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This site contains the highly fictionalized ramblings of a raconteur looking for a place in the medical world. The vignettes presented are cobbled together from various and sundry places.  Any resemblance to actual people, places, or events is purely coincidental.

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Tuesday
Jun222010

holy bleepity bleep

DateTuesday, June 22, 2010 at 7:52AM

One of the hallmarks of new experiences (in my twisted brain) is that I instantly think "Woah. Dude. I, like, need to blog about this." And yes, if you pictured a Bill&Ted sort of Keanu Reeves voice, you'd be right.

I've lost count of how many of those moments I've had in the short month I've been working in the ICU.

My preceptors definitely took me under their wings and taught me great stuff about how the unit generally works and how to order various tests and equipment.  Yet it is the nurses who are the real teachers I work with.  New grads and veteran CCRN's alike, almost all of them have a way of explaining the "why" behind what they are doing that feels more like a clinical rotation than a working relationship.

In short, I'm not just learning my job.  I'm starting to learn why they are doing what they are doing.

A couple weeks back I was temporarily shifted to an overnight floating shift.  I move from floor to floor as new patients are admitted.  It's complicated and challenging because I'm the only secretary for the hospital (except for ED, L&D, and Psych).  It's radically different from spending an entire shift in one unit.  Normally I can anticipate the needs of the team and smooth out any rough edges when it comes to communication with outside departments.  Totally not an option when floating for the whole hospital.  The moment I get started with an admission and build out the paperwork, my pager is going off and I head to another floor.

Needless to say it isn't my favorite thing.

I took the shifts to learn as much as I can and to see exactly what else was out there on the floors.  Call me selfish, but I love the attention we all pay to each other in the ICU compared to the floors.  Every one of us in ICU is within earshot of each other at all times.  We can constantly see each other.  As a result, complete and total communication is easy.  On the floors people are off in the distance.  Communication is stunted.  Feels much colder if you ask me.

It may be a function of patient acuity.  Then again it may not. Some folks have suggested to me that the more sick the patients, the tighter the team becomes.  I'm not sure I buy that because the setup on the floors where the nurses are within sight lines of all their rooms (Peds for instance) seems to favor a tighter group.  Much in the way we're essentially in each others business in ICU, the Peds nurses are flawless communicators.

It's something I'm determined to pay more attention to as time passes.

So that's the setup.  Here, then, are some of the more interesting things I've seen in the short weeks I've been working the floors, soaking up as much information as possible.

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Extubations.  Most positive, but many done in the name of letting the body die.  Some were quite painful for the family decision makers.  I've read lots of nurse blogs about letting go at the end vs. the consequences of fully coding a patient.  But seeing it is another story.  Who wants their loved ones full of tubes and drugs?

I believe it's hard to know when a soul leaves a body.  But weeks spent trying to wean someone off a vent with no luck, plus a failing renal system compounded with countless meds to make the heart beat is the kind of situation I wouldn't wish on anyone. For our longer, chronic residents in the ICU I pray the family will often turn to hospice.  Maybe that isn't right, but comfort, not pounding on a chest, pumping a vein full of drugs, and rearranging vent settings daily can't be right either.

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Amputations from uncontrolled diabetes.  If there could be a poster child for the face of uncontrolled diabetes, it's the man with no legs below the knee, gangrenous fingers, and almost complete blindness, stuck on a vent being dialyzed every other day.  I lost count at eight different kinds of tubes running in and out of him.

Someone needs to photograph him to scare people into controlling their diabetes and eating better.

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Aspirated hamburger.  I watched my first bronchoscopy as a result.  Woman eats lunch at a large chain hamburger place, eats too fast, and lodges a particularly large bite of burger in one of her primary bronchi.  Scope suction couldn't get it out because it had partially softened and was coated with secretions.  She won a trip to the OR.  Moral of the story?  Chew your food and eat slowly.  I've been off burgers for weeks now.

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I'd never seen a rectal catheter system.  We use a popular brand that drains liquid/semi-liquid stool.  Think of a foley with a larger tube.  Same balloon end, but a softer, larger variety.  Terminus is an ostomy-like pouch.  Efficient and very easy to discreetly empty with little to no odor. 

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Intrathecal chemo.  But it wasn't via a lumbar puncture.  If there is one thing that would inspire fear in me, it would be a patient of mine receiving chemo through a needle in their head.  I don't know why the site was chosen in the head, but there were a handful of specialists buzzing around the patients room during the site placement and throughout the first infusion.  Everyone spoke in whispers for the first hour.  It was eerie.

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Just a taste folks.  There's way more to come.  Quick someone pinch me. I still can't believe I'm working in a hospital.

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Saturday
Jun192010

sheridan morning

DateSaturday, June 19, 2010 at 9:57PM

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Monday
Jun142010

leaves

DateMonday, June 14, 2010 at 1:21PM

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Saturday
May222010

the ICU. like woah.

DateSaturday, May 22, 2010 at 1:04PM
This past Monday morning, smack dab at 7a shift change in the ICU, I leapt head-on into a world of unknowns. With a census of over twenty patients, most nurses doubled or tripled up, a table of eight first-year residents, at least a dozen second and third year residents floating in and out, and a handful of various respiratory, radiology, EKG, housekeeping, and magement staff, I could barely remember my own name much less anyone else's.

There's a lot of folks in our ICU. Both in the beds (at times) and around them.

In some far away land of perfection I would have already had the prerequisite order entry training classes before day one in the ICU. Instead I was vaulted into the chaos, hovering nervously next to my preceptor as she deftly entered chart orders, paged doctors, ordered various and sundry bits of equipment, and generally ruled the roost.

In five minutes I saw how much of a mother hen a unit secretary really is.

Five minutes later I realized I needed to become exactly like her to be useful to the team.

I lost track of time because when I came up for air it was lunch time.

---

After five days of training I've seen and learned more than I imagined possible. I have another three weeks to go with a preceptor, but by Thursday I was comfortable sitting on the other side of my ICU (ours is a sort of loop with two sides) working as independently as possible. There is definitely much more for me to learn around protocols for ordering certain therapies and equipment, but I have a really solid foundation and am starting to build up my own work flow.

What I didn't expect, or rather, what I was amazed at, is how frickin' awesome the staff would be. It's a little early for me to guess why, but I think it has something to do with critical care in general. It takes a village, and no matter how seasoned the nurse or doctor, everyone relies on everyone for help when it is needed.

One of the senior nurses took me aside on Friday and explained a little of the magic of the team to me. I'm paraphrasing of course, but it went something like "Honey, if you have a question about something, never ever be afraid to ask. That's our job. We question everything constantly. You should too. Someday soon you'll know which orders look right and which ones don't. Ask someone. If you want, find me and ask me even if it isn't my patient. We all work together sweetie. All together."

That exchange blew me away. Good stuff.

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The hardest part for me right now is any sort respiratory order. I'm comfortable reading medication sigs, although we don't transcribe them. I've learned what labs and procedures are generally ordered for new admits and morning rounds, but there are still outliers I'm unfamiliar with.

When it comes to respiratory orders and therapies, I'm a blank slate. Bipap machines and vent settings don't make much sense to me, and the various breathing treatments are completely new in my world. One of the senior nurses, the very same one who took me aside for the above pep talk, agreed to show me around a bipap and vent next week at my request. I sort of think if I see the machine and how it works, the orders will make a bit more sense to me when I'm seeing one written in physician scratches in the chart. At least I hope so.

The other hard part, the one that will fade away in time, is the bajillion phone extension/pager numbers that are part of the web of communication needed in any ICU. I swear both of the senior clerks are human Rolodexes, able to conjure up phone numbers in the blink of an eye.

You know how I remember phone numbers? I program them in my iPhone so my lazy ass can touch a name on the screen when I need to call someone. That won't fly at work anymore.

I've dialed more phone numbers in the past week than I've dialed in the last ten years. Everyone tells me in time the digits will stick in my brain, but until then I'm constantly sifting through internal web pages for phone numbers. I've started a spreadsheet with the most common physician/department numbers I use, but it'll be quite a while before I'm able to recall all that information.

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So week one down and dusted. There's a ton more to learn, but I actually work in a hospital. In critical care. With cool people.

How'd I get so lucky?

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Tuesday
May042010

the job

DateTuesday, May 4, 2010 at 5:51AM
History, well at least my own personal history, has just been made.

I received and accepted an offer for a position as a Unit Clerk in an ICU (swinging to Telemetry) with one of the hospital systems in the area. The job is entry level but I'm about to become immersed in critical care in a way I didn't even dream of this early in my career shift.

Terrifying is the word at hand to describe what I'm feeling at the moment.

Six months ago work involved sitting at a desk and typing away. Each day brought trivial challenges that were easy to cope with and completely forgettable. There were no surprises and even new work didn't quicken my pulse. My eyes on the RN prize, working at the bank only served to pay for school. Nights and weekends were reserved for classes.

As of today I haven't held a job in six months. During that time I became a CNA, moved closer to finishing all my pre-nursing pre-req's, moved to a significantly smaller apartment, lost one of my closest companions in life, and actually found time to stop and smell the roses between A&P and Chem classes.

Calling the recent changes drastic is an understatement.

Next week orientation to the hospital system begins. Although I'll still sit at a desk typing away, the stakes are much higher. I've heard nurses allude to the intimate immediacy of results that working in critical care brings. While I won't be touching patients, I'll be working with a team of people focused on the minutiae.

So what do I bring to the table? The opposite of what I suspect most folks bring to healthcare. I have a limited medical background, reinforced through a bit of coursework and a touch of clinical training. Instead, I spent lots of time in the corporate trenches where I learned to organize my time and prioritize, manage people and expectations, and perhaps most important of all, communicate across many levels.

That latter is the kind of thing I honestly don't see in many people. In my previous jobs in information technology I met so many poor communicators it shocked me. Awful emails, banal presentations, mind-numbing conference calls, and ambiguous goals were laid down in front of me daily by "college educated" people. (said the college dropout, me)

I honestly think they should rename the industry misinformation techonology

There's no doubt I'll meet more of the same kinds of people in the world of healthcare. The difference is that my new job demands I help improve communication. According to one person I met during my interviews with the ICU folks, if I can make it there, I'll make it anywhere.

So it begins next week. New job, new industry, new future.
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