A Little Rant And Some Failures

[JBMmom, MSN, NP]

There are some days that are easier than others with this pandemic. I feel like I'm becoming that friend/family member that just can't "get over it". I know others here are having similar pandemic experiences, so I'm just venting.

We've been tripled in the ICU for weeks, it's exhausting and concerning for patient care and outcomes. I was transferred to the PACU last night to cover three intubated patients being held there and it was the first shift in weeks that I actually got out on time. In many ways it was nice because I was not in charge and no one needed any help. It was just me and my three patients, and another float nurse came by every couple hours to help with turns and baths. But I also caught myself in a judgmental mood for a while. We had an overdose patient who was COVID positive last month. After over 40 days on the vent, he was trached and last night he was in PACU. Looks like he's going to make it. This patient will be arrested on domestic violence charges if he ever leaves the hospital (or long term care rehab), and he has made so many choices over the years that have hurt others- including some of the staff that admitted him last month. COVID has robbed us of some truly wonderful people. Right now there's a father of six who probably won't make it, a couple weeks ago we lost a former police officer with two young kids, the list goes on and on. Of all the people to get the miracle everyone is praying for, it's this guy. I did my best to provide the appropriate care, but I admit I found myself avoiding him when he was calling me over for the 40th time to explain why he's in the hospital and why he can't get up and leave. 

The other night I had a young man in his 30s maxed on high flow with a nonrebreather over it. He was hypoxic and intermittently confused. He would remove his oxygen and then drop his sats, even into the 60s. I went in and out all night, at least 3-5 times an hour. I didn't make other staff do it, except once or twice when I was in the room with one of my two other patients. Everyone else just wanted to intubate him to stop the alarms from going off. Not getting a blood gas, not trying medication, they just wanted to intubate. I realize that hypoxia and confusion are potentially appropriate indicators for intubation, but when he had the high flow on, he would sat at 98% when positioned on his stomach or over on his side. I told them that I refused to intubate him just to have another patient die on me. I wanted to give him a chance on the high flow. Well, the oncoming nurse decided before we were even done with report that "I'm not listening to that all day, he's buying a tube". I was so annoyed. We don't intubate for staff convenience! (or at least we shouldn't) I saw last night he's on the vent and proned now.

Are other places keeping people on high flow or BiPAP for extended periods? Are we waiting so long that people are exhausted and that's why they die? We've had people on those for as long as two weeks before intubating to try to get them through with self-proning and positioning.  Are any places still intubating somewhat early on, and are those outcomes better? I'm SICK of everyone dying. 

Last week I had a prone patient and when we went in to turn her head, her oxygen levels dropped and weren't recovering. She was already on 100% and it didn't help to try and bag her. I called the daughter and held the phone up so she could talk to mom and say goodbye. Until then we had been wondering why we had this very ill woman with many comorbidities on the vent and proned. We knew it was futile, why was the family doing this to her?! Well, it turns out the daughter was being discharged from a short term rehab facility three days later and just wanted to see her mom. So I felt like an *** for being judgmental. I really try not to be but lately it seems to be creeping in more, personal failures. Maybe just a sign I need a break.

Anyway, thanks for reading and letting me get that off my chest into the cyberworld. I know we've all had it rough lately, hoping that you all stay healthy and well. Take care of yourselves.  

[toomuchbaloney]

Yeah. You've had a rough go of it.  You are experiencing the symptoms of traumatic stress. Your traumatic stress is not related to a single terrible or emotionally jarring event.  Instead your symptoms are related to cumulative trauma and cumulative grief heaped in abundance over many months.  The emotional pain and suffering for some of our nurses has been just too great a burden.  

I bet you have some mental health benefits available to you through your facility.  Please reach out to your management and tell them that you need some kind of a change or break.  Hopefully they will get you set up with some time to work through this and heal some. Having someone to talk with therapeutically will help.  Good luck!

[nursej22, MSN, RN]

JBMom, I agree with TMB about the trauma you have endured. I hope this latest wave is over soon and you can get some relief. Venting is vital, even if it is to us, your virtual tribe. 

I am unable to return to the bedside, but I so appreciate you, and others, relating your experiences. I admit, I am becoming jaded about the lack of vaccination and masking around me, but then I read you and I redouble my efforts. 

You are a hero. Take care!

I look forward to your book (hint, hint) 

[JBMmom, MSN, NP]

Thank you both. I had the night off last night and a good night sleep has definitely done wonders! I will probably get in touch with our employee helpline, although I do have a job change coming up in just a few weeks, so there's a bright spot. I'm sad to leave my coworkers in this situation, but 50 hours a week or so for the past few years has just gotten to be too much. When it's just a per diem job I'll probably find a better balance. I still love my job, just hope this pandemic finally comes to an end. 

And I'm flattered you would read a book I wrote. It's been greatly therapeutic to me to write here, but I'm not sure I could ever write anything important enough for a whole book. 

[SmilingBluEyes]

I hope things do get better for you JBM!  You deserve a medal.

[LTC Advocate]

I am not an ICU nurse but does intubation sometimes cause a whole new set of potential problems? In LTC some staff are quick to admin or order sedatives for our residents. Sometimes this is the best option especially for the resident. However I do not think it should be the first. 

Hang in, you seem to be a very apt and empathetic nurse! Trust in your knowledge and instincts and most importantly, your empathy! 

[JBMmom, MSN, NP]

1 hour ago, LTC Advocate said:

I am not an ICU nurse but does intubation sometimes cause a whole new set of potential problems?

You are absolutely right and for that reason, intubation is ALWAYS the LAST option for treatment of patients. Just like anything else we want to use the minimum amount of intervention to achieve our desired outcome. If you can redirect a patient in long term care and avoid sedatives, that's preferable. If we can keep patients on high flow oxygen or BiPAP and get them to self-prone until they get better, we will always do that. We have had a few people make it without being intubated and get better, but only very few.

Once we intubate someone we have to start sedation. Sometimes people require paralytics in order to get them to be compliant with a ventilator. People can become hypotensive, whether due to the sedatives or their body's reaction to infection and then they may require pressor support, That brings a host of problems, especially for the kidneys and can kick people into kidney failure. The patients faring most poorly are obese people. Whether they are diabetic or not, obesity is like COVID candy. Sometimes people develop an aspiration pneumonia because we do try to start tube feeding people while on the ventilator and sometimes hey do vomit and aspirate causing additional infection. There has also been an increase in fungal lung infections with COVID patients, and a source is generally not identifiable. Most people that are intubated with COVID pneumonia develop acute respiratory distress syndrome. This is diagnosed based on the ratio between the % oxygen being delivered by the ventilator in comparison with the arterial measurement of oxygen in the blood. That tells us how well the oxygen is crossing the alveoli and getting into the bloodstream. We try to improve the oxygenation by placing people in prone position for 16 hours a day, turning their heads and making them "swim" by repositioning their arms and legs every two hours. (This morning I had to unprone and reposition a 420lb patient, and it's killing our backs) With COVID pneumonia, patients eventually can't get the oxygen across their alveoli into the bloodstream and they will have excessively low oxygen saturation levels until they go into cardiac arrest. 

So that's the very long way of saying, yes, you're right, ventilators are really NOT a good option. But when the choice is not intubate with 100% chance of death, or intubate with 90% chance of death- most patients and families try to win the lottery. We wish they could all win, we really do. 

[LTC Advocate]

4 minutes ago, JBMmom said:

You are absolutely right and for that reason, intubation is ALWAYS the LAST option for treatment of patients. Just like anything else we want to use the minimum amount of intervention to achieve our desired outcome. If you can redirect a patient in long term care and avoid sedatives, that's preferable. If we can keep patients on high flow oxygen or BiPAP and get them to self-prone until they get better, we will always do that. We have had a few people make it without being intubated and get better, but only very few.

Once we intubate someone we have to start sedation. Sometimes people require paralytics in order to get them to be compliant with a ventilator. People can become hypotensive, whether due to the sedatives or their body's reaction to infection and then they may require pressor support, That brings a host of problems, especially for the kidneys and can kick people into kidney failure. The patients faring most poorly are obese people. Whether they are diabetic or not, obesity is like COVID candy. Sometimes people develop an aspiration pneumonia because we do try to start tube feeding people while on the ventilator and sometimes hey do vomit and aspirate causing additional infection. There has also been an increase in fungal lung infections with COVID patients, and a source is generally not identifiable. Most people that are intubated with COVID pneumonia develop acute respiratory distress syndrome. This is diagnosed based on the ratio between the % oxygen being delivered by the ventilator in comparison with the arterial measurement of oxygen in the blood. That tells us how well the oxygen is crossing the alveoli and getting into the bloodstream. We try to improve the oxygenation by placing people in prone position for 16 hours a day, turning their heads and making them "swim" by repositioning their arms and legs every two hours. (This morning I had to unprone and reposition a 420lb patient, and it's killing our backs) With COVID pneumonia, patients eventually can't get the oxygen across their alveoli into the bloodstream and they will have excessively low oxygen saturation levels until they go into cardiac arrest. 

So that's the very long way of saying, yes, you're right, ventilators are really NOT a good option. But when the choice is not intubate with 100% chance of death, or intubate with 90% chance of death- most patients and families try to win the lottery. We wish they could all win, we really do. 

Thank you for that indepth education! I knew it wasn't the best option and should be used as last resort(intubation). 

In LTC when I made the decision for a sedative, I always evaluate what is best for the resident. If other intervention have failed, they are putting themselves and others at risk, if they are suffering especially when having frightening delusions, I will use the sedatives. I will not however use them before any of that. Only in extreme circumstances,  usually when other nurses cannot help, I will use sedative first. It's always based on the situation and most importantly the resident/patient. 

 

[LTC Advocate]

May I take the time to give ICU nurses some well deserved praise. I look at all of you as earth angels. When I was in nursing school, I was having a very tough time and was seriously considering quitting. My mom who had COPD, went into respiratory failure. Her ICU nurses were amazing! They told me the worst info I could hear and yet they comforted me. They knew I was a nursing student and allowed me to do assessments on my mom with them. (Fitting as she was always my guinea pig). 

The way they treated me and my mom inspired me to not quite nursing! And here I am. My mom died that day but I nor her ever felt alone. Thank you ICU nurses,you are truly earth angels. 

[JBMmom, MSN, NP]

1 minute ago, LTC Advocate said:

It's always based on the situation and most importantly the resident/patient. 

The same principle should guide all of us in our practice! Thank you for your question, and for indulging my very long response with a read. Wishing you all the best. My years in long term care were challenging but rewarding. This pandemic has required so many LTC facilities to become family to residents while they are restricted from visits with their own family. It has been a sad and difficult time, thank you for all that you do for your residents!

[JBMmom, MSN, NP]

1 minute ago, LTC Advocate said:

May I take the time to give ICU nurses some well deserved praise.

You are deserving of the exact same praise! We serve different patient populations, but you and your skills are just as vital to your patients as my skills are to my patients. As I mentioned, I started in LTC and enjoyed working there for five years, but I know that I would probably not make an easy transition back there if I ever changed jobs. I can see everything about my patients' vitals with a quick glance at a monitor in the ICU. You have to rely on your assessment skills, and your coworkers, to keep everyone well. You sound like a wonderful nurse, I'm glad for your residents that they have you caring for them!

[LTC Advocate]

4 hours ago, JBMmom said:

You are deserving of the exact same praise! We serve different patient populations, but you and your skills are just as vital to your patients as my skills are to my patients. As I mentioned, I started in LTC and enjoyed working there for five years, but I know that I would probably not make an easy transition back there if I ever changed jobs. I can see everything about my patients' vitals with a quick glance at a monitor in the ICU. You have to rely on your assessment skills, and your coworkers, to keep everyone well. You sound like a wonderful nurse, I'm glad for your residents that they have you caring for them!

Well thank you for saying so! I have to give the care aids credit as well. They are a gold pot of info when the residents start going "off" for lack of a better word! Use. I do not always have their no at my fingertips and do rely of assessments. Never thought about that!