Darkfield

I'm taking an informal survey here. I work in critical care and I see quite a lot of death. My attitude towards death has become quite callous - when someone is sick, they should be a DNR, and when someone is really sick, they should be comfort care. I'm more relieved than upset when people die and death in general does not bother me. My question for all of you who have had experience with dying patients is this; does touching and handling death on the job change your perspective when one of your own family members is dying? Are you more likely to make Grandma a DNR or be at peace with someone's passing? I'm also interested in this; do you think it is normal and healthy that nurses are comfortable with death or is there something wrong with people who can joke on the way to the morgue and cry during lifetime movies?

I work in the northeast. I think our attendings are very good about addressing code status with the families when it starts looking bad or when the pt is very elderly or has a poor quality of life. If the family states they want to do DNI/DNR or comfort care, our docs are usually very good. We have more problems with families who want to push and push and push. The worst cases are with families that have a lot of faith and they think faith is that God will do a miracle at the last moment, not that God will do whatever He sees fit. We had a woman maxed on five pressors, pulmonary hemorrhaging, that we coded six times in twenty-four hours because the family would not accept death. I've seen a pt made dnr over family objections one time because of medical futility (on echmo, hfov, sats in the 70's). Our comfort care patients are kept in the ICU if death looks likely soon. If they weren't on pressors/intubated, they go to the floor sometimes. The only I do for comfort care pts is q8 vitals and t&p. We don't have good education and/or policies on comfort care and I think we could work on that. We do a great job until then, and then it's seems like it is sort of up to the RN what they want to do.

Not all places are that terrible! You might feel bad for leaving, but if it is for your own sanity, do it. Go somewhere else, and switch to days. Having no circadian rhythm is a killer. I know what you mean about being irritated when someone starts up a long conversation. If you have things to do, you have things to do. You can't get them done if you have to sit around and be therapeutic.

He went for a trach and came back with a 6th pleuravac, draining the pericardium and two jp's, draining the puss around his treachea instead. Then I was off for a few days. There is a happy thank-you card from his family in the break room, so I'm assuming all went well.

We started using them after evidence showed that MRSA is found (not on those stupid yellow gowns) most often in the basins. My friend counters that by getting a new bath basin each time she bathes someone, but that isn't very practical, landfill wise. I'm not a huge fan of the cholorhexadine because they leave the pt sticky for a few minutes. I just feel like soap and water get a person cleaner. The real source of infection was probably the wet washcloths that I used to find the basins, saved to be used again. Clean, but wet, sitting the dark...a perfect breeding ground.

I've been a nurse for about four years and I find myself making a lot of little mistakes, but you learn. I do stupid things, but I never do stupid things more than once. If you break a rule, think about how important that rule is. The pt is supposed to be npo. Why? because they have a bowel obstruction? having a procedure? MIght or might not go to surgery? In any of those cases, I doubt a bit of ice is going to hurt things in the long run. Just keep swimming; you'll learn.

monotherm foley caths. Unless you've got a freak ICU pt that doesn't need a foley (that happens) or someone with a 3way, it's the way to go.

Had a guy who aspirated his own vomit when he was drunk, ended up with empyema, loculated fluid collection, all out white out left lung. Five chest tubes. He was in the OR for a trach when I came on the other night, but he came back with 2 jp's draining the abscess around his trachea (pure purulence) and pleuravac draining a pericardial abscess instead. My colleague and I were, somewhat morbidly, betting on his survival. I've had two other pts with five chest tubes who both died. One was virtually brain dead and the other had severe pulmonary co-morbidities. (that's a fancy way of saying bad COPD.) Wondering if you fabulous ICU RN's out there have any bright ideas about this poor man's chances? I'd like to see him make it. I really would.

exact same at my place a little further upstate. 7 max at night on med surg and it only goes down. I worked days with a 5-6 max and it was unbelievably busy and sometimes unsafe. Would never take more pts.

I'm guessing the original poster doesn't actually know what a paralytic is-it is completely inappropriate to suggest for a post-extubation pt. The fact that the nurse in question's response to confusion is to "sedate" tells me a little bit about his/her knowledge.

Just have to reply to this as well; the pressor you use has a lot to do with why you are using the pressor. If the pt is septic, for example, you'll want levophed because it constricts the periphery and increases flow to the central organs. Dopamine has a more inotrophic effect, but it causes far more arrhytmias than levo. I see it more in pts with a cardiac etiology than anything. I've seen pts for whom levo was not enough, and I've seen patients go hypotensive because of levo. Off topic, but so many of our pts that come from outside hospitals get to us septic with dopamine running, because the providers are still following the mantra, "levophed, leave'em dead,".

I can't imagine ever ever running a drip like this on my old med surg floor. I may have had insulin twice and a lasix drip; otherwise the only thing resembling a drip was a pca. And why would a line be dc'd with a pt still on a drip, especially one that is as terrible as dopamine? If the pt still needs dopmine, isn't there a chance that they're unstable enough to need another pressor or iatrogenic? Back in goes the line. What kind of a floor is it where the nurses can manage a critical drip but not central access? I'm sorry, but this sounds like an enourmous train wreck waiting to happen.

I just want to say I had the ultimate patient last night. Sometimes I feel like a terrible person because I like it when people are really sick, but I don't actually want them to be sick, right? But this guy was; one of those weird MICU pts that was healthy until he went into ARDS for apparently no reason at all, and got put on the oscillator. He was doing ok on it, and then his kidneys shut down, and he was put on hemo. He didn't tolerate that, and CVVH/CRRT was started right before my shift. Without an anti-coagulent. Duh. When I got on, I started heparin, got a bad blood gas, started nimbex, BIS and train of four, I ran like crazy, but it was really rewarding. All too often, our very sick patients are hopeless-if they live, what sort of quality of life will they have, and why are we doing this to them? But this guy was very very sick and he really had a lot to live for. I took stellar care of him, and the CVVH ran like a dream. It never does that. Then the machine malfunctioned and the HD nurse had to take it down and restart it. I was so disappointed. But it was a great night.

I know a lot of Europeans that wear scarves around their necks when they have colds...I saw a German girl do it in India, and it was about 85 degrees out.

That is not a ton of propofol. Are you sure you're not talking about mg instead of mcg? Most people I've met can stay awake on 15 mcg/kg/min. In answer to the original question, if the pt was comfortable, I'd leave her where she was. That's actually ideal, someone that will wake up a little bit, but is not uncomfortable. Sometimes you have to snow pts if they are unstable or fight the vent or are on a vent setting that requires near paralysis for compliance. But hold off if the pt tolerates it, I think. You ever meet the folks that have been snowed for two weeks or more? It takes them a long time to come back to planet Earth.

That's ridiculous. We have this old fashioned vents in CT and MRI that work on pts who are stable enough to transport. The RT sets them up and then bags while two people push the bed. How can you steer the bed and bag at the same time with an IV pole? Aren't you afraid you're going to extubate someone?

We aren't allowed to do certain things because it is a teaching hospital, I think, and the residents need to learn to do everything and think of everything. With things like taking out staples, I think it is a nursing issue rather than a doc one. I could go to the MICU attending about the staples, but depending on who it is, they might not care. The patient is going to die anyway, but it just irks me that we would drop our standards because of that.

I have a pt who has been in our ICU for over a month now. Uncontrolled diabetes, severe respiratory distress. On the vent for about a month, he's since been trached. Can't wean him down from 100% FIO2. Five chest tubes. Around three weeks ago, he had a thoractomy. He has staples on his back on the left side. They are growing into his skin. I can physically remove staples, but I am not allowed to at my facility. Today, I caught the thoraccic resident as he was doing his speedy rounds and handed him a staple remover. This is why he wouldn't remove them: -He's going to die anyway, and staples are the least of his problems. Did you see his chest xray? Exactly. If we remove those staples, all the pus from his lungs will leak out all over. Anyway, last time he was turned (two days ago, according to the doc), a chest tube kinked off and he blew another pneumo. Me: We bathed him three hours ago, and he did fine. Full turn and everything. No pneumo. Besides, you can't just not take care of a patient because he is going to die. His butt gets dirty, and we clean that even though it won't save his life. Him: no, He is too unstable to turn. If you can get his O2 down to 80, I'll remove the staples. WTH? Does he think we don't turn pts? And this is the story of the MICU, 20% of our pts won't live, and we know it, but we take stellar care of them. This pt, we've done a great job with. Besides his lungs, he is so much better then when he came in. He was morbidly obese, and now he's just obese. We've healed the extensive ulcers on his leg, and nearly fixed the abcess in his armpit with our great nursing care...he'll probably go septic again from the staples. What do you guys think?

I love it when other people become nurses. I am in ICU, and I love what I do. There are days that I hate it, but I'm in where the drama is. Life, death, blood all over, old family feuds boiling over, some of the weirdest cases, good and bad doctors, mercy flights, young people who are really really sick and then get better (or don't). Daily, I see the sort of thing that people watch TLC for. And I get paid. When I tell people that nursing is great, I also let them know that it isn't easy, that I hated school and almost dropped out the first semester. And that it is constantly stressful, and you'll be in a lot of situations that you won't know how to deal with. I'm not really about holding someone's hand and making their day better (occasionally, but it doesn't thrill me to the core of my being) but about learning as much as I can about the human body and its pathologies, and how to apply my knowledge. If you are a pharmacist, you know a lot. But you never get to see your work in action like we do. We are right there, with patients. I think it would be frustrating to see be, say, in radiology, because you might see something wrong with a patient, but all you can do is take an x-ray. We're different. And if you burn out of your job, there are a million other things to do. Management, telephone triage, public health. There are niches for nurse entrapeneurs; a market that can only be filled by use. The nursing shortage is not over where I live; and there is a huge primary care gap that needs to be filled by nurse practitioners.

I would never lie to patient about their condition or prognosis, but about my own ability to do something? Definitely. Your patients need to have confidence in you, and if they think you can't do one thing, they won't want you to do anything else. To learn to start iv's, you have to just stick people.

I always think they're going to sit back up again; I dreamed that it happened once. And I always leave their gown on when I bag them. They look different dead, though. Deflated. Their faces look like melted wax. There is a definite difference, and I think you are not crazy when you say you can feel the spirit leaving the body. Who can say you are wrong? None of us have died and lived to tell the tale.

A distribution person who wears a scrub top with high rise elastic waisted jeans.

A lot of new nurses are in it as a second career, which contributes to the aging. I would say about half of the nurses I went to school with were over 35. And you have to be a little bit mature-I didn't see a lot of people who were fresh out of high school, and those who were didn't always make it.

open fractures.

We have a guy with an open chest (I haven't taken care of him) and someone mentioned in report that there are paddles on SICU, we can't do cpr on him. He has a sternal wound and a wound vac. Does anyone know-if someone with a chest wound flatlines, can we not to cpr? It wouldn't work to shock, right?