Nurse Sean (dot) com

I answered the call bell, “I need some help right away!” yelled the nurse in the room that called.

I ran to the room to find her holding back what had to be the strongest elderly lady I have ever encountered. Even with two of us, we struggled to stop her from plowing out of her hospital room. Her IV pole was (of course) left behind, and the IV that had desperately been put in her foot was millimetres from being pulled out. Not to mention the Foley. I gave her a bear hug to hold her still while her nurse organized her drains and lines to safe positions.

“This room is haunted! HAUNTED! I have to get out!!!” Was this particular ladies complaint. I stopped for a moment to consider the possibility. After all, we had all heard the ghost stories…but those were from the room down the hall.

She pounded at me as I hugged her; she burried her head in my chest, wailing, crying, screaming. “You wouldn’t do this to YOUR children would you?!?!?” She protested.

“You’re OK, everythings fine, you’re safe here.” I tried to convince her, but nothing was working. She kept screaming like a banshee.

All of a sudden, she stopped dead in her tracks and became silent. Her eyes were staring at the RN pin that I proudly display on my scrubs.

“OH, you’re a registered nurse! Don’t do it! Don’t waste your life with this job.” She said calmly, with purpose.

Then her head dived against my chest again in endless wails and sobs. “Please help me! Please help me!”

“You’re safe now, don’t worry, you’re safe…”

Report from evening shift went a bit like this:

“Ten days post-op for an unresectable tumor. He has been completely fine and almost ready to go home until tonight. At about 17:00 he began having difficulty breathing, abdomen became very distended and firm. He then began having rigors. Temp. 38.5, BP 134/80, Pulse 82, Resps in the 30s. Sats were down into the eighties, now 94% on 5L Nasal Prongs. I placed an NG and had two liters of bright green returns immediately. ECG, Chest X-Ray done, Blood cultures, CBC, electrolytes, troponin sent. He’s Feeling much better after that NG tub. Hopefully it is just an ileus, rather than the alternatives. He just left the unit for an abdominal x-ray. By the way, I filled out an incident report. The lab took two hours to come for stat blood work. Boy did I give them a piece of my mind!”

“OK” I thought, “Perhaps it is just an ileus and he’ll come back to the unit alright. I will settle him to bed and hopefully he can rest comfortably.” I knew it was wishful thinking, but being wishful never hurts. The worst part of the situation was that I had never taken care of this patient. I didn’t know much about him.

About thirty minutes later he came back on a stretcher from his x-ray. One look at him told us he was in trouble. He was gasping for air and he had that distinctive grey colour we all know and love.

He was very weak but he shuffled back to his bed with only two nurses helping. His wife was following closely behind. At this point I was able to take a set of vital signs. Temp 36.5, BP 95/85, Pulse 130, Resps 40, Sats 88%.

“ACK” I’m thinking. This is going to be a busy couple of hours. I ran to the charge nurse and let her know that my patient appeared to be going into shock and we need his doctor ASAP. I grabbed a couple nurses and we got started on extra I.V. access.

By the time the ICU outreach team arrived, we had two liters of N.S. and Pentaspan pouring in. We had started a foley for literally only three drops of returns. ABGs had been drawn, and respiratory had switched him to high flow oxygen.

His blood pressure continued to drop so we placed him in trandelenburg’s. The doctors at this point had looked at his abdominal x-ray and found free air in his abdomen. They decide his surgical site was leaking and bowel contents wer spilling into his peritoneal cavity. They decided, quite easily at this point, that he was in septic shock. I hung flagyl and tazocin.

As N.S. bolus number three started pouring in, the doctors started talking to his wife about his prognosis. His surgery from ten days previous had been for an unresectable tumor on the head of his pancreas that was blocking flow from his duodenum. It had been unresectable, so the surgeons had bypassed the duodenum by performing a gastrojejunostomy—thay had attached the stomach to the jejunum to drain.

What still has me in shock still was that even though it was ten days post-op, the patient and his family were unaware that the tumor was unresectable. They didn’t know that the patient was palliative, they didn’t know he was unsavable. They still had hope that his life was still indefinitely long.

They horrifically had chosen the moment he was on death’s door to tell them this fact and to let them know they should make him a DNR and let him die. They had TEN DAYS to tell him his fate, and had neglected to do so. The surgeons hadn’t had the simple decency to sit down with the family and discuss end-of life issues. Until, of course, he was in the process of dying.

The surgeons, ever hopeful, grabbed his bed and wheeled him to the OR. Perhaps they could find the exact cause. Perhaps they could fix him, clean him out, and send him to the ICU. But, as he told his family, he would probably never leave the ICU.

We use a computerized system, so while he was in the OR I could follow his progress. I saw the moment in the computer when he came out of the OR and was given a DNR status. They were withdrawing all treatment (not care) and letting him go peacefully. They didn’t expect him to live long.

The surgeon came back to update us. His abdomen was indeed filling up. He was incredibly septic. There was nothing they could do. They opened him and closed him almost immediately. The family was already aware.

I remembered the last thing his wife said before he went downstairs to the OR, “If we could just spend one more month together, I would be happy.” That month had turned into minutes.

The decision was made to bring him back to the unit. We set up a private room with chairs and a window with a beautiful view.

When he was brought back, it was obvious that he only had a couple minutes of life left in him. His BP was 60/30 and his Pulse was in the 30s. His resps were just small gasps every ten to fifteen seconds. His breaths almost silent under his chest.

His small gasps stopped and I pressed my stethoscope to his chest. I had never declared time of death before. I couldn’t hear his heart, but I could hear gentle whiffs of air in and out of his lungs.

“It won’t be long now.” I spoke softly. We watched in vigil until we saw his head fall gently to the side and mouth open. I listened to his heart for the requisite one minute. I still could not hear his heart, but there were no more whiffs of air. I told the family he was gone, and left them to say their goodbyes in peace.

In the end, I knew that the team of nurses I was working with did an incredible job. We were, as one nurse stated, “a well-oiled machine.” We anticipated every order the doctors relayed to us, yelling, “we just did that!” with each one.

The only critique of my work was that I struggled in answering many questions of the RTs, Doctors, and ICU nurses regarding the patient. I hadn’t even so much as introduced myself to the patient before this crisis happened. For example, I felt bad when I had to look at my flow sheet in order to tell them his surgery, whether he was on antibiotics, and even his first name! I was truthful though, and when I didn’t know an answer, I said, “I don’t know, but I will find out right away” as I was taught. Sure, it would be nice to know all this information instantly off the top of my head, but I was basically finding out about his situation at the same time they were.

It was a sad night. It was a tough night. But it made me much more confident of my abilities in a crisis. I realized that I really DO know what to do in an emergency situation. More than anything, I learned to trust the nurses who surround me. We are an amazing bunch of people, and I cannot imagine working with anyone else.

Hi everyone,

I wanted to write a quick update considering it has been several days since my last post. I am on a long stretch of eight hour night shifts, so I’m feeling a little beat up. Last night was a particularly tough night! One of my patients unfortunately went downhill and passed away. I’m looking forward to writing about the experience.

I also have a post in the wings about lateral violence in nursing (AKA: Nurses Eat Their Young). It is a controversial topic and I look forward to putting my “spin” on it. Especially in light of all the “blog wars” that seem to be occurring in the nursing blogosphere.

Thanks everyone for keeping me entertained with your awesome writing! Keep those posts coming! And don’t forget, if you have a blog or link that you would like me to add to my roll, please don’t hesitate to ask.

Bye for now!

Sincerely,

Nurse Sean

I recently renewed my membership to The New Democratic Party of Canada. I am very proud of this fact! If I were an American, I would probably be crucified for being part of such a left-wing party. I’m proud to live in a country that doesn’t put you down for supporting a party that supports socialized health care, gay rights/marriage, strong environmental solutions, equality for women/minorities, and strong social programs to help alleviate poverty.

Here’s a link to their position on public/socialized/universal health care.

I have seen so many blog posts/comments and discussions at allnurses.com that are very much against universal health care. I thought I would start a list of reasons I love Canada’s health care system. This will be added to on a continual basis as I think of new reasons or examples.

1. Currently on my unit there is a homeless woman who found refuge at a homeless shelter. The nurses who assessed her at the shelter were worried about her condition and sent her to the hospital. She was dirty, weak, malnourished, and on death’s door.

There is also a very rich businessman who was sent to our unit after many weeks of traveling Canada and the U.S. for opinions on his condition. Every surgeon told him to go to our unit, to our surgeon. He is considered the best of the best.

Both of these people had the exact same condition; a deadly cancer that was slowly killing them and needed to be removed. Both of them received the same surgery from the same surgeon. Both of them received the same care from nurses, physiotherapists, social workers, residents etc. They lived in identical hospital rooms next to each other and recovered at the same rate.

Both patients walked out of the hospital on their feet. The wealthy business man (back in his suit and tie) went back to his mansion and luxurious life, and the homeless woman went to her new apartment with homecare nurses put in place and adequate government funding for her to survive (away from the streets). The social safety net had successfully caught her.

The treatment they had cost approximately $500,000. If health care were privatized, the homeless woman would never have been able to receive the surgery. She would have died on the streets.

When it comes to health care, we are all treated as equals. Some will go home to mansions, some will go home to crappy apartments. However, we will all be treated with respect and dignity when we are sick.

I strongly believe that health care is a right, not a privilege.

2. Hospitals in a socialized health care system are not-for-profit. This is an extremely important detail for many reasons. However, for number two on my list, I want to focus on the idea that in a not-for-profit hospital, health care professionals (read: nurses) are not forced to become customer service agents.

Our hospitals are functional. They aren’t overly “pretty” or filled with pleasantries to attract “customers.” Hospitals here are there to serve the needs of the community, without having to stoop to gimmicks like having food courts in the lobby so that patients will choose that hospital first!

Our professionals are truly professionals and can focus on executing their skills, rather than focusing on whether or not patients like them. We are not insulted by being presented with satisfaction surveys or “customer” complaints. When I’m putting a tube through your nose, poking you with needles, and shoving Foleys in your bladder, is it really an appropriate time to ask if you are happy with me?

I’m not even directly affected by the American system of treating patients as consumers, but I am continually insulted by it. The idea that well-educated, skilled, brilliant professionals can be lowered to feeling like a fast-food worker, is horrifying*. Does an architect, lawyer, or manager submit themselves to satisfaction surveys? NO! They let their work stand for itself. Nurses should the same.

I have never worked within the American system, but I am in love with the Canadian system. I feel it is a much more mature, humane system that treats its patients and employees with respect. The power is balanced between all individuals, rather than just the patient, because we all pay for and use the same system. I know that if I am ever sick, I will receive the same great treatment that I give every day.

*I don’t think fast-food workers should be made to feel like lesser citizens, but unfortunately (and unfairly), they are. Please, for the love of god, be nice to fast-food workers. You have no idea how tough their job is if you have never been there. They are continually treated as lesser citizens, and that is NOT right! I just wanted to clear that up.

When I first read Tilda Shalof’s book, “A Nurse’s Story: Life, Death, and In-Between in an Intensive Care Unit” three years ago, it changed the course of my entire nursing career.

When I began work on my Bachelor’s degree in Nursing, I was dead set on becoming an Emergency Room nurse. My vision was completely tunneled, and no other alternative was acceptable. When I wrote a paper in my first of four years entitled “Why I Became a Nurse,” I wrote that I became a nurse because I loved the television show ER and I wanted to be just like the nurses I saw on TV. This reason was partially in defiance of what I felt was an essay topic suitable for a grade three class, and partly because I wanted to be unique. I was quite aware that what they were looking for were stories of being “called” to the profession.

However, in Tilda Shalof’s book, I found a new hero (sorry Carol Hathoway)! The author takes our hand and pulls us, with eye’s wide open, into the world of the ICU. When I first read the book, I had minimal real-life hospital experience. I had only spent about eighty hours on a medical unit giving bed baths and helping patients to the bathroom. At the time, the ICU was a completely mysterious and inaccessible place (and to a large extent, still is). There were no television shows that focused around the lives of the doctors and nurses that inhabited their halls, and I knew that my education would not include any critical care experience.

Thanks to Shalof’s accounts, I discovered that the ICU was a completely unique experience in nursing. Instead of many patients, the nurse has one patient that they focus on completely throughout the day. Shalof describes in much detail the many focused tasks that ICU nurses are continually performing: all the tubes that must be checked, the monitors that must be monitored, and the constant assessing and adjusting of treatments.

But as nurses know, the direct patient care is only the tip of the iceberg. Shalof shows us the true behind the scenes workings of the ICU: constant debates with doctors, the nursing of families, the education of new nurses, the chaos of being charge nurse. She also reaches into the depths of a nurse’s soul to expose the emotional vulnerabilities in caring for extremely sick patients, as well as the fear that comes with the possibility of making a mistake at any time.

Fortunately (and this is my favorite part of the book), Shalof completes her portrait of the ICU with descriptions and dialogs of the nurses and doctors that surround her. Each of them with a unique personality that shows differing opinions and complementary strengths. These characters are her support group and remind me (and will remind any nurse) of those that surround them in their own jobs.

Shalof does not shy away from any topic. From discussion of adoring some patients while disliking others, and certain “shitty” nursing tasks, to a mother’s possible indiscretions with her mentally handicapped Son. These stories serve as the backbone for her larger discussion of nursing as a profession.

When I first read this book I was focused on the fascinating stories and tasks performed in the ICU. But on more recent readings, I realized that the true story is the angst that the author is feeling throughout her career. She discusses foremost the fine balancing act nurses must walk between emotional connection and disconnection with each patient. This constant struggle causes turmoil and (I would say) neurosis within nurses.

Another reoccurring theme is that of how much treatment is too much. Shalof vividly describes stories in which families and doctors go too far to keep patients alive, instead of allowing them to die peacefully. The characters in the book all add their opinions to this ongoing debate that does not have a concrete solution. From this debate comes one of my favorite mottos that I have taken to heart, “We can withdraw treatment, but we never withdraw care.”

The moments that connect with me the most are her brief, yet poignant descriptions of floor nurses. Shalof describes the absolute chaos she and her patients feel when they are transferred out of the ICU with 1:1 nursing care to the floor where nurses may have up to eight patients. As a floor nurse, I can see the shock this causes a patient, and the difficulty they and their families have when being transferred. I have often witnessed their anxiety when a nurse is not present at all times. In fact, we jokingly refer to it as ICUitis, and is usually diagnosed during a night shift when the patient starts hitting the call bell every two minutes for the smallest of reasons.

Now, I said that this book changed the course of my entire career, and that is true. The moment I finished this book in my first year of nursing school, I abandoned all plans to become an ER nurse, firmly aware that I wanted to work in the ICU. I have read this book again and again and I continue to come to the same conclusion. In fact, I have just recently been accepted the Critical Care certificate program and will begin the theoretical portions this fall.

So, I tip my hat to Tilda Shalof (and all of “Laura’s Line) who has inspired me in my career and my nursing care. Shalof has since written a book entitled “The Making of a Nurse” that describes her life outside of the ICU and how it affected her career. I recommend both books with all my heart, which is why they have a permanent home on my blog (look to your left). There is not one single nurse that would not benefit from a read of this extraordinary realistic account of ICU nursing. I only hope somebody, someday writes a similar account of nursing from the perspective of a medical-surgical nurse.

I just wanted to say good luck to all the new Canadian grads writing the Canadian Registered Nursing Exam today. It WILL be a long, difficult day, but you will make it!

For those not familiar with the test, it is an eight hour long test made up of hundreds of multiple choice questions, and a very large, daunting section of short answer questions. There are not a lot of questions that force you to know specific data. Instead, it mostly looks at your ability to think through situations and ensure you would act appropriately.

Some complain that the test is too focused on psychosocial/ethical/community issues and doesn’t actually test whether or not someone knows how to be a nurse (i.e. knowing every complication to every drug, knowing every nook and cranny of anatomy etc.). To those people I say, “perhaps you’re defining how to be a nurse wrong.”

All in all, it is just a test! The vast majority of those graduating from a Canadian university will pass (something like 96%) because Canadian universities have standardized curriculum. What I mean is, the test isn’t all that different from the ones you get during your education. If you passed those, you’ll pass this one.

I want to add that I am extremely proud to come from a country where almost every new nurse graduating has a bachelor’s degree! Education is far too undervalued in other countries. Even if you plan to be a bedside nurse for your entire life, PLEASE do not underestimate the value of more education.

My first thought was, “I have been incredibly jinxed with urine output lately!” It was getting to the point where I was more surprised if my patients actually peed an appropriate amount. The doctors were getting used to my frequent pages begging for boluses for my dry patients.

Yes, my patient’s urine output was only 200cc for the entire shift. I resigned myself to this fact after about ten minutes of manipulating and milking the tube, and falling short only of pushing on my patient’s bladder and begging. I had no choice, it was time to call the doctor for another bolus.

What luck! The doctor was standing by the nursing station flirting with the young nurses. Granted, he his young and devastatingly handsome, but do the girls really need to giggle like that?

I hesitantly walked over to him, taking deep breaths, attempting to overcome my absolute fear and intimidation of talking to doctors. Causing the most trepidation was having to interrupt his “professional” conferencing with the nurses.

“errr…hi….I…ahhh…have a question.” I hate the way I sound so nervous when I talk to doctors.

“What is it?” He went from flirtatious to serious, bored, and bordering on annoyed. Sometimes it just doesn’t pay to be a male nurse!

“My patient has a low urine output. Mr. Smith that is, no! Sorry! Mr. Elliott!” I’m stammering. I’m getting more nervous. Why can’t I just be confident like everyone else?

“Tell me his story.” He said, not looking at me.

This is approximately the moment I panicked. I just expected him to ask about cardiac history, and order a bolus of Normal Saline.

“Errr…well….unresectable tumor of the panc…no liver….geeze…” I point to my abdomen and the doctor gives me a look that most definitely accuses me of being a complete idiot. His eyes ask who the hell let me take care of his patients. “His pelvis, it was in his pelvis.”

“I can see you don’t know anything about this patient, just get me his chart.” He sighed. I gave him the chart and ran away embarrassed. The truth was that I had been caring for this patient for days and knew him inside and out. I had read his chart front to back and knew his entire medical history. I had assessed him numerous times and knew every wheeze and bowel sound.

The patient got his bolus, but I had completely failed at my report to his doctor. As I lay in bed at night reliving the moments of the day (we all know this is a nurse’s favorite past time, and is potentially what leads us to insanity), I asked myself, “tell yourself honestly, did you know this patient.”

The answer was a definite yes. Where I had failed was in my preparation in giving report to the doctor. I didn’t organize my thoughts and the patient’s situation/needs into an organized presentation for the doctor. I failed to use my communication skills properly, and I failed to project confidence in my patient’s needs.

My hospital has begun teaching the SBAR method of reporting a situation to a doctor. Never until this moment have I fully understood exactly why it was necessary. SBAR stands for Situation Background Assessment Recommendation.

I had a Eureka moment as I lay there in bed desperately trying to find a way to improve myself. When I need to talk to a doctor, I just need to stop, organize my thoughts using SBAR, and then proceed. If I had done this, my side of the conversation would have looked more like this:

“Mr. Elliott had an output of 200cc concentrated urine for my shift. He had a laparotomy on Wednesday for an unresectable tumor with a colostomy creation. He has had a low output for the past 72 hours and has received two 500cc Normal Saline boluses, the last one at 23:00 yesterday evening. He has a history of hypertension and a MI in 2004. His vital signs are all stable and unremarkable. I think he would benefit from another bolus.”

I couldn’t help but wish I were the type of person that could just roll words off of my tongue with no effort at all. While earning my degree, I had more than one professor tell me that I sounded very confident and intelligent in my writing, but verbally I struggled. It’s true!

The next morning during report I was told that Mr. Elliott had been causing problems overnight. His lungs sounding worse, his Sats were dipping low occasionally, and he felt short of breath.

Not a problem, I gave him some ventolin for the wheezing, lasix for the crackles, ordered a physiotherapy chest assessment, taught him breathing/coughing exercises, and kicked him out of bed for some walking. He had none of the problems night shift experienced.

During morning rounds, one of the doctors (the same one that caused me to stutter my words in nervousness) had a hunch that Mr. Elliott was having cardiac problems and ordered an ECG and Troponins.

Oh what joy! The ECG shows a block, and the Troponins were sky high!

Moments later, a severe looking women entered the room. She was definitely high on intimidation factor! She introduced herself as a cardiologist here for a consult.

“Can you tell me about your patient?” She said, in a way that told me she was completely bored with the situation. You could tell she would rather be elsewhere. And seriously, how did she get here so fast. And OH CRAP, I need to talk to a doctor again!

“84 year old male for unsuccessful laparotomy to remove abdominal tumor, diverting colostomy created. Low urine output times four days, chest has wheezes and course crackles, at 05:00 this morning he experienced episode of decreased Sats and shortness-of-breath, oxygen delivery was increased, and Lasix and Ventolin were given. All vital signs have been stable since. His ECG showed a block, and Troponis were 0.28” I rattled off with definite confidence. I liked the way it all sounded! I forgot to use SBAR, but I think my bedtime talk with myself had worked a little bit.

“OK” she said, and went to assess the patient. I didn’t receive one condescending look from her!

Nursing is a reflective practice. We learn how to do our jobs by examining our performance, and critically thinking in order to find ways to improve. In nursing school we called them “Reflective Journals,” and we all dreaded them. But I really do understand why the practice is important.

My conversation with Doctor McFlirty kept me up late at night because I knew that I could do better. I knew that I was not happy with my performance. I laid there in the dark, picking apart my performance until I discovered a method to improve the way I communicate with doctors.

Sure, my performance the next day was not perfect, but it was a vast improvement. With practice and reflection, I will develop the confidence I feel my patients deserve from me.

I am starting to fall in love with the changes to my sight. Sometimes change just takes a bit of time to get used to. I like the crisp, clean look that I have developed.

Last night I changed the look/feel and deleted non-nursing sidebar items and links. Today I have added three items:

1. I lengthened my “About Me” page by adding some more detail. Eventually I would like to have quite a lengthy description there of my life and beliefs.

2. I added a paged entitled “Vision.” For now, I have simply copied/pasted from a previous post I wrote. However, this will be an ever-evoloving page devoted to what I feel the future of nursing will look like. Nurses are professionals, but our current style of work pulls us in the opposite direction toward a more “blue collar” description.

3. I permanently included a poem by Walt Whitman entitled “The Wound-Dresser” about his experience as a nurse during The Civil War. I particularly like the last stanza, as it describes beautifuly the life of a nurse (not to mention its interesting allusion to Walt’s homosexuallity).

I think I have completed all the changes that I will make in the short term. From here, I will let the site develop organically as it desires. I hope you all enjoy what I have done, and I welcome any and all feedback.

And please please PLEASE, if you would like me to link your blog or website, just leave a request in my comments.

Sincerely,

Sean

Well, I have to admit that I am not happy with the new look. However, after pouring through hundreds of themes, this is the best I could do. I did indeed find an absolutely perfect theme, but in the end, it just didn’t work. And I certainly don’t know enough coding to customize these themes.

On the plus side, I do feel that the fresh, dewy leaves do a great job of representing both spring and the rebirth of this website!

So! Here it is in all it’s glory. It isn’t much right now, and I definitely have bigger plans. Please stay tuned for some exciting times here in my little corner of the world. I plan to rock the world of nursing!

I have decided to refocus my blog into a strictly (or perhaps 90%) medical/nursing blog. While I will still update regarding my personal life, those posts will be few and far between.

Here’s what I want my blog to look like:

1. Stories from the front lines! I want to share stories of my triumphs and failures from my life as a Registered Nurse.

2. Reaction to news articles

3. Sharing nursing/medical journals that I have found and read.

4. Links to nursing/medical blogs, nursing websites.

In general, I want to create a professional themed environment with an meta-theme of nursing advocacy.

I apologize, but I will be removing personal links from my sidebar and specifically listing nursing blogs etc. (see above). I still love you all and will read your blogs every day, but it just doesn’t fit into my theme.

The reason I am doing this is because blogging about my personal life just doesn’t work for me anymore. When I first started blogging many years ago, it was an anonymous world. I could share my deepest secrets. Now, the blogging world is full of friends/coworkers, and I just don’t find myself interested in sharing my secrets (meaning…things I wouldn’t tell you in real life…which, to be honest, isn’t much). I am bored of just making superficial lists of what I have been doing (which isn’t much).

On top of that, I an a nursing geek. I want an outlet for my love of research. I want a place where I can shed a positive light on this profession I love. I also want a place where I can show that nursing education does not end when school does!

OK, I made this sounds way less casual than it will be. We’ll see what shape this place is molded into. For now, you will see the format/look change frequently as I seek a website I’m happy with. If you have any suggestions or feedback, PLEASE send it my way!

Let the construction begin!