Posts Tagged ‘ICU’

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At the Terminus of Romantic Dreams, an ICU

April 26, 2012

It was early. The sun had yet to rise, but already the ICU was filled with stark fluorescence and beeping alarms. My patient sat alone and aphasic, helpless amidst the bustle of the unit. The day stretched long ahead of us.

The circumstances of Frank’s admission were unusual. The nursing report (conveyed with a snicker) was that, while vacationing in our coastal city with his mistress, he’d slipped away and visited yet another lady friend. While engaged in an “intimate” act, he’d hit his head on the coffee table and been knocked unconscious.

The paramedic’s report backed up that version of events, but Frank’s admission CT scans of the brain weren’t consistent with head trauma. Instead, a vascular abnormality was found. He’d suffered two seizures since admission to the hospital.

by utahwildflowers/via Flickr

That’s the start of “The Love Song of Frank,” the Reflections essay in the May issue of AJN. Click on its title to read the entire essay (and, once there, perhaps click through to the PDF version for the best read). 

Those of you who know the T. S. Eliot poem “The Love Song of J. Alfred Prufrock” (beautifully spun, and a favorite of bookish adolescents for its highly quotable and world-weary take on conventional society) will recognize the irony in the title.

But the essay, by ICU nurse and regular AJN blogger Marcy Phipps, stands on its own in its sympathetic but unsentimental description of a nurse’s encounter with a man who’s reached the limits of his own brand of romanticism. Some readers may have less compassion for this man and his apparent fate than others. Either way, it’s well worth a read, and not our typical Reflections essay either, if such a thing exists.—JM, senior editor/blog editor 

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The ‘Inexhaustible Well’: Notes from a Trauma Nurse on Mortality

April 19, 2012

UW Digital Collections/via Flickr

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Love Song of Frank,” will be published in the May issue of AJN.

Years ago, long before I was a nurse, I read The Sheltering Sky, by Paul Bowles. He speaks of the tendency of people to take life for granted, and says that in the unpredictability of death there lies a presumption that everything is limitless:

“Because we don’t know when we will die, we get to think of life as an inexhaustible well. Yet everything happens only a certain number of times, and a very small number really. How many more times will you remember a certain afternoon of your childhood, an afternoon that is so deeply a part of your being that you can’t even conceive of your life without it? Perhaps four, five times more, perhaps not even that. How many more times will you watch the full moon rise? Perhaps 20. And yet it all seems limitless.” 

Lately, especially at work, that quote has edged forward and lingered with me. The ICU I work in is primarily devoted to trauma, but there’s been a recent shift in patient demographics. Last week I took care of only one trauma patient—an athlete who’d had a bike accident—and then three patients with cancer in varying stages.

The patient I’m most haunted by is a 65-year-old woman who had arrived in the ER with pain and weakness and would be leaving the hospital with a stunning diagnosis of stage IV cancer, and with numbered days. When I last spoke to her she’d just met her new oncologist and was waiting to be transferred out of the ICU.

“I’m going home,” she said. “I’m going to be with my family and sit on my porch. I’m having a glass of wine.” Read the rest of this entry ?

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Losses: In Search of an Honest Prognosis

March 19, 2012

by h.koppdelaney/via Flickr Creative Commons

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

Several years ago I took care of a lady who’d suffered a small cerebral hemorrhage after falling and hitting her head. She was in the ICU for several days. Her husband stayed at her side constantly, and he became a part of a never-ending loop in which she would wake up startled to be in a hospital, and then notice her husband and ask him where she was and what had happened.  He’d hold her hand and gently relay the events of her injury, after which she’d react with mild surprise, every single time. Then she’d close her eyes and doze until she woke up to reinitiate the same conversation.

Her husband, after days of patiently playing his role in this repetitive scene, was clearly wearing down. He waited anxiously for the neurosurgeon, expecting explanations and hoping for reassurance.

When the neurosurgeon rounded later that day I heard him speak at great length about the details of her injury and the treatment plan. He ultimately advised that, although he thought she’d recover well, only time would tell.

Her husband wanted more than that, though. He pressed for specifics, firing one question after another in his quest for clarity and absolutes, until the neurosurgeon paused and wiped his brow with a sigh. Read the rest of this entry ?

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Clinic Vision

January 26, 2012

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

By Ctd 2005, via Flickr

I’ve begun volunteering at a local free clinic. While it’s been rewarding and satisfying, it’s also been fraught with challenges I didn’t expect; I’ve only worked in an ICU, and the assessment skills specific to critical care don’t translate smoothly to the clinic setting. I’m out of my professional comfort zone, and I feel so inexperienced.

Here’s what I’m used to: By the time a patient is admitted to the ICU, they’ve already been “worked up” in the emergency room. Physicians have been assigned and a preliminary diagnosis is in place. The patients are connected to equipment that displays their vital data continuously, on monitors I can see from almost anywhere, and alarms are triggered by any alterations. I’ve got easy access to radiology reports and films, laboratory values, and microbiology reports. The nursing physical assessment is thorough and paramount; I know what I’m looking for, what I’m listening and feeling for, what certain smells indicate, and I trust my instincts. I’m accustomed to not only the forced intimacy that comes with the in-depth physical assessments of critical care, but the technology and data that supplement my assessments, as well.

At the clinic my nursing role is quite different. I sit at a desk. I am to determine the reason for each patient’s visit and take their vital signs. I ask how they’ve been and what’s changed since their last visit.

One gentleman, when I ask what medications he takes at home, fishes in his pocket and drops pills wrapped in toilet paper on the desk that separates us. I sit across from him, considering how to proceed, itching to take his hand and slide my fingers along his wrist to feel the pulse of his radial artery. I wonder about his breath sounds, what his feet look like, whether I’d be able start an IV on him, and what I’m missing. There are no same-day diagnostic reports to refer to and no dictated medical histories. All I have is the snapshot capture of his vital signs and what he wants me to know.

I’m used to knowing my patients from the inside, out. Here in the clinic, I hardly even touch anyone. I feel blind.

These are the challenges I’ve found: to create a picture of my patient with limited information and subtle clues;  to listen to what someone tells me, hear what they don’t say, and know what to ask; and finally, to not lose my vision because I miss my familiar tools, but instead find a different way to see.

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Second Chances

January 3, 2012

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

by patchy patch, via flickr

I first met Ella (name and some details have been changed) when she was my patient in the intensive care unit. She’d been riding in a car she wasn’t supposed to be riding in, heading to a party she wasn’t supposed to be going to, high on drugs and not wearing a seatbelt when she was involved in a high-speed crash that left her with broken bones and internal injuries. She was in the ICU for more than a month.

Her situation wasn’t that remarkable. Ella could easily represent a common category of ICU admissions—the young adult who is often described by her parents as a “good girl,” yet who lives wildly, fearless and flip, taking risks as if consequences will never apply. I feel particularly protective of these patients, mostly because I relate to them, on some level. I remember the sense of invincibility that came with youth, and when I’m caring for these girls I often marvel at consequences I avoided in my own life. I shake my head at my younger self, alternating between feeling extraordinarily blessed and very lucky. I’m not sure the risks I’ve taken in life compare—but still, I had no concept of the fragility of life. I certainly didn’t comprehend its worth.

I cared for Ella often and became fond of her. I felt like I knew her, even though she was usually sedated. I fussed over her, when I had the time. “Don’t do drugs,” I whispered in her ear as I washed her hair. “Wear your seat belt. Stay away from bad guys!” And also, “You survive this, you can do anything!”

She slowly got better and was moved to the step-down floor. A few weeks later I ran into her mom in the cafeteria. She told me Ella was doing great, that she was walking with physical therapy and talking. She encouraged me to come and visit her, and so I did. Read the rest of this entry ?

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Top 10 (New) AJN Posts of 2011

December 20, 2011

"Consumer Choice,' BdR76, via Flickr

Some of our posts, like this one from 2009 (“New Nurses Face Reality Shock in Hospitals–So What Else Is New?”) keep getting found and read. They remain as relevant today as they were when we posted them. Our top 20 posts for the year (according to reader hits, that is) include several others like this: “What Is Meaningful Use? One Savvy Nurse’s Take”; “Is the Florence Nightingale Pledge in Need of a Makeover?”; “Do Male Nurses Face Reverse Sexism?”; “Are Nursing Strikes Ethical? New Research Raises the Stakes”; and “Workplace Violence Against Nurses: Neither Inevitable or Acceptable.”

But putting aside these contenders (why do so many of them have questions in their titles?), here are the top 10 (again, according to our readers) new posts of 2011, in case you missed them along the way. Which doesn’t mean that these are (necessarily) our best posts, or a representative sample, or that many others didn’t hit home for various subgroups of readers.

While we all get a little tired of lists by this time in the year, we don’t really use them an awful lot here at Off the Charts. So please indulge us this once, and thanks to everyone who wrote, read, and commented on this blog in 2011.—Jacob Molyneux, AJN senior editor/blog editor

1. “Notes of a Student Nurse: A Dose of Reality,” by Jennifer-Clare Williams

2. “Placenta Facebook Photos: Nurse and Mommy Tribes See Expulsion Differently,” by AJN editor-in-chief Shawn Kennedy

3. “Dispatches from the Alabama Tornado Zone,” a series of posts by Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation

4. “Confused About the Charge Nurse Role? You’re Not Alone,” by Jacob Molyneux

5. “The Priceless Clarity of Inexperience,” by Marcy Phipps, an ICU nurse and regular contributor to this blog

6. “Don’t Cling to Tradition: A Nursing Student’s Call for Realism, Respect,” by Medora McGinnis

7. “Bullying Wars: Theresa Brown vs. ‘the entire profession,’” by Shawn Kennedy

8. “Remembering 9/11: Nurses Were There,” Shawn Kennedy

9. “Killing Traditional Nursing Duties #2,” Shawn Kennedy

10. This one’s a tie: “Nurses, Hospitals, and Social Media: It Depends What Business You’re In,” by Julianna Paradisi, artist/nurse/blogger, and “One Take on the Top 10 Issues Facing Nursing,” by Shawn Kennedy

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Reading Between the Whiteboard Lines in the ICU

December 15, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

My hospital uses dry-erase whiteboards as a tool to communicate with patients and family members. Mounted to the walls in the patients’ rooms, the boards are prominent and concise.  Aside from a lot of basic information, notes get added to the board when diagnostic tests are completed, when complementary therapies have been implemented, and when housekeeping staff visit. The “meat” of the board, however, is the section that addresses plans and goals for the day. The plans and goals are updated and modified continuously by nursing staff. They’re specific to each patient, yet, despite their personalization, the goals for ICU patients tend to fall into distinct categories.

The first category includes goals which are often set by the patients themselves. They tend to require a certain amount of collaboration and active participation. These types of goals, which include things like “maximize incentive spirometer use,” “ambulate,” and “advance diet,” imply a relatively healthy state and tend to predict transfer orders.

The next type of goal is aimed at restoring health and stability. These goals don’t necessarily require patient participation and often focus on pathophysiologic processes. On the whiteboards of these rooms, the listed goals are likely to include things like “wean ventilator,” “control agitation,” “control fever,” or “increase level of consciousness.” In these cases, the goals are often of more interest to the family members than the patients.

The most critically ill and unstable patients are the hardest people for whom to establish goals, and sometimes the immediacy and focus required to support these patients preclude the time required to formulate and write goals on a dry-erase board. The more pressing the needs of the patient, the briefer the goals tend to be, and the brevity often portends the gravity of the situation: “oxygenate,” “ventilate,” “perfuse.” The goal “live” also belongs to this category, although decorum discourages writing “live” as the plan for the day.

Overall, the whiteboards are excellent communication tools. Although they’re not always utilized or appreciated by the ICU patients themselves, they often serve as touchstones for family members, who take comfort in written updates and established goals. They provide a different kind of communication to the nurses, though. In a unit where stability can be as fleeting as a dry-erase marker, the whiteboards sometimes provide a snapshot of general direction—especially for those reading between the lines.

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Thanksgiving in the ICU: Woven into the Tapestry of Traditions

November 22, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

cranberries

I’ll be working this Thanksgiving. I’ve worked so many Thanksgivings that the ICU feels woven into the tapestry of my own traditions. I don’t really mind; the cafeteria serves a fitting feast that’s embellished by the homemade treats we bring in, and although we won’t actually be watching it, the Macy’s parade will be on. Somehow, the smells and sounds I associate with the holiday will mix and mingle with the usual bustle of critical care, and it’ll feel like Thanksgiving. It’s actually a nice day to be at the hospital—for the nurses, that is.

For our patients and their families, I know hospital holidays fall far short. We have one patient, in particular, who’s been with us for a while. Her husband’s been a fixture at her side throughout her stay, and I expect to find him stationed there this Thanksgiving. Hospital turkey and television won’t give him the comfort or peace that he seeks, and I don’t know that he’ll be giving thanks. For many weeks I’ve watched him skirt a fine line between gratitude and despair; things could always be worse, but they could certainly be better.

When I stop to count my blessings, I’m overwhelmed. I belong to a profession that I’m passionate about—one that brings me great joy. I work with people I care about and like so much that I look forward to spending a holiday with them. And at the end of the day I’ll be going home, where my family will be waiting for me, and I’ll hug my kids and count my blessings all over again.

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Editor’s note—some AJN Thanksgiving posts from past years:

Brief Notes on Thankfulness (and the Nursing Profession)

Turkey, Sweet Potatoes, and Living Wills

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Realizations of a New Nurse #1: I Am Now the Educator

November 7, 2011
image via Wikipedia

By Kinsey Morgan, RN. Kinsey is a new nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA.

In nursing school, there is a growing push to educate future nurses on the amazing breadth of roles within the nursing profession. As a student, you are in some way exposed to the role of nurse as leader, advocate, healer, educator, team player, and researcher. Even this list is not exhaustive. These roles are certainly vital and important and worth teaching about in school.

As a brand new nurse, I haven’t personally encountered all of these roles yet, but there is one in particular that I encounter—and embody—every day: that of educator.

One of the most humbling realizations I’ve had since recently becoming a nurse is that I am now the educator. I’m glad to know that there are other nurses around me, as well as many resources from which to glean knowledge, but I am daily faced with the fact that people now look to me for answers. There are times when I feel outside myself, for while I give correct answers, hearing myself giving them is a little surreal. I’m sure these feelings subside with time, but I hope that I always remain somewhat in awe of the amount of trust my title elicits.

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The Priceless Clarity of Inexperience

September 22, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

Heartstudy by James P. Wells, via Flickr

I was precepting a senior nursing student last week. During an idle moment, I asked her why she’d decided to go into nursing.

She shrugged, averted her eyes, and mumbled something like “I’ve just always wanted to.”

I didn’t press it, but I’m sure there’s more to it than that. I probably shouldn’t have asked, given that I cringe when posed the same question, and usually give a faltering and inadequate “I like helping people” kind of answer . . . when “that’s too personal of a question” would be more honest.

I’ve been a nurse for years, and there are certain aspects of the profession I wouldn’t attempt to broach in casual conversation. I doubt that I could have articulated my motivations when I was a student, even if I’d wanted to. That exchange, though, calls to mind one of the most defining experiences of my nursing career.

I was a senior nursing student, doing a clinical rotation in the ICU. My preceptor and I were caring for a patient who’d been in a motorcycle accident. He’d not sustained a head injury; he’d worn a helmet. But he’d suffered a high cervical injury, and it was complete. The weight of the helmet, combined with the force of the crash and pathological changes, had caused his neck to snap.  (“Like a stick!” I remember the trauma surgeon saying.) The poor man was wide awake but completely paralyzed.

My recollections of the specific events of that day are clouded by inexperience and shock. I only know that, at some point, a day that had seemed completely normal took a tragic turn. I remember standing by the patient’s bedside, helplessly, as his heart rate suddenly and inexplicably dropped and the trauma surgeon and code cart magically appeared at his bedside.

I remember it becoming incredibly busy and frenzied. In an effort to stay out of the way, I stationed myself at the head of the poor man’s bed.  I laid my hand on his forehead, mumbling futile platitudes as he gazed up at me with fear in his eyes, mouthing words that I never grasped for what felt like an incredibly long time, until he lost consciousness.

I remember his final moments in crystal detail. Read the rest of this entry ?

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