What Do You Do: ICU Nursing, Hour One
I’m an RN in a 18-bed Med/Surg ICU. Intensive Care units are for the sickest patients in the hospital. You get sicker than we can handle the only step up is to meet your Maker or have said Maker do a miracle.
This is our Mantra:
We care for people in Septic Shock, with CVAs, DKA, decompensated heart failure, post cardiac arrest, COPD exacerbation, ARDS, drug overdose, and the post-ops of every discipline (except the open hearts who have their own CVICU). We manage treatment modalities like CRRT (continuous dialysis), hypothermia protocol, and LV assist devices like the Impella and balloon pump. Highly technical and lots of variety, which is what attracted me here.
I originally was going to write about an entire shift in the ICU but found that the first hour of a recent shift gave a decent representation of what we do. Not terribly eventful or comprehensive, just typical.
Hour One went as follows:
I walk on the unit for the first of my three 12 hours shifts. Check the board for my two assigned patients, find the nurse who had them for the day and plop down next to her. Yes, only three shifts, and yes, only two patients. Trust me, it’s enough.
The “Day Babe,” as we night shift nurses affectionately call day nurses (do they have a name for us? The walking dead……) fills me in on each patient: history, hospital course, treatments, status of each body system. I fill out all the little boxes on my report sheet in an attempt to grasp an entire patient’s health and plan of care in less than five minutes in a way that somehow qualifies me to be responsible for them. It’s always astounded me how short, random, and unregulated this process is.
Hemodynamic monitors placed around the unit display heart rhythms and vital signs on each patient. They alarm and flash with increasing levels of dismay when something is out of range. This varies from little peeps and flashes for something minor (O2 sat probe is off) to the From Hell noise that awakens your hindbrain to mortal danger (your patient’s heart has stopped beating.)
Both of my patients have heart rhythms that are compatible with life and no alarms. Yay. I fill out a quick little schedule for myself for each patient and then go to see the sicker one first.
Patient One: Small bowel obstruction status post Exploratory Lap, went into respiratory failure on the hospital floor after developing pneumonia. Came up to us to be intubated, diuresed, and get IV antibiotics until the invading organisms are killed to death. She’s in septic shock on several pressors, Cardizem and heparin drips for AFib, fentanyl for sedation.
I assess her, making the million little observations that tell me if she is really doing as well as the monitor might lead me to believe. Vital signs can be very deceiving, nowhere more than ICU. Lung/heart/bowel sounds, ET/OG tubes, pupils, hand grips, pulses, skin integrity, IV access.
She’s severely edematous. Her flesh puckers under my finger like that green brick material flowers are arranged in. I wonder what she does for a living, if she has kids, pets, if she’s married? Read any good books lately? Details of personal life are UTA (Unable to Assess) when the person is I&S (Intubated and Sedated) and there’s no family around.
I ensure all her drips are running correctly and calibrate the arterial line, which tells me her MAP is 68. Beautiful. Only as much Levophed as she needs, no necrotic fingers and toes for her. She looks good. Stable-ly unstable, we call them, when their vitals are normalized on medicated drips.
Patient Two: Older gentlemen, VFib arrest, visited the Cath lab for a variety of stents then hypothermia protocol. He’s past all that now and has just been extubated. The day nurse told me he looked good respiratory-wise. I don’t agree.
He’s tachypnic taking shallow breaths. Weak cough that isn’t getting the job done. He’ll be reintubated within 12 hours if he keeps this up. I call my friends in Respiratory Therapy for ENT suction. It helps, but he HATES it. He asks me why I like to torture him. I tell him that I don’t, that I’m trying to get him better. He scowls. He’s over it. I don’t blame him.
The rest of his assessment is WNL, and that’s not “We Never Looked,” it’s “Within Normal Limits.” Because I looked. Except…….I can’t help but notice that he doesn’t move his left side as much as his right, and his hand grip on that side is just a tiny bit weaker. Am I imagining it? His pupils both react to light but don’t look exactly the same…..and he’s not really answering my questions. He’s probably just being difficult….right?
Come on man, don’t do that. Let’s not take an emergent trip to CT and do TPA protocol right now. Fast as I can, track down the NP. He has a history of right CVA with residual left-sided weakness. The day nurse didn’t tell me that in report.
I push some IV hydralazine for his BP of 180/70. He asks for a beer. I feel foolish for worrying about him so much a few minutes ago.
The hydralazine helps for only a few minutes so I chase it with 5mg of metoprolol, pushed over two minutes because I don’t want to stop his heart, just slow it down. I make peace with the fact that I’m going to be chasing his BP with IV meds all night long.
I set the bed alarm. Dude’s awake now and I don’t trust him, even as weak as he looks. You know how 100 lb. moms can lift cars when their kids are in danger? Elderly patients can do astounding things when the delerium sets in.
Overall a pretty easy ICU assignment.
I leave his room and hear a plea for help from a nurse at the end of the hall.
I know this patient, Heroin OD. Tattoos everywhere. When I say everywhere I mean it. Many of the nurses had speculated about whether or not certain tattoos look differently when certain body parts were in certain anatomical configurations. If you know what I mean. If you don’t, don’t think about it too much.
We don’t mean to belittle people or treat them as objects. We can’t help but think these things.
The nurse called for help because he’s been on tube feeding for over a week and his Dignicare fell out. You can imagine the consequences. If you can’t imagine them because you don’t know what a Dignicare is don’t worry about it, innocence being bliss and all. I help her get things straightened out. She grateful. I promise to help her with his bath later. He’s a big dude.
Quick stop at the Accudose, grab my meds and waste Versed and Fentanyl for another nurse. We chat and make fun of the NP who’s working on the other side of the glass, not noticing us. We’ll tell him about it later.
I give Patient One’s meds after deciding that they’re all safe and appropriate for her. A few IV pushes, hang an IV antibiotic, crush up the pills, mix them in some water, flush down the OG tube.
I most definitely never pretend I’m a wizard making a magic healing potion when I do this. That would be childish and I’m a professional.
Her MAP is 64. Borderline but I’ll ride that out another 10 minutes before titrating her Levophed; you learn after a while not to micromanage your pressors……
Then the monitor starts alarming THAT alarm, the hindbrain one. Bed 24, and judging from the trace on the monitor it’s legit VTach. I start to run to the room but two steps in the alarm stops. Just a run of VT, not sustained, 20 beats or so.
I grab the rhythm strip that’s printing out and go to the room to give it to the nurse, a friend of mine who just got back from maternity leave. She turns to me and takes the strip.
I don’t know this patient. Septic on CRRT, came in yesterday.
“She looks like shit, ” my friend says. She does indeed.
Now that’s not some random or insensitive insult. It’s a thing we ICU nurses say when we get that vague unsettling feeling in our perceptive gut that even though this patient looks okay on paper or computer screen they’re going to go downhill, soon. And now here she comes with the increasingly-long runs of VT.
“I told them,” she says, shaking her head. I tell her to let me know if she needs anything, I have my unit phone.
Then I go get a unit phone and sign into it since I forgot to do it earlier. My manager runs a report every week that tells her when we forget to sign into a phone within five minutes of starting our shift. I’ll get a strongly-worded email.
Check the monitor, Patient One, MAP 72. Hah! Peek in on Patient Two. Still in bed. BP 200/103. Awesome. Bust out the IV labetalol. Take THAT. Back down to around 180/70. Sigh. NP says to give it a half hour.
Grab the aide, both patients get repositioned. Sit down to chart. Barely get logged on.
Good buddy nurse sticks her head outside the curtain and gives me The Smile. She’s helped me so many times, she knows I’ll do anything for her. Not that I want to go into that patient’s room. I do not. But we’re nurses, and we do what needs to be done.
I enter the room of the patient who solidified my belief that ultimately ICU nursing is not for me.
Now, I love intensive care. I love helping someone right in the moment they need it most. I’m good at my job and I love using my head and my heart to do it. But I can’t stay here. I’m willing to walk with a patient through difficult and painful treatments to get them better but I didn’t sacrifice my time with my family and go to nursing school to put people through hell for no meaningful recovery. I have an ethical aversion to a good 40% of what I do at my job now and that percentage only seems to be growing.
Her history is too long to recount. Her body had lost the ability to heal a long time ago. Every organ failing, even her skin. Her skin would break under our hands no matter how gently we would move her.
Her BKA stump has been infected for months. The flavor of this month was Pseudomonas. The nurse was asking for help changing the dressing. We remove the old dressing to find her stump disintegrating into the telltale light green of raging Pseudomonas infection. It looked like pea soup. We were keeping this woman alive so she could turn into pea soup before our eyes.
I couldn’t look at her face anymore. When I had first taken care of her I had paid very close attention to her face, trying to read her expression for anything I was doing that she found painful since she was nonverbal at baseline after massive stroke. Eventually I figured out everything we did caused her pain.
We still warned her of what we were going to do, still apologized. The family had instructed that no pain medicine be given “because it makes her less interactive with us.” The family wasn’t even here. Sorry she can’t entertain you like you want because of the tremendous pain she’s in. I try so hard no to judge them as I’m sure they’re are suffering too. But I fail every time and every time I get angry.
Ethics consult was “pending.” Meaningless, we have no teeth, no real influence. If the family says treat, we treat. What does “treat” even mean, then? If all we do is…..
I stop myself from going down that mental road, again. It simply isn’t up to me. What is in my power to do for this woman, right now, that will help her? I can think of nothing but to treat her gently and say a prayer for her relief.
I don’t know if it helped.
Dressing done, I leave the room with ice in my gut and go back to charting.
A few clicks done before Bed 24 alarms again.
VTach, really fast and not stopping this time. Everybody runs for the room. I’m first so I go to grab the cart with the Resus meds and Life Pack but it’s not there because my friend with the bad feeling already has it in the room. She’s been feeling for a pulse while we ran to her.
“No pulse,” she says as I walk in. I start CPR while she digs out the defibrillator pads. She puts them on around my hands and starts charging the Life Pack. “Clear!,“ I back off, she discharges the shock.
(Ahhhhh sorry. I can’t help it, it’s exactly what we’re doing when we shock someone.)
Sinus rhythm restored.
“Maternity leave didn’t slow you down, did it?” I say to her. She shrugs. Intensivist walks in and starts barking orders about STAT labs and electrolyte replacements. “Need something, call me,” I say as I walk out.
Check the monitor. Patient Two’s BP is 190/90. *sigh*
All things considered, not a bad hour. My scrubs aren’t covered in anything. I didn’t get any indecent proposals. Nobody tried that hard to die.
Eleven hours to go.
