Nurse to patient ratios and acuity in YOUR PICU

Oh, I think they know how sick their kids are, but they don't realize that we can't save 'em all, and there are some we shouldn't try. We seem to get a lot of parents who have a huge sense of entitlement, and a conviction that they should get everything they want. No matter how it affects their child. So it's fine to have a child intubated for every single one of its first 363 days (and counting) on earth if Mom and Dad don't want a trach (mostly Mom) and it's fine to ignore a child's pleas to be allowed to die because Mom and Dad aren't ready (until on Day 199, there isn't anything more we can do to stop death) and it's fine to continually do CPR on a child whose previous arrests have left her in a vegetative state and put her on ECLS when CPR isn't enough... twice. And it's okay to put the livelihood of a nurse and an RT at risk every day so that kids like these can go for a "walk" to the courtyard to see the Christmas tree or to watch the buses.

They don't even agree with each other! Our director is a blow-sunshine-up-your-butt kind of person who sees hope in every situation. He even mentioned dialysis to the family of a kid whose brain I was sucking into a canister from his nose and ears who was already on code doses of epi and vasopressin. A couple of them are realistic but don't like to tackle the difficult conversations so they wait until Dr. Happy is on. One of them is really good at taking the bull by the horns, but he's a 'junior' intensivist. And one totally sees the moral distress in the nurses and is very supportive of our feelings, but rarely does anything to alleviate them. None of them would ever refuse to do something that a parent wanted done unless it was abundantly clear the child would die from it. One of our kids had all the symptoms of HLH and was actively dying. A bone marrow biopsy would have confirmed the diagnosis, but the parents refused to allow it. So we kept the kid alive for almost two more months. The kid in my first example should have gone for a flow study but the family was afraid the kid would die en route, so it didn't happen until long after we saw a K+ of 8.9 and treated it. There are so many more... Some days I feel like I work with Dr Mengele.

You'd think so, wouldn't you? But that seems not to matter nearly as much as making the parents happy. The kid I mentioned who has been intubated each of the 364 days on earth went outside for the first time ever on the weekend and guess what... is now septic. The transport nurse who made the trip says everyone should have the chance to see the sky before they die...

It's a huge strain staffing-wise. There has to be an RN and an RT at the very least for each of these trips, and a nursing attendant to help push the equipment. For some kids, it's a parade of five staff, the bed, the vent, the IV tree and the parents. I wonder what our regulatory body (or a judge!) would say if something happened to the kid while on one of these trips.

One long weekend last summer when the unit was super short-staffed, our manager came in to take a kid out for a walk. She didn't come to cover the breaks nobody was getting, or to take charge so the charge nurse could take a patient. We filed a complaint about it with our union, but really got nowhere.

So get this! All three of the patients who went sightseeing last Saturday are now critically ill again. One of them they were able to wean down to 0.12 of norepi by giving him three litres of fluid, another clotted his hemocath and is still needing major inotropes, and the third ended up in the OR last night for a laparotomy. Does our dear MD see the pattern? Of course not.