april fool

So... I'm sort of going back and forth with ending this blog because I think the things I'm writing about most people don't relate to anymore. When I started this blog Oona was one and my Grandmother had just moved here from Cape Cod. I was still married and a stay at home Mom, doing the odd freelance photo retouching job at home. I'm sort of astounded at how much my life has changed since I put that first post up. I've gotten divorced, gone back to school, gotten my RN and am working on a unit where I'm regularly accessing central lines, that burrow into internal jugular veins, tracing a path through the vein to lie in the distal third of the superior vena cava, nestled right above the heart. I've gone from wondering how I could ever manage to give a person a shot to wondering if I'd like to be a nurse practitioner specializing in oncology, because then I would be able to perform bone marrow biopsies, not from a schadenfreude point of view because this sort of looks terrifyingly painful but I've heard in the right hands patients don't really feel a thing. I want hands that sure, attached to a body that feels equally confident in my skills. That will take time, probably a lifetime, but I don't mind passing the years on that quest. I started my ninth week of orientation today. Oh what a difference nine weeks makes. When I say what a difference nine weeks makes, we'll there was one specific episode today that comes to mind but I'm like how do I explain this in a way that those not in healthcare can understand. I'll try.

I had a patient recovering from a MUD transplant, this is a bone marrow transplant where the recipient gets stem cells from a matched unrelated donor. It's really such delicate balance when it comes to bone marrow transplant, when it comes to so much in medicine, weighing the benefits versus the risks. The risks for graft versus host disease are increased with a MUD but some doctors want to see a little bit of GVHD in order to ensure engraftment (that the patient's body has taken on the new stem cells, which decreases the risk of leukemia recurring). The patient had neutropenic fever (spiking a temp when your immune system has basically been obliterated to take on the donor stem cells) and, my God if you saw all the IV medications going in. I was using all three of the central lines, going from antiviral to antibiotic to antifungal. Potassium and magnesium replacements, immunosuppressive therapy. And there were contact precautions so I needed to wash gown and glove every time going in an out. I went in to get vitals at 4 this afternoon and brought along a dinamap (a machine to take vital signs). So I put a pulse oximeter on to get the patient's oxygen saturation and pulse and the dinamap registers the pulse at 250. On seeing that number I think my heart rate and blood pressure quickly spiked. I palpated the patient's pulse and tried to count it. It was quick, definitely tachy (meaning over 100, it was about 126) but I wouldn't be able to palpate 250. There was continuous pulse ox in the room and I turned that on to double check. It started high but then dropped to right around where I palpated it, high 120s. But there was an image going across the screen, it looked like a rhythm strip (which is an EKG reading you look at for heart function). I'd seen it the other day looking like sinus tach but this one kept looking like the patient was throwing PVC's (premature ventricular contractions) and a run of two (bigeminy) and then three in a row and then it looked like a run of V tach - all of these are very bad to see on a rhythm strip and my heart was still in my throat over seeing the heart rate at 250 even if it was erroneous. I ran out and told the resident I thought he should order an EKG and then started saying what I saw. My preceptor is like how do you know what a run of V tach and bigeminy look like? Not meanly, she was impressed but sort of chuckling at me. The resident ran into the room. And then the other nurses are like, you can't get a rhythm strip off the continuous pulse ox - and they were right. You need to be monitored, which entails having five leads (stickers) hooked up to your torso smoke over fire (red lower left quadrant, black upper left quadrant), clouds over grass (green lower right quadrant, white upper right quadrant) and chocolate close to your heart (self explanatory). I had fucked up. Sent the resident, who's first day it was (wonder how he'll view me now) careening into the room. I felt like such a complete idiot and asshole. I was so scared by that impossibly high number (250!) it clouded my thinking. Maybe it was my own heart that was still having trouble calming down. He came back in and canceled the EKG. I was confused. I've used pulse oximeters plenty of times but there was never a faux incredibly similar to EKG looking rhythm strip attached to them. But I was able to laugh at myself and that's where the pivotal difference is in the time that's passed on the floor. I probably would have bawled early on but now, well I made a fool of myself but no one got hurt. And my preceptor is always saying I'm an excellent nurse, I think she's too kind, but her heart's in the right place and I think she sees that mine is too, that I'm trying my hardest to stay on top of things and keep my patient's safe.

There was a young patient that I wrote of earlier. I really liked her and her Mom. I came in one night having had her just the night before and I knew she was off. I can't explain it, it was just a gut feeling I had. I called the resident on call that night, twice. I kept trying to get her help because her heart rate seemed too high and she was breathing too quickly and she just looked bad too me. The resident blew me off, both times. Chalked up the high heart rate to anxiety. Even when I said 'But she got something for sleep and has been sleeping for four hours and just woke up and she's in the 130s?'. The resident walked in, walked out, did no more than an eyeball assessment then left. But I couldn't put the bad feeling away and went in shortly after the resident left, with the dinamap in tow, just to check her vitals again, to reassure myself. Her heart rate was 165 and her pulse ox was 88% (not good for someone who normally was around 97-98%). She was transferred to the ICU and died a week later. It had been the last day of my night shift. I picked up my children after school that day, it was so beautiful and warm, that we went to the park. A nurse anesthetist I know, our sons are friends, came up to me and asked how work was going and I was talking her about my week and I just wound up crying and talking to her and crying, I just couldn't stop crying, for well over an hour, in the center of the other parents, knitting and eating snacks, and the children running around. Angel, that's her name, truly, and she was an angel to me that day, listened. And she gets it because she's a nurse and it was so unbelievably helpful talking to her.

Angel told me to journal about my days on the job because then I can look back and things and see what I've done right and not beat myself up when I feel like I've fucked up. So I'm writing this post from my new macbook air (13 inches and light as a feather). Once I get Word on this I think I'm just going to puzzle this stuff out on my own. My dream is be to be the nurse equivalent of Atul Gawande, to be able to write that well about medicine, but from a nursing perspective. But I don't know that I can write this way on this blog anymore, it hurts my heart too much. I feel displaced in most every role I inhabit; mother, nurse, friend, other. Maybe I'll switch to pictures if I get around to getting an iphone.

If I was really clever I would have shouted, "April Fool's!" once the resident came back to the nursing station after running to the patient's room for the stat EKG I was recommending but I'm too flipping earnest to be a tease.