The Intensive Art

You know you’re having a bad night when you find yourself saying:

“OK, fine! Let’s make a deal! You can tell me to ‘FUCK OFF’ as long as you say please at the end!”

There have been a lot of ups and downs in my first year in the ICU. My intention was to thoroughly document every incident in my blog. It didn’t work. I found myself struggling with ICU nursing and nursing in general. My great blog had been decimated through lack of posts and interest from this here writer.

A year later (well, ten and a half months), I find myself looking to write again. I am ready to start putting thoughts onto paper regularly again. But this time, I seek simplicity and cleanliness, rather than clutter and flashiness. It is a fresh start (although the archives will reveal my blogging baggage), meant to show the maturity of a nurse that has finished his starting years as a nurse and has landed comfortable on his feet.

It is meant to also show the maturity of a blogger that has “done it all,” from devastating angstful “dear diary” writing, to attempts at professionalism, from striving for popularity, to panicking about just how visible, and therefore vulnerable, blogging makes him feel. So…

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I’m a sucker for a long term blog theme; like a television story arc that lasts a season–finding resolution in the last episode of the year. My theme is indefinite, finding its end whenever, wherever, and however it’s ready. Much like the way my “new ICU nurse” theme found its end after only a couple months. Or, perhaps if we’re sticking to the television theme, it was canceled due to irreconcilable differences amongst its staff of one.

This time I’m seeking balance. My nursing career has seemed very one-sided as of late, focusing purely on the science of nursing. Each day, I can be found studying graphs, tables, and lists of scientific concepts. An there’s always the hands-on technical learning: Jugular venous bulbs, PA catheters, Oscillators, CRRT, cool guards. There’s always a new machine to master.

And one can never forget the endless parade of critical care medications to absorb as religion.

What’s missing is the Art of Nursing. WAIT! Don’t groan and run away, fearful of a nursing school style rant about some random psychosocial aspect of nursing. Instead, I’m going to make this very simple.

When I think of art, I think of paintings. I love Jan Van Eyck, Picasso, Monet, and Dali. These are all masters of the art of painting. But none of them is like the other, they are so very different in style and form. They are creators of entire complex styles of art.

Masters of the art of nursing are also complex. They all have their own style and way of nursing. They are all distinct in the way that they enact their role. You see, the art of nursing is what makes us different from each other as nurses. Otherwise, we would all just look and act like robotic drones.

Artful nursing is what lives between the lines and pages of our policies and procedures. It is the magic and mystery that lives invisibly between the graphs and diagrams within our scientific text books.

The art of nursing is finding a way to connect two tubes together that don’t necessarily belong together–but absolutely need to be together. It’s the out-manipulating a manipulative patient. It’s the hours spend washing the blood out of a trauma patient’s hair and brushing it until it shines. To one nurse, it is the micromanagement of every last detail–leaving nothing out, and to another it is seeing the big picture and knowing when to let go of the details.

My favorite vision of the nurse as an artist is literally as an artist. The bedside is our canvass and our patient is our medium. Some nights we spend hours positioning body parts, applying pillows in a very specific way, folding the blanket perfectly, positioning the IV poles at just the right angle, Organizing bedside tables and work stations, washing patients and applying creams and ointments to create the sight and smell of perfection. When finished, the patient looks peaceful, quiet, and absolutely presentable–ready for the beauty of life or the restfulness of death. Or, as in the ICU’s case, something in between the two.

As I see it, the art of nursing happens when the science of nursing doesn’t have an answer for how we do our jobs. However, It does rely on a strong foundation of the science of nursing so that we may “let go” of the black and white that rules our career and threatens to demoralize and overwhelm.

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This art of nursing is where I’m finding peace in my career. When my creative energies are put to the task, I feel a rush of joy that re-energizes my soul. This is where the power of nursing is born and thrives.

So, here’s to my new theme! May it bring these same feelings of joy and creativity to my website.

I just turned off the fans, closed the windows, and turned on the heat. I am absolutely sure that this would be the first time in about four months that any of these activities occurred. I am, after all, a lover of cold weather and gloomy skies. The summer months are spent reaching in desperation for a cool breeze and a drop of rain. I have my limits though, and I am currently curled up in my new hoodie and my favorite blanket.

I have been away from my world on a quick vacation for almost a week, just arriving back on Sunday evening. That was following by two twelve hour days shifts Monday and Tuesday. Today, Wednesday, is my first day to put up my feet, drink cup after cup of expensive tea, and reflect upon my life.

A few updates! Firstly, I was nominated for post of the day over at The Rising Blogger by Laura at Adventures in Juggling. If you look at the top left of my blog, you will see the award button that I earned. The post that was nominated and chosen was A Dark Place. I am infinitely grateful and honored. Thank you SO much to both of you!

It still surprises me how large the response was to that particular post, earning me more hits and more comments than anything I have written before. I cringe every time I read it; it seems so overly melodramatic and whiny. But, truthfully, it was exactly what I was feeling at the time, and why. Things have improved since then, and going on a nice vacation to my favorite city on the entire planet helped immensely. I feel much calmer and relaxed now, with a slight bit of renewed energy.

The problem is that my vacation was not even seven days long and was a result of a place in my schedule where I had a few days off, not as a result of me taking vacation time. I have six weeks of vacation saved up that I simply cannot take. Vacation time is a HUGE struggle on our unit as there are too many people to fill all vacation requests. To get a feel for it, people that were asking for a week off during weird times such as November or February were rejected. All but those with the most seniority get the privilege of rest.

I am feeling energized, with my biggest source of energy being that I have made a new plan for myself that I hope will work out. I have two more courses until I have completed my critical care certificate (out of five courses), so I want to finish that. I want to finish all possible certifications in the ICU. I want to complete my ACLS and become a proficient member of the code blue team. I want to finally write my test to become a certified critical care nurse (you know, and get all those fancy letters after my name).

Once I have completed all these goals, I would like to enter a Masters degree program and truly move on in my career. I’m looking at a few universities, but I certainly have my favorite. I have no interest in being a Nurse Practitioner, but am rather more passionate about the theoretical side of nursing, particularly the qualitative research side. I’d like to enter a thesis based program and work on a big project for a couple years and hopefully end up in a PhD program. Then I can be Dr. NurseSean…

I’m simply coming to the realization that bedside nursing is not something I want to do for the rest of my career. I’m already cranky and feeling burnt out after only a two and a half years. I just don’t have the endurance to make it for 35 years. My hat is off to everyone who does!

Whenever I’m at work, I look around and I see happy people that love their job. I often fool myself into thinking I love my job (or perhaps I really do at those times), but if I dig deep and answer truthfully, as previous posts have shown, I’m just not happy. But I feel that in order to make it as a nurse researcher, you need to work as a bedside nurse. You need this experience to study the experiences of nursing properly and with credibility.

At least I have a sense of humor about it all. Yesterday, I had two patients (not typical in a Canadian ICU…we generally have one). Both patients had been waiting several days for a bed to open up on the floor. One patient was particularly agitated (to put it mildly) and was, as a result, a handful. However, both patients were very low acuity and were nowhere near the sickest patient you see, even as a floor nurse.
I was the only person doubled, so when the charge nurse had to find a spot for one of our new employees, still in training, she put her with me so that I would have help. She was particularly awesome as she was reaching the end of her several months of preceptorship. I took one patient and she took the other, with the goal of being as independent as possible.

I couldn’t help but notice the snickers of other nurses, clearly rolling their eyes, and talking behind my back, shocked that I would be “training” someone new. I use the word training lightly because frankly, a first year nursing student could have cared for her patient, and she needed no help or guidance at all.

All of a sudden I’m hearing choruses of, “but you don’t know what you don’t know!”

Yes, yes, I know, it was inappropriate, but I once again reiterate, I’m new to the ICU, not new to nursing. I’ve had many students and new orientees with me. And, I repeat, these patients were really not sick enough for the ICU.

I sent one of my patients to the floor: the agitated one, yay! One nurse said, with a definite snicker, “oh good, you can help me for a minute, you have no patient now since you discharged yours.”

“Yes I do, I was doubled.”

“Please! The new person is taking care of her, I doubt you don’t even know what her lungs sound like.” She quickly responded, challenging me, I had fallen into her trap. Yup, I could definitely tell she thinks I’m an idiot. I wonder to myself: when will people stop treating me like an idiot, maybe I am an idiot…why won’t someone just tell me if I suck at this job so I can move on with my life!!!

“Yah, I do know what her lungs sound like, they’re quite clear, just a bit diminished to the left lower quadrant…pneumonia.” I guess I did know. I felt vindicated. She didn’t respond.

Where, oh WHERE do people get these holier-than-though attitudes? Oh I could go on and on…I won’t.

This post is incredible, and definitely worth echoing and sharing! A great find, if I do say so myself–and I do say so myself by the way…

One of the benefits of being away from bedside nursing is that I’ve had time to reflect on my own performance. How could I have been better? What simple precepts would have helped? Being out of the “fog of war” has given me a clearer view of what’s right and what’s wrong in health care. Our culture doesn’t offer much positive encouragement for the nursing profession. That’s a costly shame, as many Baby Boomers soon will discover. To help out, I’ve come up with eight ways to become a better nurse.

1. Pay attention to how you perceive your patients
2. Intend nothing but the best for your patients
3. Speak the truth in a way that echoes your wisdom, not your darkness
4. Act on the facts but respect your intuition
5. Live your life as a connection to something greater than yourself
6. Work through your hardest times, not against them
7. Mind your mind: its power to destroy is its power to heal
8. Focus on the moment, not the past

Some of us are cut for bedside nursing, some of us aren’t. I think if you’re in bedside nursing and enjoy what you do then you’re a Jedi Knight who commands more respect than you probably receive.

For those of you who don’t quite enjoy what you do, think about your reasons for what you do. Consider the eight precepts (or make up your own) and see if anything changes for the better. You have more options than you realize.

Feel free to add your own suggestions for becoming a better nurse. If I get to 101, I’ll post your thoughts here and promote the living shit out of the list.

I hope the list I’m offering here helps you to become a better nurse, a better person, a better part of our quickly-changing world.

This post has come at an important time in my career in which I am particularly struggling with bedside nursing. It has given my a lot to think about over the next few days as I take a short rest from work (does five days count as rest?)

A powerful post! Here’s the original item link:

8 Ways to Become a Better Nurse : phil baumann /*rn*/

In the next couple months, I will be CRAZY busy!

In the next couple weeks, I will be oriented to code blue stuff and will be expected to be part of the code blue team. More anxiety…awesome…

In September I renew my nursing registration. This involved gathering documents, writing learning plans/goals, proving that I met last years goals, etc. Not to mention the $400 it costs!

In September, I also start the next course in my critical care certificate program. This time I will be studying pathophysiology. Crap, another $600.

In October, I have both BCLS and ACLS. Apparently, ACLS comes with a text book to read and study. I love to learn, but this is getting ridiculous! Oh yes, and that’s another $375

All on top of a full time job that is constantly threatening to destroy me with anxiety, fear, and frustration.

Did I mention I was moving into my new condo in October? Yes, I have to find time for that too…not to mention all the money for furniture and lawyer feets etc.

I think I’ll plan my next vacation right now!!! Oh wait, I won’t have any money left for one…

My dog ate yet another power cord for my MacBook yesterday. between my iBook and MacBook, he’s chewed three cords over two years. Unfortunately, I didn’t notice it wasn’t working until my laptop gave me the low battery warning, despite being plugged in–meaning I had no computer all of a sudden, without warning!

PANIC!

I was forced to use my iPod Touch for 24h as my main internet access. I don’t have an iPhone yet as I’m still on a contract with my current phone. Plus, the plans here in Canada are WAY overpriced and not even unlimited. Even further, I really REALLY don’t want to have a three year contract with the one and only company that sells them.

For now, the iPod touch is just fine. I really have no good use for the phone part of it at this time. It seems that wherever I go, there is a perfectly fine wireless collection. And I don’t have any plans for cool live-blogging from helicopters or the middle-of-nowhere.

But, what I did discover was that it was, besides a couple exceptions, a perfectly good substitute for a full blown computer. Now that apps are downloadable, it is even more simple to use…particularly when it comes to facebook and twitter. Even google has an app now that makes using google reader easier. I just couldn’t watch the Big Brother live feeds, and I couldn’t join my favorite java chat room.

Hey CBS/Big Brother! I would pay VERY well for an application that allows me to watch the live feeds on the go with my iPod touch. I swoon at the idea!

Two more shifts until I leave for beautiful Victoria, British Columbia for four days.This jewel of a city is my destination of choice–for living. I was intending to move there last year, but it simply didn’t happen. It continues to remain my dream and I am considering applying there for grad school.

Ahhhhh…such dreams…

Time to start making some road-trip music mixes!

There’s one other thing that has been getting me down in the ICU, more than anything else. That is the shear tragedy of the entire place. Here’s a cross section of patients that I’ve had recently.

1. A 49 year old woman who was fine one day. Then nobody heard from her in many many days. She was found several days later, face down in a pool of her own urine (that she had aspirated on as well). She had had a massive hemorrhage that even bone flaps and drains couldn’t fix.

2. A young fit women who was rock climbing without ropes or a helmet. She fell 100 feet. Very very broken. It’s amazing just how many family members will appear out of nowhere for an argument over whether someone should live or die; regardless of how estranged they are.

3. A drunk driver who slammed into a minivan who had a broken leg and a stable C7 fracture and is going through severe DTs (of course). The family of three (used to be six before the accident) that he hit was being taken care of on the other side of the unit.

4. A man that was simply walking down the street on his lunch break. A piece of construction equipment fell on him. He experienced a traumatic brain injury and is not expected to survive.

5. A young women with severe respiratory failure. Nobody knows why. They ran out of tests to run. She died. I wonder if the autopsy gave them answers?

6. Have you ever seen what a body looks like when a femoral line goes interstitial that was running high doses of levophed? Nobody noticed for two days because he was so swollen to begin with.

It goes on and on and on. It seems that not a day goes by that I don’t hear wailing coming from some distraught family. There’s also the fighting between family members. I’m finding that with these big big tragedies, the emotional walls that I have built over the years to deal with the sadness of nursing are being torn down. I need to find some better coping skills!

I PROMISE the next post will be a happy one. I swear!!!

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I haven’t been around lately (maybe one or two of my three readers noticed). I went to a dark place in the world of nursing: a long tunnel filled with fears, regrets, and frustration. I really didn’t think I would be able to come out the other side of this darkness, I still haven’t, but at least now I’m 68% positive I will.

Let me explain:It happened as quickly as someone flipping a switch. I went from being excited about my career, from engaging and learning, from dreaming of future career paths, to hating every moment of every day that I had to be a registered nurse.

Some would call my symptoms depression. I was nauseous all the time, I was exhausted and slept twelve hours a day, I struggled to leave my bed on my days off, and if I did, it was only to lay on the couch and watch television. I was miserable and cranky, moody and angry.I would start to cry at the thought of reading nursing blogs or forums.

In disgust, I ran from everything nursing related.To an extent, all these feelings are still there, they are simply improving. I have yet to truly regain my desire to be a nurse anymore, going so far as to look through job search sites, browse college program brochures, and contemplate running away to become a Buddhist priest.

These are the examples/things that are getting me down.

1. Learning the ICU is a tough gig. My knowledge base is general surgery, not trauma, neuro, or medical. Every day I’m given a patient that I’m absolutely clueless about. Drains I’ve never seen, equipment that is mysterious, treatments that are frustrating, and procedures that are completely bizarre. And of course, as an ICU nurse, you feel as though you should know everything about everything. What I wouldn’t give for a nice simple bowel resection patient. And, frankly, I have barely even begun to learn ICU nursing. Soon, I will be expected to take my ACLS and start being part of the code blue team, then I learn PA catheters, then CRRT, and on and on. There is never a moment where I get to feel comfortable. There’s never a day I walk in and see my patient and say, with confidence, “I know exactly how to deal with this.”

2. I’m tired of being tested. I’m tired of having other nurses breathing down my neck. I’m tired of being treated as though I came with zero experience and need to be helped with every little skill. Who knows, maybe I’m doing a horrible job, but nobody has said anything, and one would hope they would. I’m very good at knowing my limits–I’m almost too cautious–so trust me, I’ll let you know if I need help.

3. On two occasions, when my patient was in trouble, despite doing a great job at handling the situation and stabilizing my patient, I was told I was too calm. “If it were me, I would have been freaking out. I didn’t even know you needed help. If you needed help, why didn’t you ask?” First of all, I did ask–just not you. I had a doctor and another RN who was familiar with my patient helping out. Second, since when is staying calm in an emergency become a negative?

I can’t believe I was accused of being too calm by two separate coworkers on two separate occasions.Let me just say this: Just because I’m new to the ICU, it doesn’t mean I’m a new nurse. I’m used to dealing with very similar emergencies on the floor with less staff, no doctors, and less resources in the form of medications and monitoring equipment. Perhaps I’m not panicking because although things are going bad, it is in a very controlled environment.

Next time my patient’s MAP is 48, I will jump up and down, scream and shout, cry and have a nervous breakdown. THEN I’ll get the fluids and Levo. Makes so much more sense.

4. I’m not a bitch/asshole. Therefore I’m not a good nurse. I’m not bossy, argumentative, crude, crass, or rude,  therefore, I’m simply not a good advocate for my patient. I’m willing to wait a minute or two for my doctor to finish with another patient before discussing my issues, rather than interrupting him rudely to come attend to my patient’s needs immediately (not an emergency by the way). I shouldn’t let doctors dismiss me like that, I was told. Ugh!

5. I don’t spend my entire day complaining about management, the new residents (I can’t believe how mean some of these nurses are to them!!!!), attending physicians, nurses on other floors, my patients, the colour of the curtains, or worst of all, I don’t say rude things about my patient, such as “what a waste of skin!” within hearing distance. Therefore I’m not hardened enough and jaded enough to be a good nurse. I’m too kind and sensitive.

6. Example: My patient had recently been extubated. He was sitting in a chair comfortably, laughing and talking with his family, his lungs sounded clear, he was breathing about twenty resps a minute, he was on 2L of oxygen, and his Sats were 99%. He was all ready for discharge. I did a blood gas. Apparently, I’m a bad nurse because I didn’t run to the doctor in a panic (yes, apparently as an ICU nurse, I’m supposed to be panicked all the time) because his C02 has risen from 44 to 50. Sure it’s high, but we treat the patient, not the numbers, right? It’s an important number, but I didn’t see the need to panic. I’m a bad nurse.

7. I’m tired of working twelve hours on weekends, holidays, and nights. When I started nursing school at age twenty-four, was single, and loved to go out all days of the week partying, working shift work seemed like fun. Fast forward to six years later, I’m in a relationship with a kid (my dog) and it just doesn’t fit my lifestyle anymore. I want a “grown-up” job where I work in an office downtown, get weekends off, get vacations (almost impossible right now with my seniority), get Christmas off, and most of all, I want to come home after work with energy to do stuff in the evening–rather than be so exhausted that even breathing is hard.

8. I’m truly tired of dealing with patients, and especially families,  that are completely horrible, ignorant, rude, people. I want to spend my days surrounded by well-balanced individuals for a change.

These are the tangible ideas that I am able to write down. There are also many intangible feelings that I just can’t put into words. Honestly, the best way to say it is that I feel as thought there is a dark cloud over me and my career. I’m trying to snap out of it, and I’m slowly succeeding. But really, this is why it has been so tough to write–I simply didn’t want to think about nursing whatsoever.

Sorry for the depressing post, but I thought I’d explain a bit about my absence, and give a bit of an update. I regret that I won’t have numerous posts about the many interesting firsts over the past few months, but alas, I just couldn’t do it. Here’s hoping things improve!

Edit: Thanks everyone for your wonderful comments! I wish I had written this earlier. Just writing it all down made me feel better, but to do it in such a supportive public forum is that much better! Just to clarify though, I’m not a new grad. I worked on a surgical unit for two years prior to ICU

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Change of Shift is up over at Parallel Universes. Go check out this great edition. Don’t forget to spread the word and offer some link love.

07:00–I’m sitting in the staff lounge with my tea in one hand. The day staff is trickling in. Between smiles, you can tell we are all miserable from being up so early and having to work. Everyone watches the large clock on the wall slowly move toward 07:15

07:15–We are given our bed assignment: just the bed number, the rest we will have to wait until we see our patient and hear report.

07:15–I walk to my assigned bed, curious about the acuity. Because I’m just a month of orientation, my patient assignments alternate between ridiculously easy, and slightly challenging (to me) but relatively easy for any other ICU nurse. At this point, a lot of my patients have been completely non-acute. They are walkie-talkies who have been waiting days for a bed on the floor. I’m used to taking care of 6-8 sicker patients than these ones. So, taking care of only one has had the tendency to lead to many head-banging boring moments.

I look at my patient: a moderate number of IV drips, ventilated. This may be one of my more challenging days. A thought crosses my mind: It actually is exactly one month since I finished orientation. That means another batch of newbies will be starting. That means no more easy patients for me. Time to step it up to the next level. I think I’m ready.

07:30–Report is done. My patient is a very tragic case, as most ICU stories are. She broke a hip and had respiratory failure post surgery so was never extubated. She ended up in the ICU paralyzed and sedated. When her respiratory status improved, they weaned the sedation and paralitics. She never woke up. Tests and EEGs showed brain death. A CT scan showed copious fat emboli in the brain stem. She never will wake up.

Family is the true issue. Fights over who will make the long distance trip to see her and “pull the plug.” Add lawyers, social workers, feuding siblings, devastated boyfriends, and a frequently shared family history of severe mental health issues, and you have the makings for a very interested scene.

What it boiled down to is that we were keeping her alive until the appointed family member could make the trip, see him, get all the information that he and his lawyer want, and then “pull the plug.”

07:31–I start my head-to-toe assessment. Spending time in the ICU will hone anyone’s assessment skills quickly. Not out of necessity alone, but out of pure availability of time. I can stop and listen to the lung or heart sounds for several minutes if I desire. I can really take the time to find those pedal pulsed.

Besides my assessment, in no particular order, I do many other things: print of rhythm strips to analyze and add to the chart, check placement of the oral-gastric (OG) tube before testing for residuals and flushing, check blood sugar and adjust insulin drip, suction secretions from her mouth but decide against deep suction as the lungs sound great, change the central line dressing as sweat and phlegm have pulled it away from the neck.

08:00–Crap! It’s already time for my first set of vitals and Ins and outs. No problem, it doesn’t take long.

I check my lines, following the lumens of the central line to their stop cocks to their labels to the pump and to the bag. Dates are checked, labels are checked, concentrations of drugs are checked, the art. line and CVP are zeroed and their wave forms and square waves are checked.

08:15–Respiratory therapy is present to assess and adjust. She putzes around, changing the position of the ETT, fiddles with the ventilator, and does a couple suction passes. She asks if there are any concerns. There are none.

08:30–The dressing to my patient’s incision (remember that hip fracture?) is leaking copiously and has saturated the dressing, the soaker pad, her gown, and much of the bed sheets. I change the dressing, leaving the rest for later.

08:45–The resident-du-jour is present for pre-rounds. He should be assessing the patient, but they never do. He reads the charting since yesterday, asks me for an update, writes down my assessment, mumbles a bit about nothing, and moves on.

09:00–Tip the urine, check the glucose, insulin is running high, adjust insulin rate, enter vital signs, suction mouth, perform mouth care. Tylenol, colace and Antibiotics are due.

09:15–I have to chart everything that has happened so far, including the visits from the RT and residents and every task I performed. Of course, I have to chart my head-to-toe assessment.

10:00–Vitals, urine tipped, glucose checked, insulin adjusted, patient turned, mouth suctioned. It’s also time for a break!

11:00–Vitals, urine tipped, glucose checked, insulin adjusted.

It’s time to start fussing over my patient a little bit! I wash her hair and brush it, I then take my time and clean every nook and cranny of her body. I call for some help and we turn her, wash her back, change every last piece of linen, slather her from top to bottom in moisturizer, turn her on her side, and tuck her in with warm blankets.

11:45–The dietician is at the bedside. Great! I wanted to clarify her tube feed orders.

12:00–Vitals, urine tipped, glucose checked, insulin doesn’t have to be adjusted! YAY! But it’s time to do another head-to-to assessment. It’s always faster the second time, but it still must be charted. OG tube is checked for residuals and flushed.

It’s break time again.

12:30–My break is interrupted by my charge nurse because the “team” is at my bedside wanting report. My adrenaline peaks, I hate presenting at rounds.

I get there and the resident who had done pre-rounds is there and starts giving a brief description of the patient including issues, problems, new stuff that he learned from me in the morning. There’s really not much for him to tell.

I give a complete systems assessment, CNS, CVS, GI, GU, etc., then the respiratory therapist reviews their assessment of the respiratory system, dietician gives recommendations, pharmacist reviews medications, physio shares their imput, charge nurse interjects with his opinions.

The attending physician asks the resident several obscure questions that he has no chance of answering. The attending proves his intelligence by going into a long lecture explaining the answers to these questions.

Goals, plans, new orders are received from all departments. They leave to go the next patient. I go to finish my break.

13:00–Vitals, urine tipped, mouthcare

13:15–I chart that rounds took place and what orders I received. I then complete the orders, which in this case are basic: increase analgesic, decrease fluid intake, change ventilation mode etc.

13:30–The bed across from me is getting a new admission. At the same time, the admitting nurse is trying to help send her other patient to the OR. I help by infusing all the blood products the patient needs before the OR. Then I help with the art. line insertion and lumbar puncture on the other patient.

14:00–Vitals, urine tipped, mouthcare, glucose checked, no adjustment needed in insulin, patient turned.

14:30–I made a mistake with the blood products I helped infuse. I feel horrible despite the very minor nature of the mistake. The doctor is informed but nobody cares. I fill out an incident report despite the fact that the nurse I was helping said there was no need.

15:00–Vitals, urine tipped

15:15–Physiotherapy is at bedside. They don’t to much because there truly isn’t any rehabilitation in this patient’s future. They do a couple deep suction passes after listening to her lungs, and then move on.

15:30–The visitor’s boyfriend arrives with someone pushing him in a wheelchair. He breaks down in sobbing tears and commands his assistant to, “just get me out of here.” That was his version of saying goodbye. It lasted about thirty seconds.

16:00–Vitals, urine tipped, glucose checked, patient turned, mouth care, next head-to-toe assessment completed and charted. OG tube is checked for residuals and flushed.

My educator arrives and decides to go over “head” patients, including: traumas and all types of strokes/bleeds. It was fantastic to have some one-to-one time with this stuff. It’s great to be so supported!

17:00–Vitals, urine tipped, more meds given, time for break.

17:45–I have to mix up some more fentanyl and insulin for the next shift, I change a couple lines as well, I also change the tube feed set-up.

18:00–Vitals, urine tipped, mouth care, glucose checked, patient turned

18:15–I make the mistake of going into another room to help a nurse. This patient is VERY sick and has a 2:1 nurse to patient ratio. I almost have a panic attack! The room is FULL of large machines such as the prismaflex for CRRT and many others (who’s existence I wasn’t even aware of.) I decide that I’m happy with my “easy” patient.

18:30–A smaller version of the “team” is around again: just the attending and resident as well as the overnight attending. They are going bed to bed giving report. They actually skip my patient–such a boring patient for everyone but me!

18:45–I start cleaning up. I make sure the patient is clean, positioned nicely in bed with straightened sheets. Her leaky leg dressing is redressed again. Lines are organized nicely. The side table is cleaned and straightened-up, supplies are replenished and organized nicely. The Foley is emptied. I wipe everything down with sanitizers–not because I have to, but because I like to at the beginning and end of my shift–infection control is everybody’s job!

19:00–You guessed it, Vitals, urine tipped.

I have fifteen minutes with which to sit and relax, reflect on the day, and praise my luck that no bowel movements occurred.

19:15–The same nurse that gave me report is back, which is nice. I can give a “Cole’s Notes” version of report. Of course, she’s of the interrogation-type when it comes to report, “why didn’t you do this?” and “Why did you do that?” or “You totally missed this and forgot that and did this wrong!” and of course, “The doctor shouldn’t have done that! Why didn’t you tell him to do this and that instead?”

My mood can’t be ruined though. I know I did a good job and I am happy with myself. Plus, I have two days off now!

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