This Is Intensive Medical Care!

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    Has this happened to you? You walk into the nurse’s lounge, get your assignment; head out the door for report only to be told that you are getting a third patient who has been in the ED all day so “hurry up”. You get report on your two patients (rushing through the assessment as quickly as possible) and just as you go into the empty room assigned to your third patient, the phone rings and it’s for you.

    You put the phone down after report and look up at the call light flashing brightly (of course, it’s one of yours). You finally finish with patient number 2 just in time to see patient number 3 being wheeled into his room. Oh joy! You promise yourself that you will make it to the restroom AFTER you get him settled in. It’s okay, you’re a nurse and we all know how big a nurse’s bladder can be.

    Now let’s focus on your third patient: a 70 year old gentleman with end stage HIV. He weighs exactly 80 pounds (actually, he resembles a survivor of the concentration camps) ; every bone and tendon stands out. It is painful to look at him. You finish up all the essentials (assessment, consents signed, history filled out) and you give him the call light/ tv remote.

    Once you have regrouped and organized you are ready to deliver medications, change dressings, etc. - all those things that contribute to the comfort and healing process. Once you get the ball rolling, you have it made. Unless there is a blimp on the screen, a glitch in the plan, a problem with the plan! Prepare yourself: the call light goes on and you’re off - the race has begun.

    Now let’s add to the equation. You walk into your first room and notice that your patient, a 78 year old female with a long health history compounded with more than 20 visits to the ER, now needs some serious attention. Her Lasix has not kicked in and you can hear the gasps as she struggles to breathe. A simple Lasix “chaser” is not going to help at this point. You page respiratory, an arterial blood gas is the thing. Next you page the physician and stand by the patient with the insane hope that your presence can somehow assuage her shortness of breath. Twenty minutes later and your patient is on the ventilator but, you have to fight with the physician to keep the patient sedated on Diprivan (he prefers 2 mg of Ativan every 4 hours). In order to get the drug most suitable for your patient, you must get a pulmonary consult for ventilator coverage. You clean up the patient, the room, and, oh yes, the husband’s belligerent attitude (“she was fine when I left her”) and hand him the box of salty snacks he slipped into the patient’s delicately balanced diet because, after all, food is love and he felt the need to “spoil” her a little.

    The call light beckons you away from his angry accusations. Your second patient has been on your mind, and in your prayers for the last 2 hours (“dear God please let her stay stable while I take care of my other two patients”). The poor woman needs a bedpan; the other nurses have been great about helping her out while you are stuck in the other rooms and hopefully she can understand. She does. This is her third hospitalization since that horrible day she found a lump in her breast while checking herself in the shower. She is here this time because her first round of chemotherapy made her too ill to be at home, alone. She refuses a foley catheter and you respect her wishes despite the difficulties her refusal create.

    We laugh and joke while I help her get comfortable in bed. I have removed the surgical bandage and examined the skin surrounding the stitch line. It looks pink and flat and healthy, “edges approximate” gets tucked away in your brain for documentation later. She tells me her story while I help her move around a bit and give her a quickie bath and linen change. She is hopeful that she will beat this “thing”. I help her with her gown. I am prayerful for her. I will miss her because tonight she will transfer to a step down unit. I tell her to expect it (even at 0300 hours) because that is the way it is: one patient leaves or expires and a room opens up.

    Now I can try to sit in front of the computer and chart. That has to be the one thing that can become harder and harder. You organize your paperwork and your thoughts and begin entering the information for each patient; a call light or alarm goes off and there you go flying down the hall. The minute you finish with that business, you sit in front of the computer and realize you cannot remember what was next. This night I count the times I am called to the room by call lights, not just my patients, but call lights and alarms. Seventeen times by the time we have been on duty four hours.

    My 80 pound patient’s call light goes on and I am filled with disbelief: he is gasping for air. He has brought with him an advance directive. It is a piece of paper which states that he does not want “heroic measures” done. When you can’t breathe, however, you change your mind quickly. I offer him several options and he makes his choice. Respiratory places a device which is intended to deliver the maximum amount of oxygen to this patient’s lungs; I explain to him the next step. We both hate the bipap device but together we make an agreement. I will keep him comfortable tonight and tomorrow he will speak with the physician about further treatment options.

    I have experienced physical pain. Serious, unrelenting, mind numbing pain. I understand pain and the patient who finds they are imprisoned by pain. You must find relief for them as completely as you can; the physician must understand the patient’s needs. Sometimes the collaboration between the patient, the physician, and the nurse runs out of fuel. Sometimes it is the physician and sometimes it is the nurse. My belief that no one should suffer needlessly was born as a result of an injury. I now make it my business to see that my patient remains if not pain-free, then at least in “control” of their pain. If the medicine can be given every four hours, I give it. I find that this attention to “control pain” benefits the patient. They don’t wait so long for relief that the pain gets ahead of them. I have lost my temper only once and that was with a coworker who did not give a cancer patient ANY pain medication on her shift, “she didn’t ask for it” is not an excuse - some patients are stoic unnecessarily.

    Now I am given a bed for my post-surgical patient. I dare not drag my feet on the transfer because I have another post-surgical patient waiting in PACU. This patient had open heart surgery (coronary arterial bypass grafts) more than three weeks ago. He noticed a slight redness at the base of his sternum a week ago. He says he chose to ignore it; now he has a high temperature and a sluggish green drainage at the site. Oh yes, the site is bright red and swollen. In report I am told they evacuated more than a half cup of secretions from the now seriously infected incision site. Whether he knows it or not, his life is endangered. He will stay in ICU for several days so that the intravenous antibiotics can get a foothold on the infection.

    Before I can accept my new patient, the patient in the assigned room must be transferred. This means paperwork, calling report (and finding the nurse willing to take report at the time you are ready), packing up the patient and their belongings, and finally, carting the patient off to their new room. In the hospital where I currently work, the cleaning group is so good that the problem of cleaning a room quickly doesn’t exist. Finding a tech to transport the patient out of one room to the next can be tough. Techs are few and far between. We overwork our techs, but what choice is there?

    Sometimes it feels like we are on a treadmill. We get the patient in, treat them as best we can and then we get them out. Get ‘em in, get ‘em out!

    Many nights I stand at my work station and look down the hallway and wonder if there is some way we could get things under control so we could have more contact on a personal side with our patients. By this I mean I would love to find time to sit in a chair in the patient’s room and listen to them. I don’t have that luxury now. When I need information, I just want to scream: just tell me yes or no; now just sign the consent! Eeek!

    I try to get everything done in a timely manner. Most often, it’s done and that’s the miracle in itself. Timely? Ha-ha! I have worked night shift all of my nursing career (except for one summer when things were really slow and I needed any shift I could manage) and nights are somewhat less chaotic but nevertheless challenging. The young in our intensive care unit have not learned to say NO to bullying family members; this causes heartache and lots of anger. Two weeks ago I had 3 belligerent family members who planted themselves against the empty bed in a two patient room. They placed their chairs directly in front of the bipap machine and dared the staff to eject them. Their dad was struggling with pancreatitis. He had a Dilaudid PCA which they pushed to deliver the pain med until I came in and could not awaken the patient even with sternal rub. After consulting with the physician and presenting him with an ABG incompatible with life on this planet, I removed the PCA pump. I was screamed at by the family (thank God Charge backed me up). I explained everything to them and asked them for their cooperation. They begrudgingly helped me by cooperating with a plan of care that WE developed. The patient did well on bipap that night; his pain was controlled by me, and the family actually went home to rest. In our unit, whether the family stays at night is “nurse’s decision”; a weak and demoralizing rule of thumb which often cripples the nurse’s ability to care for the patient.

    So, now you’ve seen a night within the intensive medical unit. Like so many jobs, there are many facets. Some times the hospital you work for cares for the nursing staff and their ancillary support. Often times it is hard to see that. Especially when the things they do confound it’s employees. We are all alike, that is, we work for a living as well as personal satisfaction. As nurses, we want our opinions to count; we want to be part of the team.

    We need to support each other; I am very fortunate to work with the group of nurses that I do.
    Last edit by Joe V on Apr 30, '08
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    About walk6miles

    Joined: Jun '06; Posts: 333; Likes: 352
    RN critical care areas
    Specialty: ICU of all kinds, CVICU, Cath Lab, ER.

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  3. by   suanna
    Hospitals that try to cut costs by reducing the nurse to patient ratio in critical care need to read this. There seems to be a never ending sub text with the supervisory staff that the critical care staff get off easy because they "only have 2-3 patients". We lose our aid to float first, then the unit clerk -we can put in our own orders, and best of all if we have a night when we aren't all up to max and above with our assignments and might be able to give the patients the care they deserve- we are always first up to float to ANYWHERE in the hospital.
  4. by   walk6miles
    Thank you for your comments; I agree. My emotions were swirling around and around when I wrote it. I wish I could say things will change but I know too well from experience that what is going on in our hospitals today is just a sign of the times and things to come..sadly, the day that non-medical professionals run the hospitals is the day that begins the demise of compassionate, safe patient care.
  5. by   stand1982
    phew im tired after reading this. its my night off and i also have had many nights like this in recent years.but i do remember early in my career when i did have time to spend with patients. you got to know your patient by talking to them. we use to give each of our patients back rubs as part of nightly duties. boy things have changed and not for the better. i long for the olds days when charting wasnt a matter if the computers were up or not.
  6. by   RNPATL
    Wow, what an awesome depiction of a single shift as an ICU nurse. As I was reading your words, I could hear your shallow breaths running from one priority to another and wondering if you had met the needs of any of them. Your passion about pain management is truly inspiring and I totally agree with you. Excellent, excellent writing and I only wish that those in their ivory towers could spend one single shift with a nurse in ICU. Perhaps then they would see life and death a little more than an issue of productivity. It is also nice when you work with a team of nurses that support each other. Thank you for sharing this story!
  7. by   walk6miles
    Thank you for your kind words. They came on a day when I very much needed them! God Bless!
  8. by   macspuds
    What a wonderful and true to life article this is. Thanks so much for sharing. I have read several articles in this issue that say what I believe as a Nurse also. Franlky I am concerned for folks like you all are hard to find. It has been good to see what I have been feeling and doing put into print. I am grateful to know that there are others out there, for as you know, there are the unfeeling and seemingly uncaring ones who are in it just for the paycheck. Thanks again.-----macspuds
  9. by   walk6miles
    My thanks to you. I enjoy feedback (keeps my spirits up) and especially enjoy when other nurses share their experiences with me.
    God bless.
  10. by   icu_nursie76
    That was an awesome story! sounds so familiar.
  11. by   walk6miles
    Thank you soooo much. I am convinced that they (paranoia settling in??) are now trying to kill the nurses.... kill all the older experienced nurses so you can hire new nurses and save the budget!! Unfortunately, the new nurses miss symptoms (subtle); make mistakes because they are not properly oriented/trained to critical care situations and in the case of one newbie, refuse to take on a third patient who is turning blue in the med-surg bed while he CRIES yes, CRIES in the men's room.
    I am not saying any of this is limited to the number of new nurses in ICU however, inexperience is more dangerous than any other consideration (except drugs).
    Hey nursie! Isn't life challenging!!
  12. by   greenergrass
    What beautiful writing. We were with you all night long. Thanks for putting a voice to the plight of not only the nurse, but your patients.

    I too, felt your shallow breathing (enlarged bladder & dry throat) throughout your shift. Most of us have been there.

    Quick question: What did you do later to celebrate your heroic accomplishment?

    You deserve a celebration & some self-care with your hard work & dedication!