Requesting words of encouragementâ€¦ Iâ€™m a new grad having a breakdown at work right now.

nurseactivist · Nov 14, 2015

"What if he codes?" Critically ill, unstable patients code. Every death is not your personal failure. Try to look at it objectively. Yes, Ms. Smith died. She is 95 years old had Ca, CHF, renal failure, huge brain bleed. It happens. Or, we brought her back (barely) 3 times and lost her. Maybe it was her time.

I did a lot of second guessing in ICU. I finally decided to move on from ICU after hanging in there for a year. In retorspect, I should not have been questioning how much dopamine I gave to a critically ill person at death's door who had they survived would have had no quality of life.

LPNtoRNin2016OH, LPN · Nov 14, 2015

I am a sensitive person and used to be someone who borrowed "other people's worries". Seriously, I would cry when someone I have never met was on TV talking about loosing their husband, etc. I have been like this since I was a small child according to my mother, I am like a sponge and soak up whatever emotions are around me. I have had to learn to turn this off for work and in life. I cannot let myself feel strong emotions towards my patients, it clouds my judgement. I am empathetic/understanding and offer my full support to the patient and patient's family but internally, I am detached from the situation. I mentally prepare myself (it comes more natural now than it used to be) when I am in any facility (Work or clinicals) to put my "armor on" and not absorb the sadness around me.

It sounds cold but it's what I have to do. I had to toughen up some and learn I can't feel everyone's troubles, it would ruin me.

Hang in there friend.

KelRN215, BSN, RN · Nov 14, 2015

I'm orienting in the cardiac ICU and tonight I just cracked. So far I've lost four patients, including one last night. It was awful because it could have been prevented. Despite continuously updating the doctors, they wouldn't put in any new orders for him. Just monitor him,â€ they said. Mid shift he coded and we lost him.
I'm exhausted tonight.
My patient looks bad: vented/sedated, febrile, lactic/trops/sugars/ WBCs/ BP/HR increasing, poor renal fct, on many drips and not doing well. Something bad is going to happen. While hanging a new gtt I froze in the room, started feeling tightness in my chest, hyperventilating, and crying. I don't know what to do. What if he codes?
My preceptor sent me away to hide for a bit. I've locked myself in the staff bathroom. I feel so pathetic.
I soooo want to be a cardiac ICU nurse. I don't want to give up. As stressful as this is, I love what I do. But many these people are so sick and I feel like I'm going to kill somebody. Though I'm just following orders, it was my hands that killed people. My orientation is ending next week and I feel so overwhelmed.
Does anyone have any advice for pushing through this? Also, please share stories of similar experiences, so that I don't feel so alone right now.
Thank you.....

A couple problems with your bolded statement here.

First, nursing is NOT "just following orders." You don't blindly follow orders that you disagree with or that are harmful to your patient. It is your duty to question (and refuse to implement if the order is dangerous) these orders. I recall a resident ordering a liter normal saline bolus for an infant who weighed about 10 kg once. The nurse and pharmacist rejected the order. Fluid boluses for children are usually 10-20 cc/kg. I had a resident from the same service once tell me that it was "fine" that my 2 month old patient's heart rate was 83. He was rotating through from the adult hospital, no clue what normal pediatric VS are. 83 is bradycardia for an infant and this child was exhibiting yet another sign of increased intracranial pressure. Yeah, within 10 minutes she was seizing and we were pushing her crib directly into the OR.

Second, it was not your hand that killed these patients- unless you intentionally bolused them with potassium IV push or turned off their vent or pressor drips. Patients in the Cardiac ICU are SICK. Many of them will die. Regardless of what you do or don't do, many of them will still die. It is their disease process that will kill them, not your hands.

Death is a part of life. Every single one of our lives will end in death. Though I've heard some people on here say "it never gets easier" or "you can't get used to it", I disagree. I think it does get easier. I don't remember the last time I cried about a patient's death. And my patients are children. The truth of the matter is that no matter what any of us do, a child with high risk stage IV neuroblastoma who relapses 3 months off treatment is going to die.

Horseshoe, BSN, RN · Nov 14, 2015

A couple problems with your bolded statement here.
First, nursing is NOT "just following orders." You don't blindly follow orders that you disagree with or that are harmful to your patient. It is your duty to question (and refuse to implement if the order is dangerous) these orders.

As I was reading through the responses, I wondered if anyone was going to address that comment.

Second, it was not your hand that killed these patients- unless you intentionally bolused them with potassium IV push or turned off their vent or pressor drips. Patients in the Cardiac ICU are SICK. Many of them will die. Regardless of what you do or don't do, many of them will still die. It is their disease process that will kill them, not your hands.

Well said.

hawaiicarl, BSN, RN · Nov 14, 2015

I feel for ya, happens to the best of us, some patients are just ready, and occasionally you have no idea.

I remember one time I had a syncopal patient we were working up, looked perfectly fine, all tests were normal. I had an orientee with me, and we were talking story with the patient, and he straight up died midsentence on me. SR, straight into VT, no R on T, nothing, plain up and died.

Another time we had a GI bleed, been scoped 3 times, couldn't find the source of the bleed. Started copious bleeding, slapped in an NGT drained 10 suction cannisters of blood out of her. BP in the toilet, general surgeon called in, stated "Nothing I can do she would never survive surgery." We just had to sit there and watch her bleed out, very frustrating.

Another anecdote, we had a nurse just off orientation, 8 years experience, but new to our hospital. First night she has a super sick 42 year old post code patient. Died, but since it was within 24 hours was a coroner's case. Second night, same room, same nurse, patient also 42 years old, super sick patient, codes and dies. Also within 24 hours, also a coroner's case. So she calls up the coroner, and he pauses and says "So let me get this right, when you get a critical 42 year old you put them in the same room, with the same nurse ............ (phone silence)" She was devastated, we all thought it was funny as Hell.

If you look at your national statistics for expected mortality, you will see that for a lot of cardiac surgeries 5% is the norm. Your hospital may be a percent above or below this norm. This means that 1 in 20 dying is NORMAL, and EXPECTED. This doesn't reflect on your skill, you need to realize that cardiac critical care is a different animal.

Regarding your specific situation, the Dr. telling you to just monitor the patient, may be telling you "I know, the patient is going to die, call me when he codes." Or if he is a clueless resident, or hospitalist, use your chain of command and jump over his head. This means mentor-charge nurse-nursing sup-attending-specialist-cardiac surgeon-chief of medicine (check the chain of command at your facility). Careful if you ever have to do this though.

Cheers

OCNRN63, RN · Nov 14, 2015

Patients die in the ICU all the time, I remember one time we actually ran out of body bags we had lost so many.
The "just monitor" line given by the docs is just another phrase for nothing else we can do. Think about your patient, look at the differentials and interventions. What other options could they implement? A lot of the times there is nothing else.
Take the emotional out and look at the system objectively. You'll be a better nurse for it.

OP, this is a very wise post from a wise poster. Please read it a few times and think about what's being said.

RestlessHeart · Nov 14, 2015

I'm orienting in the cardiac ICU and tonight I just cracked. So far I've lost four patients, including one last night. It was awful because it could have been prevented. Despite continuously updating the doctors, they wouldn't put in any new orders for him. Just monitor him,â€ they said. Mid shift he coded and we lost him.
I'm exhausted tonight.
My patient looks bad: vented/sedated, febrile, lactic/trops/sugars/ WBCs/ BP/HR increasing, poor renal fct, on many drips and not doing well. Something bad is going to happen. While hanging a new gtt I froze in the room, started feeling tightness in my chest, hyperventilating, and crying. I don't know what to do. What if he codes?
My preceptor sent me away to hide for a bit. I've locked myself in the staff bathroom. I feel so pathetic.
I soooo want to be a cardiac ICU nurse. I don't want to give up. As stressful as this is, I love what I do. But many these people are so sick and I feel like I'm going to kill somebody. Though I'm just following orders, it was my hands that killed people. My orientation is ending next week and I feel so overwhelmed.
Does anyone have any advice for pushing through this? Also, please share stories of similar experiences, so that I don't feel so alone right now.
Thank you.....

New Nurse or not...you WILL be fine.

Listen....Did you do what you know you should? Did you care? Do you care about your patients? Sometimes the best thing you can do is "let them go home" NO I do not mean help them or give extra meds, snowing etc. I mean just be there if you can. That last journey is one they must make alone but being near and caring means so much and may actually help to settle your nerves. In my Hospice years we had to learn that dying is every bit a part of living as living is. It IS hard to stand by and have your patient fade before you. At some point you must know AND understand that you can only do so much.

I wish I could just reach out and hug you and walk with you. You arent alone Lil One....we've all been there. As long as you KNOW deep in your heart that You TRULY DO CARE.......all else will fold into place. I would be proud to have had you as my nurse along with several others here.

Take peace deep....into your soul...in the deep far away place you dont let others see, wallow in it, cry a bit, hug yourself a bit, kick and scream and ****** and rant....then shake it off.. plant your feet, square your shoulders, get that head up high and git to steppin...somebody else already needs a nurse as good as you

SubSippi · Nov 15, 2015

Patients die in the ICU all the time, I remember one time we actually ran out of body bags we had lost so many.
The "just monitor" line given by the docs is just another phrase for nothing else we can do. Think about your patient, look at the differentials and interventions. What other options could they implement? A lot of the times there is nothing else.
Take the emotional out and look at the system objectively. You'll be a better nurse for it.

What he said.

You have to remember, you're taking care of SICK people. What you're doing at you job is just giving them a chance, it's not a promise. Nothing you do is guaranteed to work, and even if it does, you're just buying some time.

Bad things are going to happen, it's the name of the game. But matter how many mistakes you make, at the end of the day I guarantee you're at a net positive when it comes to good things you've done during the shift. And like Dranger said, sometimes there's nothing to do, and even when there is, it's not always appropriate.

Just do your best, ask questions, and pay attention. It always sucks to lose a patient, but keep in mind that hardly anything (good OR bad) that happens in a hospital can be credited to just one person. Don't be so hard on yourself...you're new, you're not supposed to be good at it yet.

LadyFree28, BSN, LPN, RN · Nov 15, 2015

A couple problems with your bolded statement here.
First, nursing is NOT "just following orders." You don't blindly follow orders that you disagree with or that are harmful to your patient. It is your duty to question (and refuse to implement if the order is dangerous) these orders. I recall a resident ordering a liter normal saline bolus for an infant who weighed about 10 kg once. The nurse and pharmacist rejected the order. Fluid boluses for children are usually 10-20 cc/kg. I had a resident from the same service once tell me that it was "fine" that my 2 month old patient's heart rate was 83. He was rotating through from the adult hospital, no clue what normal pediatric VS are. 83 is bradycardia for an infant and this child was exhibiting yet another sign of increased intracranial pressure. Yeah, within 10 minutes she was seizing and we were pushing her crib directly into the OR.
Second, it was not your hand that killed these patients- unless you intentionally bolused them with potassium IV push or turned off their vent or pressor drips. Patients in the Cardiac ICU are SICK. Many of them will die. Regardless of what you do or don't do, many of them will still die. It is their disease process that will kill them, not your hands.
Death is a part of life. Every single one of our lives will end in death. Though I've heard some people on here say "it never gets easier" or "you can't get used to it", I disagree. I think it does get easier. I don't remember the last time I cried about a patient's death. And my patients are children. The truth of the matter is that no matter what any of us do, a child with high risk stage IV neuroblastoma who relapses 3 months off treatment is going to die.

THIS.

I work where children come in and are sick, or at risk of dying-I work at a Level I Trauma PediED.

Some kids die at the hands of others and they come in dead; some are so sick that they can crump or on their way to crumping when they arrive; some physicians are well versed, and others aren't; but we do the best we can for what the pts need, even when it looks like they are not going to make it.

I've worked in this business for 10 years, in several settings, and humans die, and a lot do, no matter what technological and scientific advances we have, it is still a fact of life.

You have been given some pretty good pointers; it will be up to you on making a plan and reflecting on what type of nursing practice you need to pursue, as well as how to handle the aspects of this business; whatever you choose, understand that there are people who are sick and can be gone in a blink of an eye, despite those good intentions.

Best wishes.

iPink, BSN, RN · Nov 15, 2015

Sending hugs your way as well. I, too, have lost a patient when I was about 6 months off orientation when I worked Stepdown ICU. It was devastating because I was just talking to her and the next minute she coded and was gone. It would often break my heart when I had to transfer my patients to ICU because I felt they were going there to die. That was my thinking when I was a new grad but I will always be grateful to the education I received by those ICU nurses who reminded me that the patients that had to be transferred to the higher level of care is no fault of mine. People get sick and despite their treatments, they can get worse and may die. Some get better and return to our unit.

How is your working relationship with your preceptor? I ask because you were having a breakdown at work and you came to us (allnurses), which is fine and we are here for you anytime but having someone to talk with face-to-face who can give you a physical hug makes a difference. You are still on orientation and you felt the MD was wrong but as an orientee that would have been the opportune time to ask your preceptor why you felt the MD could have done more. Your preceptor could have prepared you and educate you all at the same time. Maybe even could've shared their experiences when they first started in ICU and ways they dealt with each death. ICU is tough and because of your love for it I hope you don't give up.

CryssyD · Nov 15, 2015

I feel for you. I only lasted about a year and a half in PICU--I loved working with kids, and loved making them feel better: but when they died...even when I knew it was for the best, that they would have been so much worse off had they lived (because of brain damage)...I just couldn't take it, it seemed so unfair.

I have mentally post-gamed every code I've ever been in, because that's how I learn from the experience. But I don't use that time to try to assign blame--to myself or anyone else--and neither should you. Nothing will batter your soul quite so badly as blaming yourself for someone's death. You did your best and that is all anyone can ask.

In over 25 years of nursing, I remember every single person I watched die, from the bloated, pumpkin-colored man with end-stage liver failure I watched being coded in my nursing school ICU rotation, to the elderly woman peacefully breathing her last shaky breath with her daughter holding her hand in a hospice unit. There is nothing wrong with being affected by death--it is our last transition, and one we will all face one day; it is profound and terrifying and can be hideously wrong or serenely beautiful--it depends on the circumstances. Just don't let it scare you away from where you want to be--remember, you're one of the good guys, fighting death with all you have; you can't win them all, and that's OK. I think, on balance, we win more than we lose these days.

By the way, I admire the heck out of anyone who works cardiac ICU--it scares the holy bojangles out of me!

anon456, BSN, RN · Nov 16, 2015

I was hired into Peds ICU as a new grad, and I get it. I took advantage of my workplace's free mental health services and got myself some counseling for anxiety. It made a huge difference!

I wonder if you should transfer to another floor for awhile and then come back when you are more experienced? It sounds like you are very smart and have the medical part handled, but learning how to deal with the emotional part is very hard.