B.M.S.M.I.T.S.

I survived what I feared might be a week from hell. I was at work way too many days the past two weeks but it wasn’t all bad. The worst part was sitting through an 8 hour class on pain management. That was torture. They could have crammed all that material into three or four hours. It was a joke to sit there listening to all the stories and sidebars- I was more exhausted at the end of 8 hours of sitting there than I am in a 12 hour day running my ass off.

Last Friday on my one day off before I went into my three day weekend stretch of work, my Surly cyclocross bike came in. I went over to REI and got all the kinks worked out and fitted with cleats. Cleats and curved handlebars plus a road bike and only two big chainrings are a whole new experience for me. I practiced on the grass in the backyard with the cleats until I felt confident enough to go out for a very careful 15 mile ride on the bike path.

It’s hard to get a new toy the day before you have to go back to work! But it's probably a good thing. I have to be careful not to fall off the bike or tip over with my feet locked in the cleats this week. I’m running an ultra in Wyoming next weekend and I need to keep my body intact.

I have been off orientation for a month as of today. The first two or three weeks we had a low census, almost no patients. I was lucky to get any patients at all, so I didn’t get hard assignments. Two of the charge nurses like to give me tougher assignments, the other two I’ve worked with gave me easy patients, mostly transfers out to the floors. I’ve been the transfer queen the past few weeks. I’m ready to move on to a bigger challenge.

I did get a couple of challenging patients and assisted with two procedures at the bedside. Last weekend I had a patient who was septic. She had an abscess in her arm and I saw the surgeon do an incision and drainage of the abscess at the bedside. That was cool. There wasn’t too much pus coming out though, which was weird. You’d think being that sick there would be a ton of nasty drainage in there. I got to do my first sterile dressing change on her arm the next day. I was a little nervous because I don’t feel too confident about knowing how to do different types of dressing changes. I knew what to do because I watched him do the I & D and put the first dressing on the day before.

It was funny, I haven’t thought of Roger in a while but he was right there standing over me as I pulled out all the gunk packed into the hole in her arm, irrigated it, put on the sterile gloves and re-packed it. Why is it that I still get that feeling like I’m being watched whenever I put on sterile gloves?

I watched this patient improve over three days. She had a temperature of 104 the first day and was puking bile, her skin was red all over, and I worried when I went home that first night that she might die overnight from septic shock, and by the third day she was walking the hallway, eating food, and had transfer orders to go to the floor.

We have about half a dozen new nurses orienting right now on our floor. They all have prior nursing experience but it’s interesting to hear their perceptions of coming to ICU after doing floor nursing. They all find it intimidating. I look at them and think how much it would help to have their experience, but it sounds like they are as scared as I was when dealing with these sick patients and all the lines, vasoactive meds, going on road trips and bedside procedures.

Over the weekend it was pretty quiet on the floor and I had two patients but they weren’t too challenging. As a result I wasn’t too tired on my third day in a row yesterday. Michelle was in charge and she gave me a challenging assignment. I had one busy trauma patient and another who was not much work at all and didn’t belong in ICU. When I got report in the morning I found out none of the admission paperwork had been done on the easy patient. I figured I’d get to it over the day. I knew I'd be challenged and busy. One little fear in the back of my mind was the fact that the trauma patient's doctor was the BIG MEAN SCARY MOST INTIMIDATING TRAUMA SURGEON.

B.M.S.M.I.T.S. was on call that day, which meant there was a chance I might have to deal with him. He's mostly been working at the new hospital, so it was unlikely we'd cross paths unless the patient developed some sort of complication.

Before we had rounding I was assessing the trauma patient and the intensivist walked into the room. He asked me what his lungs sounded like. I told him I didn’t hear much of anything on that one side. He told me that the morning chest x ray showed a big pleural effusion on this patient. He said we’re going to have to either put a chest tube in or do a thoracentesis. He asked me to call the trauma surgeon to see what he wanted to do, and to let him know that he was available to do the procedure if the trauma surgeon wanted him to.

My worst fear came true. I knew what I had to do and I went to the nurses station dreading it…

I had to call the BIG MEAN SCARY MOST INTIMIDATING TRAUMA SURGEON. No way around it, he was the one on call. The one who intimidates and terrorizes even the most experienced nurses!

While waiting for my turn at rounding I went over to look at the chest xray and then it made sense what I heard when I listened to his lungs. I also needed to get something else for this patient, he was in so much pain when he woke up because he wasn’t pushing his PCA button at night while sleeping. I wanted to get him a continuous dose of pain medication at night. The intensivist told me to ask the big mean scary most intimidating trauma surgeon about it when I talked to him.

The big mean scary most intimidating trauma surgeon was in surgery and the unit assistant paged his nurse for me. I knew I’d have to have all my ducks in a row when he called so I got all his labs together and looked at the med sheets and everything. I knew I had to not be so intimidated by whatever he said so I’d remember to ask him about the pain issue too.

The nurse never called back so after rounding I put in a page to the trauma surgeon again. I was running my butt off trying to keep up with all the medications for the trauma patient and I was way behind on checking orders and I hadn’t spent any time getting paperwork done on my other patient, fortunately he was stable. The only weird thing was that he was draining nasty pinkish orange goo out of his nasogastric tube. I asked him if he ate anything pink the day before. He said no. It was the weirdest looking stuff. It wasn’t bloody pink, it looked more like a mixture of pepto bismol and orange juice with chunks in it. I kept flushing the tube so it wouldn’t clog up. I was glad it was coming out of the tube instead of him vomiting it up.

The intensivist was going off the floor and he stopped by to remind me not to let the trauma surgeon blow off this patient. By 11:00 I heard the trauma surgeon was in surgery and he was going to come up and see the patient in a half hour.

Of course right at 11:30 everyone in the world wanted to see me- the doctor for my other patient, the nutritionist, the social worker all came by at that time. I was busy talking to the other patient’s doctor when the unit assistant came up and said, “The big mean scary most intimidating trauma surgeon is on the phone.” I looked at her.

She laughed at my expression. In a deep gravelly voice mimicking the surgeon, she said, “He said, ‘I want to talk to the charge nurse’. Michelle’s at lunch, so he’s all yours.”

I finished up with the other doctor as fast as I could and grabbed my pile of stuff on the trauma patient, swallowed the lump in my throat, took a deep breath and picked up the phone. I told him about the pleural effusion and that the intensivist offered to do the procedure, and what did he want to do.

There was silence on the other end. My hands were shaking. I took another breath and then I asked him about the pain medication. I asked if he could have a continuous dosing at night.

More silence. Then all he said in his low gravelly voice was, “I’m not a fan of that”. He hates to oversedate his patients, but sometimes I think it doesn’t give them enough pain relief.

There was another long silence. Then he said, “Give him Toradol 30 mg IV every 6 hours for three days only.” I read it back to him.

More silence. Then he said, “Let the intensivist know I’ll look at the chest x ray and then I’ll tell him what I want to do.”

I said, “Okay, thank you.” Then he hung up.

I was shaking all over. I took a deep breath and one of the other nurses who was watching me talk to him said, “Good job! I’m proud of you!”

I put the Toradol order in and got back to running my butt off between the two patients and reassessing them. I was grabbing medications and doing accuchecks, getting insulin, and trying to stay up with the constant potassium and antibiotic drips on this trauma patient, when the intensivist came back and said he talked to the surgeon and he was going to put in a chest tube in about 15 minutes. I talked to the trauma patient's family and told them the plan.

I have only watched and marginally assisted with one chest tube insertion a few weeks ago, so I had a slight clue of what they needed but my brain was so full of everything else that I had to stop and think- fortunately one of the other nurses who was precepting a new nurse offered to help. They both came in and watched and helped me get things together. I was so lucky to have them there because I was trying to remember all the supplies I needed and the medications, I kept having to go back to the Pyxis because I was afraid I didn’t get enough Versed and Fentanyl. The other nurses got the chest tube cart for me and the pleurevac and we got things ready. I asked the intensivist how much Versed and Fentanyl to give the patient to start, and the unit assistant wanted to watch too. It was great having the two other nurses and the assistant there, we had to move the guy around, put down all the pads on the bed and pull out supplies and draw up meds and take vitals, there’s so much to do for a procedure you really do need several sets of hands.

The intensivist came in and he looked amused at the four of us in there, he knows we’re all new nurses and he was probably hoping it wouldn’t be a three ring circus. But it went great, I had everything he needed and I’d pulled out all the right stuff for the dressing. If I hadn’t watched the chest tube insertion a few weeks ago I would have been clueless. One of the nurses did vital signs, another one pushed meds, and I got the supplies and handed them to him.

The minute we got the chest tube set up, the patient dumped 1500 cc of fluid into the pleurevac. It was amazing, all this stuff came pouring out of his chest. That’s why he didn’t have any breath sounds and was in so much pain, with a liter and a half of fluid compressing his lungs!

We got through the whole thing smoothly, I didn’t screw up anything or break sterility and the patient did well. By the time the whole thing was done and cleaned up and I reassessed the patient, it was almost 3:00 and I had transfer orders for my other patient, but I hadn’t even touched his admission paperwork! I hadn’t eaten lunch either.

I got caught up on meds on both patients and then told Michelle where I was. She said not to worry about the admission paperwork because we didn’t have a room for the guy yet, and that she’d watch my patients so I could go eat.

After lunch I had a million more meds and afternoon assessments and other stuff to do, and was way behind on charting. I thought I might have to stay late to finish up charting after that chest tube, but I got partially caught up. For some reason the patients on the opposite side of the hall from me all had various alarms going off all day long and each of those nurses had a preceptor with them, so there should have been two of them to keep on top of their IV pumps and ventilator alarms and everything else but the alarms kept beeping and I didn’t have time to keep going in and checking what was beeping between running my butt off. I was trying to think and the alarms were making me crazy., I was starting to feel a little overwhelmed just because I couldn't think clearly with all the background noise.

By 5:00 I had things basically under control and was thinking about starting some of the admission paperwork, but my brain was completely fried. I realized this when I went to do accuchecks and vitals at 6:00 on my two patients and wrote down the numbers on the opposite flow sheets. Fortunately I caught it before I went to get insulin for the first one. I went and got one of the other nurses who helped with the chest tube and asked her to double check me. We have to have a second nurse check our insulin anyway, but I asked her to check that I had the right numbers on the right patient. My brain was shutting down and I still had almost two hours to go and a half dozen different medications to do on my two patients.

I felt bad because I was leaving the night shift with so much to do. I like to be able to give my patients a bath, I never got the abdominal dressing changed on the trauma patient because we were so busy with the chest tube, and of course the admission paperwork.

Once I got the insulin done on both patients, I was about to sit down and chart, and the unit assistant came up and said, “We have a room for your patient.” There was no way I could transfer him at shift change, or without paperwork. Michelle told me she would pass it onto the night shift.

I finished all the meds and basic charting for both patients at 7:01 p.m. I was waiting around for the night shift to get out of their group report and went through as much of the admission stuff as I could.

I gave report and got out of there. I survived! I survived the BIG MEAN SCARY MOST INTIMDATING TRAUMA SURGEON! He didn't bite my head off, either. He didn't even get surly with me.

I hoped there would be a beer in the freezer when I got home. There was.

Sleep is my next priority.

And then I need to go get surly on my Surly. WAHOO!

Peace, love, dirty and surly,

Towanda, ICU RN