breaking sterile technique.

“I’m good. My patient’s pretty sick, but I’m good.” Still no eye contact as I twist the catheter until it pushes into the urethra.

“I heard there was a misunderstanding over a code cart.” I hit the prostate. More twisting of the catheter.

“No misunderstanding. She tried to take the cart, I explained the severity of my patient’s condition, and I kept my cart.” Up to the hub, no urine out. I take my non-sterile hand and push on the bladder.

“Oh. I knew the team had used this code cart last week.” Healthcare art. “And I wanted to make sure it was ready for the next transplant.” Seven days of scheduled surgeries and now she’s worried about it. What about the hip replacements all day yesterday? Those can bleed almost as much as a gunshot wound to the spleen.

“Sandy,” more bladder pushing, “we check those code carts every day.” Finally! Urine! It’s gross, thick and red-tinged, but urine. I hate to think what this guy’s creatinine is. “It’s been checked seven times since the last code, plus an 8th time by me this morning before the patient rolled back.” I secure the catheter to the leg, bend down to hang the bag on the table, and stand back up to finally make eye contact. “And we don’t have to move a code cart to check them.”

She looks at me. She looks at the catheter. The room is silent; everyone’s eyes down to whatever they’re working on. Her face morphs from chastisement to fake bubbliness. I get more nauseous from that than the smell of the liver being prepped. “Ok! Looks like you’ve got everything under control here!” Yes, now leave us alone, I say, internally impersonating Grumpy Cat.

As the door closes behind her, a slow whistle comes from the surgeon’s prepping the liver. “Oh shut up, Schmitty.”

No code that day.

The Come to Jesus Talk

The come to Jesus talk is a conversation in which you lay it all out there, expose the truth, the reality of the situation, and usually the direness of it. I’ve given these talks more times than I can remember and mostly to drug addicts. Although, patients with heart attacks and heart failure come in a close second. I’m blunt. “If you don’t stop smoking, you’ll be dead in three months.” That patient’s HF was so bad, his only option was hips surgery, which no one would do unless he stopped smoking 2 packs a day.

Most of these talks are met with feigned interest by the patient, some with serious looks, some with shame. 25% of people who have heart attacks make lasting changes. Only 25%. What am I working towards as a nurse? What difference am I making? Are these CTJTs making any difference? I do my job, both as a nurse and as a Christian, give these people the knowledge and tools to help themselves and improve their lives. And most of them blow me off. I’ve learned to let it roll off my shoulders. If I let it bug me, my own stress level would ruin me and be unmanageable. Self preservation.

“Broken wrist. Only history is positive for meth.” Greaaaat. Meth withdrawal. My favorite. My look of annoyance must have shown since the night nurse giving report quickly added, “he’s not your typical meth head. Really nice guy.” Sure. My skepticism proved unnecessary, since, while I can usually spot a meth user 60 ft away, I would have had no idea without that positive lab report.

After a few days of having this patient on the unit, we had developed a good rapport. He requested his family not be told about the meth, so the day I discharged him from the hospital, I waited till his mom left, pulled up a chair, and asked him what was going on. The twenty minute conversation that followed broke my heart. His out of control ADHD, leading to his meth addiction, it seemed miraculous that no one knew about it. He started and still ran his own successful business, functioning normally in society. And that’s after ten years of daily meth use. 

“It will catch up with you,” I told him. “Drugs leave a trail and you cannot hide from its devastation. It will take your family, your job, and every other facet of your life.” He didn’t roll his eyes at me. We talked about the next steps, how to fight it. I gave him the literature, hidden in his boots, so the family wouldn’t find it. 

I didn’t cry. Until I got home. This talk didn’t roll off my shoulders, it stuck there like a monkey. “He still had a good life, a life worth saving,” my then-boyfriend assured me. “Some people are more worth saving than others.” Whew. I hate hat explanation. All life is worth fighting for, worth saving. I truly believe that. That boyfriend and I eventually broke up due to our differing opinions on abortion and other end of life issues, so looking back on those statements, it makes sense coming from him. It wasn’t a good enough answer for me though. I don’t decide who is worthy of saving.  I simply save as much as I am capable of saving.

The question though, is why do some stick with us more than others. Was it the good rapport I had with this patient? Was it the similarities I saw between us, the common ground in life? Was it the impressive and unorthodox nature of his drug addiction? Was it the hope that he could be one of the few that survived? Is it my own personal level of empathy on any given day? If you have an answer, please let me know. And let me know how to combat it, how to continue letting that monkey roll off my back.