Posted on by jparadisirn

It Makes Me Shudder (When the line between victim & perpetrator blurs)

 Chapter 23

 The police officer stands silently in the doorway of my patient’s room, watching as I listen to her chest with my stethoscope. Her breath sounds are clear and equal on both sides. Next, I check the tube threaded through her nose into her stomach. It’s draining dark green fluid into a suction canister fastened to the wall. I measure the amount of fluid in the canister and record that number in the electronic chart. I feel her pulses. They’re strong, and easy to find, coinciding with the numeric value for her heart rate on the monitor overhead.

When I’ve finished the assessment, the officer speaks. “I don’t know how you nurses do it. I couldn’t work with hurt kids. It would break my heart everyday.”

“I don’t know, I guess I think of it more as helping,” I offer. “I couldn’t be first on the scene like you police officers. I mean, putting yourself in lethal danger in order to protect the nameless public takes more heroism than I could muster.”

“I guess we just sort of pick the kind of work we’re able to do, then. By the way, my name is Mike.”

“Hi Mike, I’m Niki. I’d shake your hand, but I need to wash it first, after I take off the glove.  I don’t want to be rude, but I’m pretty cautious about spreading germs.”

“Understood. Thanks for the information.” Mike has a cute smile, and gentle eyes. “Well, I gotta go and see if the detective has any new information for me. If she’s cleared for now, is it okay if I send the mother in to see her kid?”

“Sure.”

“Well, Nurse Niki, if you have any questions about the case, or information for that matter, feel free to give me a call. Here’s my business card.”

I watch Officer Mike leave the PICU, holding his card in my hand. He seems like a nice guy. Maybe in a few weeks I will call him. Maybe it’s time I stop wearing my wedding ring on my right hand and take it off altogether. I put his card in the pocket of my jacket.

Half an hour later, my patient’s mother enters the PICU. She’s young, early twenties. She’s wearing grey sweats that hang from her slim hips over a pair of black plastic flip-flops. A blue and black hoodie drapes over her ribbed white tank top, revealing an equally skinny torso.  She looks like she doesn’t get enough to eat, but her acrylic nails sport elaborate nail art. She’s wearing huge gold hoops in her ears too. ‘Go large or go home,’ comes to mind.

Mariella, our social worker, accompanies her, and introduces me to the mother, who looks me up and down suspiciously before noticing her unconscious daughter on the hospital bed with all the tubes connected to her. She starts to cry. This is the cue I depend upon in order to form some sort of therapeutic bond with parents of abused children until who hurt the child? is established.

I drag a lounger from the other corner of the room to the child’s bedside, and Mariella settles the mom into it, and then fetches a cup of coffee, and a blanket from the PICU’s warmer. She wraps the blanket around the mom’s shoulders, before handing her her card, and leaves the unit.

An awkward silence fills the room.

“So. Do you have any questions?” I begin.

“How long is she going to be in the hospital?”

“We don’t know that yet. Hopefully, she’ll come off the breathing machine sometime tomorrow. She’ll probably stay another night here, then be transferred to the regular pediatric unit, and spend some days there too. She’ll go home when there’s no bleeding and the surgeon lets her up out of bed.” I avoided adding, “Unless social services removes her to their custody.”

“Why would she bleed? I thought the surgeon fixed her?” She eyes me suspiciously again.

“She repaired your daughter’s liver, that’s right, but a lot of the body’s blood travels through the liver. There’s always a chance that the wounds will still bleed. She could lose a lot of blood again if that happens. We’re watching her closely to prevent that. That’s what all of these machines are helping us do.”

“Oh.”

In my experience, parents involved in their child’s abuse take one of two stances with nurses: They are either angry and argumentative, or they campaign to win our sympathy. This mom chose the latter.

“He didn’t kick her, you know. He works hard, and when he comes home he expects things to be in order. Sasha isn’t a good girl. She doesn’t do what she’s told. I have to get on her all the time. She lies too. I don’t know why they think he kicked her. Maybe she’s got cancer and it’s making her bleed.”

“Sasha doesn’t have cancer. The doctors can see that with all the tests, and during the surgery too. He’s not Sasha’s father, right?”

“Naw. He left before Sasha born. He was no good.”

I fall silent taking in this information.

“Has he hurt you or Sasha before?” I know I’m going to have to chart her answer.

“He’s only mad when we deserve it. He don’t hit when we do what we should.”

“Have you ever thought that you and your daughter deserve to be safe in your home? That a man shouldn’t hit a woman or child, ever?”

“You got a man, Nurse? You know how hard to raise a child alone is?”

A sudden realization slapped me in the face: This woman and I are both single mothers, wanting to have relationships with men who are not the father of our children. I could be her. The thought chilled me.

We didn’t talk much the rest of the shift. In the morning, Mariella returned with a female police officer. They escorted the mother out of the PICU. Soon afterwards, Mariella returned.

“They’re taking her down to the station. The boyfriend is saying she kicked the girl. He says he tried to stop her.  We’re hoping she’ll file a report against him with the details of the assault, so he can be charged.”

“You might want to know,” she added, “The mom is known to us. We have an open file on her. Sasha was the result of rape by her mother’s boyfriend. And our boyfriend, we’ve seen him before too, when his father was arrested for breaking his arm.”

I can’t believe Mariella earned a Master’s degree to do this kind of work. I think her job is more difficult than mine.

Later, I talk to Liz about it. “I hate when the lines between victim and abuser are blurred like this. I don’t understand how a mother wouldn’t choose a better life for herself, and especially for her child.”

“You’re new at being a single mother Niki,” she said. “You’d be surprised how lonely it can be out there.”

Something about the way Liz says it makes me shudder.

I know I won’t be giving Officer Mike a call anytime soon, either.

Posted on by jparadisirn

After The Flood (Nothing angers a PICU team like child abuse)

Chapter 22

At Raquel’s house, I sat on the sofa listening to The Cowboy Junkies with a blanket wrapped around my shoulders. Raquel brought me another mug of cardamom-spiced tea. Upstairs, Maddie played with her cousins.

Raquel sat on the sofa next to me, and put her head on my shoulder like she used to do when we were kids and something bad had happened.

“It feels like the flu, doesn’t it? The grief, I mean,” she said. “It’s weird how grief actually has physical symptoms: nausea, muscle aches, and shortness of breath.”

“How can you tell the difference between grief and an anxiety attack?” I asked.

“When it’s anxiety you can’t breathe at all,” was her answer.

“At least then I’d be unconscious. I might actually feel better,” I grumbled.

“I think it’s time we switched you to something stronger than tea. I’ll go open a bottle of wine. We’ll order pizza delivery for the kids’ dinner tonight. Grant can fend for himself.”

Maddie and I stayed the weekend with Raquel and Grant while Simon moved his things from our rented house into a near-by two-bedroom apartment. Because parenting Maddie was the only thing of value we shared, we were able to come to a divorce agreement through mediation. Our meager assets were split down the middle.

As for Maddie, we didn’t need King Solomon to decide what was best for her. Since she was at school during weekdays, Simon and I agreed that she would stay with him the nights I worked, and with me on my days off. We alternated weekends, and would take each holiday as they came.

“But Niki, that means you’re either at work, or have Maddie at home on your time off,” Raquel pointed out. “How are you going to have any sort of social life?”

“I’ll figure it out if it happens,” the words sounded doubtful, even to me.

 ***

I told Liz and Gerald about the divorce during a quiet moment at the nurses’ desk.

“Wow, Niki, I’m sorry to hear about you and Simon. I knew you were having troubles, but I always thought you’d work things out. I’m really sorry.”

“Thanks, Liz. The hardest part was making the actual decision. Once I knew that Simon was miserable too, the emotion sort of went out of it. I just hope Maddie will eventually understand.”

“How’s she doing?” asked Gerald.

“She seems okay. She uses it a little for sympathy. Like she complains about how hard it is to pack for her father’s during the week, so she wants new clothes to keep at Simon’s apartment. She also fibbed, ‘I forgot my homework at my Mom’s house,’ as an excuse to her teacher last week instead of owning up to not doing it. I guess it’s to be expected. Fortunately, the only thing Simon and I tend to agree on is how to raise her, so the rules are the same in both homes. Maddie’s the only thing we have in common anymore.”

“Have you told Corey yet?”

“No, I haven’t seen him lately.”

Liz said, “Oh,” but Gerald gave me this funny look before his pager went off, calling him to another unit.

***

 Around midnight, we admitted a seven-year old girl from the OR where a surgeon repaired her ruptured liver. A police officer trailed alongside her bed as it was pushed into the PICU room. He waited outside the door while Gerald connected her breathing tube to the ventilator, and I transferred the leads from a portable unit to the overhead monitor. A unit of red blood cells infused into her central line. Her vitals were stable.

The recovery room nurse read off report: a ruptured liver caused by blunt force trauma to her abdomen. This kind of injury often occurs during a bad car accident, but this little girl had been kicked in her stomach. Hard. By her mother’s boyfriend.

Horrified, I asked, “Why would a grown man kick a child?” then realized how naive I sounded.

The police officer answered, “The mother reports he kicked her after she brought home a kitten he’d told her earlier she couldn’t keep. He left the premises afterwards. We got the bastard. He made a call on his cell phone from a friend’s house. We picked him up a couple of hours ago.”

“Where’s her mother now? Was she with him?” I thought I might kill the guy if I’d been her.

“She’s the one who called the ambulance. The EMTs called us,” the officer continued. “She told them it was an accident, ‘he didn’t mean to get so angry, the girl doesn’t listen to what she’s told all the time.’ We have a detective interviewing her down the hall. She may be booked too, if there’s enough evidence.”

Nothing angers a pediatric intensive care team more than child abuse. We spend our careers saving the lives of children with defective hearts, lethal infections, or damaged in car accidents. Treating a perfectly healthy child whose parent battered them angers us more than pretty much anything. When the loving parents of our other patients see the police in the unit, they figure out the situation pretty quickly, and then the PICU becomes tense, more so than usual, fed by their anger too.

The Adventures of Nurse Niki is on holiday hiatus, resuming with the next chapter on January 2, 2014. Happy Holidays to all her readers!

Posted on by jparadisirn

Is Everything Okay? (Niki’s nursing assessment saves a baby)

  

Chapter 17

I woke up in the afternoon having slept poorly after the bad dream. Schlepping my way into the kitchen, I made a cup of tea.

Simon dropped Maddie off from school, and then went back to coach practice. I helped Maddie with her homework while starting dinner.

During dinner Maddie chatted animatedly about what her friends at school are up to. Simon tells us about a new project he’s introduced to his students. He notices my distraction and asks, “Is everything okay, Nik?”

“Oh, yeah, I’m fine. I just didn’t sleep well today.”

Simon gives me a curious look, but makes no comment.

I kiss them good-bye before leaving for work.

***

Corey brings a ventilated baby with pneumonia to the PICU at change of shift. He turns his head away, but not before giving me a look so sharp I catch my breath.

Pointedly, Corey gives the report to Kathy. As he leaves the unit, he looks at me again. Silently, I mouth the words, “Can we talk?” but he puts his head down, rapidly disappearing down the corridor outside the PICU.

Kris is finishing her day shift charting at the nurses’ desk. I suddenly realize she’s seen all of this.

“Everything okay, Niki?”

“Yeah, why?”

“I’ve never seen Corey transfer a patient so fast when you’re here, that’s all.”

“Mind your own business, Kris.”

She raises an eyebrow at me, and returns to her charting.

***

Later in the shift, the pulse ox alarm in Kathy’s patient’s room sounds, and she gets up to check on it. Poking her head out the room’s door, she says, “Niki I need to suction him. Would you help?”

At the crib, I manage the ambu bag; manually giving the baby breaths of oxygen while Kathy suctions its breathing tube to remove secretions. Nothing comes up, so she places a few drops of normal saline down the tube before making another pass. A bit of yellow-green mucous comes up. She replaces the ventilator tubing, and silences the pulse ox alarm again when it continues to read 90%.

“That’s funny. His oxygen saturation should improve after suctioning,” she observes out loud.

“Maybe he’s due for a respiratory treatment,” I offer. “I’ll page Gerald.”

Gerald administers an aerosolized medication into the ventilator tubing, and then gently taps on the baby’s chest and back with a soft rubber percussor. Kathy suctions again, while Gerald bags. Still, no significant secretions. The baby’s oxygen saturation drops to 85%.

I listen to his chest with my stethoscope. There’s breath sounds on both sides. However, the little guy begins pulling hard with every breath. We watch as the tiny muscles between his ribs pull in with the work of breathing.

“He’s getting worse.”

Gerald takes him off of the ventilator, and starts hand bagging again. I suction without secretions, while Kathy pages Dr. Polk.

“He’s down in the ER, assisting with a pediatric trauma. He said to keep bagging.  He’ll be up as soon as he can.”

“I’m not sure we can wait that long,” I said. Not only were the sats less than 80%, but now the baby’s heart rate was dropping.

“What’s wrong?” Kathy called out.

Insight flashed before me, “His breathing tube is blocked.”

“Are you sure? asked Kathy. “How do you know?”

“It has to be. His chest sounds are good. He’s moving air, but he’s not getting oxygen from either the vent or the bag. We’ve got to pull the tube out now!”

“Dr. Polk said to continue bagging until he arrives,” warns Kathy.

“The baby is going to code if we don’t pull the tube now,” I insisted.

“Yeah, and who’s going to take responsibility for that, Niki?” Gerald cautioned.

“I will,” I said. “I’m pulling the ET tube.”

I removed the tape from the baby’s face, allowing the tube to slide out easily. At its end was a glob of thick, white secretions half the diameter of a ping-pong ball. It resembled a wad of chewed up bubble gum. I laid the mucous-blocked tube on a paper towel, and placed it on the bedside table. The baby started to cry.

“Well lookee there,” said Gerald. Immediately the oxygenation returned to 100%, and his heart rate returned to normal.

The three of us remained at the baby’s crib, watching him breathe; Gerald helping him out with occasional bagged breaths until Dr. Polk arrived.

Flying into the room, Dr. Polk saw Gerald bagging his extubated patient.

“Who pulled out the goddamn ET tube?” he roared.

“I did, Dr. Polk.” I held up the gelatinous ET tube for him to see.

“Good job,” he said. “Everything looks okay.”

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Collusion (Niki coaches a parent on talking to doctors)

Chapter 13

The next night I returned to the PICU, and found that the eleven year-old transferred to the regular pediatric unit on schedule. As predicted, Dr. Eubanks not only discontinued the Fentanyl infusion before the transfer, but the puny IV morphine pushes too. It was out of my hands now. Or so I thought.

Later in the evening, I see the eleven year old’s Dad standing at the nurses’ desk, asking for me. I go to talk with him.

“What did you do last night to get my daughter pain medicine?” He demands.

“Um, I asked the PICU doctor for it,” I said. I didn’t think I should say that this was because I knew the surgeon wouldn’t order it.

“How’s she doing tonight?”

“She had a pretty good day. In the afternoon she rode a wheelchair to the play therapy room, played some games, and then walked back to her room. Right now though, she’s screaming in pain, and her mom and I can’t get her to stop. I asked the nurse to give her pain medicine, and she told me Tylenol is the only thing ordered. We gave it to her, but it doesn’t stop the pain. How do I get her more pain medicine?”

“Oh, boy,” I think to myself. My role of patient advocate is clear; I’m trying to think of how to word my answer without getting fired.

The child’s father, advocating for his daughter, doesn’t allow me this luxury.

“Are you a mother?” he asks.

“Yes I am. I have a daughter about the same age as yours,” I admit.

“So, if this were your daughter, what would you, as a nurse, do to get your daughter more pain medication?”

Silently, I think to myself, “Well, I was looking for work when I found this job…”

Out loud, I tell him the truth:

“Dr. Eubanks is a very good surgeon, but he doesn’t like his patients over sedated, so he doesn’t order a lot of pain medications for them. Your nurse isn’t calling him for more, because he will probably yell at her if she does. She’s afraid of him.”

“It’s only 9 pm. What I would do is tell the nurse I want to speak to Dr. Eubanks, now. She’ll make the call at the desk for you. When you get Dr. Eubanks on the phone, tell him your daughter is screaming in pain, and this is unacceptable; you expect her to be comfortable in the hospital. Tell him you want him to order appropriate pain medication for your daughter.”

“Got it!”  He said triumphantly. “Thank you.  Anything else?”

“Yeah, if you would not tell anyone that I coached you on this, I’d appreciate it. I’ll probably get written up if the pediatric nurses or Dr. Eubanks find out,” I solicited.

“Not a problem. I appreciate you honesty and help,” he promised, leaving the PICU, presumably looking for his daughter’s nurse.