Wednesday, February 28, 2007

I've been tagged!

Yeah! I've been tagged by MICU RN and I am a little excited about it...and by a little I mean I threw both hands over my head and pumped the air for a while and then did a little dance. In my office, where other people work. You see, inside the big, professional, grown up TC lies the little, nerdy, sat-alone-at-lunch TC (awwww, poor little TC). It's true, I have an inner dork. So the thought that I have friends (albeit, invisible internet friends) makes me happy. And for those of you who'd say, "Mom, your inner dork is really your outer dork." I say, "Go to your room!"

Anyhoo, here's the 4 things I can't live without/wish I had(on the job version)

1. My laptop. I have an unnatural love for my laptop and I'm not afraid to say it. It's an IBM thinkpad, no, I don't know what version-I'm not that much of a dork-but it is old and it can take a beating. See "I am IS's worst nightmare". (It's near the bottom.) I will never have a desktop computer again. And I have to beat the family off it with a stick. Mmmmm, love, love, love it.

2. a really good ICU nurse-you know the kind-anticipates everything, likes her job, is up to date on all things critical care, has a heart of gold, knows everything about the family dynamics, knows how to get the doctor to do things/order things that we need and isn't afraid to beg, threaten, plead and cajole. Their are certain units I go to where I'm practically extraneous because they do such a good job of managing the donor and the family. And extra large, Starbucks coffee to all such nurses.

3. My "Go" Bag. I was given it by another coordinator who was leaving and didn't need it anymore. It's one of those large, boxy, black bags on wheels with the telescoping handle-like the ones the drug reps use. It has, seriously, 7 million pockets, some of which are hidden. Like a spy bag. I can hear Q say, "And if you open this, Bond, a cloud of black smoke will come out and allow you to make your escape." Oh, I wish. That would be so handy for meetings.

4. My Peeps. I have the best team...5 other women and myself who slog through every call period together. It's so nice to have someone to call at 3am with a question about management or just to vent. And of course to call on the ride home so you don't fall asleep. These chicks got my back. And the recovery specialists. And the inhouse coordinators. I really do work with a great group of people and if you have your own great group of people, you know how it makes your job worth going to . And my medical director. A surgeon you can call day or night and he isn't pissy about it(just very groggy...."who's the patient again?"Down to earth, likes to teach and takes time to explain things and HE'S A DEMOCRAT!

Joke: Why are surgeons and sperm alike?
A: Because every 1 in a billion becomes a human being!

They love that one in the OR! Anyway, he's one in a billion

Extra bonus answer:My husband-I could not do this job without him. Period. I have the best husband on the planet.

Now, who do I tag?

I think....Mama Mia and Jen, because I'd like to see the responses from a seasoned nurse and a brandy new one. Tag-you're it!

Oh! and the thing I covet:that every family that has the opportunity to donate says yes! Less than 1% of all deaths are brain dead and medically suitable to donate, so we have to make each opportunity count. If you needed an organ you'd believe in organ donation, wouldn't you?

Tuesday, February 27, 2007

New Grand Rounds up

The day off and a new Grand Rounds. What could be better. Check it out over at Musings of a Dinosaur.

Thursday, February 22, 2007

Remind me why I work here?

I keep telling myself that it would be so much nicer to do three 12 hour shifts and call it a week. Back in PICU, where patients are small and the body fluids are cuter. None of this call crap, driving all over the state in my ancient car which needs a ton of repairs(and new tires). Most of all, I hate the bullshit that accompanies my job. I haven't ever really worked a corporate job before. In the hospital, if you pull your weight, your peers respect you. People care that you can handle an emergency and that you show up when you say you will. If someone doesn't like you, you pretty much know it.

I have never worked with the amount of complaining and backstabbing as I do with this job. It makes me nuts. You would think that working with death and dying would give people some perspective, but alas, it is not the case. I'm starting to think that someone who I don't get along with is starting to sabotage my reputation-but that'd be CRAZY TALK, right? I mean, we're all adults, right? I'm not usually paranoid, but this week I was totally ready to walk.

Anyway, I went in today and talked with my peeps. That's right, I got peeps. They gave me some perspective and cheered me up. I love my team. I really do love my job. We also got to dissect some discarded organs today too, for an anatomy lesson and that made me happy. Tonight I'm going to get some rest and gear up for my last weekend on call for this cycle.

Oh, and check out Change of Shift over at Protect the Airway. There's some good reads.

Tuesday, February 20, 2007

Studiously avoiding work...

By reading Grand Rounds. Love the Oscar Theme, BTW. Like Anna Nicole Smith and trainwrecks, I just can't not watch.

Saturday, February 17, 2007

1 down, 2 to go

I woke up before anyone else this morning, so I actually have a chance to do some writing. Yesterday's OR went fine and I was home in time for The Soup...mmmm, mindless viewing. We had some glitches...I can't go into everything, but it involved one doctor giving another doctor a piece of his mind for a good 10 minutes while I held the phone(doc on the recieving end was scrubbed in). Both attendings. It was nice not to be the one yelled at for once, usually the TC bears the brunt of everyone's frustrations, but I felt for him.

My last 2 cases that I've gone out on have pretty much been to relieve a coordinator who'se already gotten consent and manage the patient until the OR and then do the OR. It's nice not to be emotionally involved sometimes, especially after this case. You don't always get what you want, but sometimes you get what you need. So I guess I've been given a little break to recharge my mental batteries.

And I love going to the OR. I only worked there for a year-I just like clinical management too much to stay in the OR. I like being in the ICU with the patients and following them day to day. I hope to go back to school soon and get my nurse practitioner with maybe a first assist on the side. When my first daughter was little, I though long and hard about going to med school, but I didn't know if I wanted it enough to devote a decade of my life to it and all the sacrifices that'd go along with it. Once you're a doctor, you can't really turn around and say, "well, I have a million dollars in unpaid student loans, but I think I'd really rather be an artist." I think there's still a frustrated surgeon lurking inside's so amazing to be inside a person, really seeing what anatomy looks like and cutting and sewing and fixing things. I'm still bitter that nurses don't get gross anatomy or even a look at a cadaver cut open once. (At least at my school.) But that's me-the happiest day of 5th grade was when I learned we'd be dissecting frogs.

Anyhoo, last weekend was really quiet and I'm due for an allnighter-we're already pretty busy this weekend, so I'm gearing up for anything.

Friday, February 16, 2007

My weekend

Last weekend, I was on triage. Want an idea of what that's like? Read here. In the meantime, I'm in a holding pattern. I have a young donor and we're going to the OR at 1500. I was just complaining the other day that all my OR's seem to be at 4am. Fortune has smiled on me today, Hopefully, God willing and the creek don't rise, I'll be home in time for The Soup.

I'm thinking of doing a post on the ethics of who gets listed for an organ. Should drug addicts get a new liver? More to come, but I'm interested to hear peoples stories on the matter.

Tuesday, February 06, 2007

Grand Rounds

Dr. Couz does a great job at Grand Rounds this week. Take a look and you'll find out about the human beings behind the labcoats.

Saturday, February 03, 2007

When you watch a child die

People take a surprisingly long time to die. I have seen frail, elderly persons on morphine drips go for days, every breath sounding like their last. When we do a DCD, we never really know how long it’s going to take for that person to cardiac arrest (aka die). We might have a good idea, an educated guess, but no one, except maybe God, knows for sure. I’m up front with the family about this. If the patient doesn’t die within 60 minutes, they can’t be an organ donor. We don’t bring up donation until after the family has decided to withdraw care. Then they’re placed on comfort care, an IV drip, usually a narcotic and a benzo, like morphine and ativan, so they won’t suffer as they die. The DCD donors that I’ve had didn’t have much neurologic function at all and I don’t know how much they really feel, but just having an intact brainstem will make your breathing ragged and gasping and it’s very difficult to watch if they’re not sedated.

It’s weird to get up in the middle of the night to go to work. Triage called me at 1900 yesterday to give me a heads up. Another TC and her orientee were doing a DCD donor and our policy states that two TC’s need to be present for a DCD, or a TC and a hospital services manager. Orientees don’t count, although this one has a good head on her and a lot of nursing experience. Even so, would I go and help them for the OR? The logistics of a DCD are a little complicated, one person usually does the ICU/family support part and one person gets the OR ready and has the teams standing by to start the recovery after the patient arrests (dies).

I tried to nap but I was too wound up. I called triage back to get the info on the patient. I already knew it was a PICU patient, but I found out it was a 5 year old. I reminded myself that I was only doing the OR. I did four DCD’s last year, the youngest was 18 months. That one was grueling. Through a series of misfortunes, no organs were transplanted, which is really heartbreaking when you see how much it means to the parents, who are so desperate to see something good come out of their tragedy.

At 0130, triage called me to say the OR was at 0330 and would I please be at the hospital by 0300. The hospital was 45 minutes away, but I didn’t have to shower and my bag was ready, so I snuggled up next to the baby and tried to sleep for another half hour. After twenty minutes or so I knew it was hopeless, so I kissed her and got up. Love Monkey was still awake, the night owl, so I kissed him goodbye and left. I gassed up the car, got a cup of tea and started the drive. I made it there in no time at all, given the hour. On the walk up to the unit I passed clusters of family, crying quietly.

I walked in and found the TC, her orientee and the hospital services manager, who was quite cranky to still be awake. Those girls do keep better hours than I do, usually. Why was I here? I mean, the orientee is no idiot and she probably has more nursing experience than the other two of us combined. And HS, well, she looks very cute in her scrubs and she does know the hospital, but really we only needed two of us, not four. I’m a big believer in keeping a low profile on the unit and not having a big gang of OPO personnel hovering around.

All right, to make a long story longer. I guess I need the catharsis because believe me, when I got home later in the morning, no one wanted to hear about a dying five year old. I went to the OR to make sure every thing was ready. The staff had done a nice job of setting up an empty room with chairs, dim lights and some low music playing. I was not eager to meet the surgeon. The last time I did an OR in this same hospital, with a pediatric patient, he screamed at me in front of everyone. I introduced myself when he came in, I’m not sure if he even remembered me. The tech was one of my favorites. We went over the case and the plan for extubation and pronouncement. The doc showed his humanity when he started talking about recovering from a little kid. I guess I forgave him then for the screaming.

The music was courtesy of us. Last week I was in the office and saw one of my coworkers sitting on the floor next to a CD player listening to some soothing musical interludes. “It’s music to play during DCD’s”, he explained. “Do we have to use it?” I asked. “Oh, no, it’s just if the family wants.” I quipped that I would rather have some Led Zeppelin playing when I passed, would he please keep that in mind in case I was ever a DCD. Cause I’m really not an easy listening fan.

Back in the OR, the staff was counting instruments, the tech was pounding ice and the surgeon was getting ready to scrub. I was the lookout, to tell them all to be quiet at the first sign of the patient and family. I kept thinking about the time I was the lookout at my sister’s wedding shower and she walked through the other door and the surprise was ruined. This was like waiting for some dreadful party to begin. And they did come in from the opposite direction. I wasn’t ready for what I saw. I guess I was expecting a crib because I’d heard she was small, only 15 kilos. Instead, the staff pushed a bed with a full grown woman in it, her mom, wrapped around the little girl like the pod around a pea. A train of people followed in their wake: the intensivist, the resident, both TC’s, HSM and the little girl’s grandmoms, holding on to each other.

As soon as I saw them turn the corner, I ran into the OR and told everyone to be quiet. The other TC had told me earlier that she expected the girl to go quickly. They got everyone settled. I handed the paperwork to the orientee. If you don’t know what else to do, grab the clipboard and keep track of everything. We had to write down all the times: time in the room, extubation, q5 minutes vital signs, time of pronouncement. The PICU nurse would monitor the drips to make sure she was well sedated. The intensivist walked over to mom and whispered something. She nodded and a minute later he pulled the tube. Mom was crying and kissing her. The grandmoms were crying. I was crying. I kept thinking how I was snuggling my own little girl just an hour before.

See, that’s the problem with having this job and an active imagination. I am always thinking of ways I could die, my husband could die, or the kids could die. It’s a morbid hobby and I go to it the way your tongue seeks out the empty space when you lose a tooth. Give me a situation, and I can find the danger in it. It makes my husband crazy and I’m not sure it makes us any safer. I mean, how much can you worry about? When I worked in the ER, I started to go a little nuts thinking about all the things that can go wrong, all the freak accidents that happen. When I got this job it made me more at peace, for a while, as it made me appreciate what I have. Recently, though, it’s been getting to me again, so I just try and redirect my focus until it passes.

The little girl is still taking agonal breaths in her mother’s arms. My tears have dried a little and I’m starting to wonder why this is taking so long. The other TC was certain that she’d die “right away”. The pump with the morphine is binging and then I realize that the primary ICU nurse is not in the room. She’s out in the hallway. The intensivist goes out and gets her. As discretely as they can they try to get the pump working again. By now, we’ve been in the room watching this little girl die for about 15 minutes, but it seems like hours. A few minutes after the morphine pump is fixed, her respirations taper off, then stop all together. The doc takes his stethoscope and listens, then feels for a pulse. He nods to the nurse. I look over at the other TC. She’s comforting the grandmothers and doesn’t seem to realize the little girl is dead. We only have 5 minutes from this point to make the incision. I walk over to mom, who is kissing her daughter’s forehead. I say gently, “Mom, it’s time.” Then, my coworker comes over and I start to take off the leads and other wires that attach her to the monitor. She picks the girl up in her arms and the nurse and I detach and grab as many lines as we can: foley, numerous IV’s, A-line. We walk as quick as we can to the OR next door. Someone stays behind with the family. We get her on the table and the OR staff springs into action, putting the grounding pad for the cautery on her lower back and taking her gown off. I’m helping untangle the sheets and I find two Matchbox cars rolled up in there. I try not to lose it.

The surgery starts and I go out in the hall to collect myself. The family has left. The other TC walks over to me and says, “Well that went well!” I just look at her. I know what she means-everything went off without a hitch. No problems getting pronouncement, having comfort care started or getting the OR on board. No surprises. And you do get a “high” when you’ve been up all night, running around and juggling a million things. But to say that watching a 5 year old die went well is a stretch for me. Especially when I hadn’t even planned on being in the room, hadn’t mentally prepared myself for all that. That’s just her way, she’s bubbly. The tech comes out and she’s still effervescing. He looks at me. “How’d it go?” He asks. “It was horrible.” I say.

The OR goes fine, Again, I’m not really sure why they needed me, her and the orientee are doing fine. When it’s all over they wash the little one and put a gown on her again, because her mom wants to see her afterwards. I pack up to leave.

I’ve only been out for 7 hours, but on the ride home I’m wiped out. I crank up the radio and Stone Temple Pilots fills the car. The last pediatric DCD I did was an 18 month old who died in a house fire, his mother found lying on top of him, trying to protect him. They were both organ donors. I try to imagine being at the funeral of my husband and baby, the numbness, the endless line of people offering words of comfort. I force myself to stop. As Atticus Finch said in To Kill a Mockingbird, that’s the kind of thing that leads to slow, steady drinkers.

Instead, I start thinking about what kind of music I’d like to die to. I was joking when I said Zeppelin, but now I reconsider-maybe the Rain Song would be nice. After that, I’d pick Beethoven’s Eroica, which I got as a Christmas present one year from my husband, because he said it reminded him of me. Again, I try to think of something else, but in the end I just crank the music up even louder. I want to share this whole night with someone, but how can I tell anyone these things that I see? Sometimes after work I have to choose between being down and bringing someone else down with me. Who wants that? So I just keep writing about it.