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When it Happens to One of Your Own: Niki’s Heartbreaking Admit

Chapter 60

It’s 1730, and I’m caught up on patient care. Not only this, but so are my coworkers. It’s been a quiet dayshift, but none of us say this out loud, because that’s the fastest way to jinx your shift. I helped Craig transfer his last patient to pediatrics, and he’s left early. The remaining three of us sit at our pods and finish charting. We have an hour left before night shift arrives.

Of course, it was too good to last. The phone rings and Sue picks up the phone. I can tell by what I overhear we’re getting an admission. A trauma. A motor vehicle accident.

It’s a fifteen year-old boy, intubated by paramedics at the scene. He was the unbelted passenger of the truck his buddy was driving. They crossed a freeway barrier, and hit an oncoming car head-on. Our patient flew at least thirty feet before hitting pavement. He coded on the scene. There was a fatality in the other vehicle. The driver of the fifteen year-old’s vehicle survived without significant injury.

We call respiratory, and a ventilator is set up in the room. I pull out kits for arterial and central line placement. Neurology calls to have us prepare for an ICP monitoring device insertion.

It’s all hands on deck as the paramedics roll the boy into the PICU. He is strapped onto a back board, and wearing a neck collar. I step up to the gurney as we prepare to transfer the young man onto the hospital bed. He’s unconscious, and there’s blood spattered on his face. His face: I take a closer look, and I recognize his face! Oh my god; it’s Liz’s son, Nathan.

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A Happy Shift (Niki explains PICU pain management)

Chapter 12

My next shift, I take report on a child admitted following surgery earlier that afternoon. The medical plan is for her to spend the night, and then transfer to the regular pediatric unit in the morning.

The surgery was successful, and the patient will make a complete recovery.

“I’m concerned that the surgeon hasn’t ordered enough pain medication for her,” the day shift nurse says.

I look over the prescribed medications. I agree.

“How’s her pain control been for you?” I ask.

“So far, she’s mostly slept since coming back from the OR, but when the residual anesthesia wears off, she’ll hurt bad. You may have a rough night.”

“Did you call the surgeon for more meds?” I glance at her chart for the surgeon’s name, which answers my question. Of course she didn’t call. It was a waste of time.

The child’s surgeon, Dr. Eubanks is skilled and well loved by his patients and their families. Among nurses, however, he is notorious for under-medicating for pain. A nurse requesting more on behalf of her patient gets an angry refusal for her trouble.

Before judging Dr. Eubanks as a sadistic bastard, however, let me explain how some nurses contribute in the development of this behavior in some surgeons.

Bear with me.

There are three kinds of nurses whose patients always code:

The first is the most skilled and experienced nurse. She or he has Rock Star status in their unit and is the go-to nurse for the most critically ill admissions. This nurse’s patients code frequently, because they nurse the sickest of the sick.

The second nurse is the up and comer. Not yet a Rock Star, she or he is on their way to joining the rank. This nurse possesses strong skills, but is still gaining experience. They’re trusted with patients unstable enough to go badly.

The third type of nurse doesn’t really have cardiac code patients. They have patients with respiratory arrest caused by a heavy hand with narcotic administration. Often these nurses work in habitually understaffed units. For others, a sedated patient makes a happy shift. Although causing respiratory arrest is not the intent of either nurse, it’s a side effect of their care. If these nurses’ patients are intubated, respiratory arrest doesn’t occur, but they are too drowsy to wean off the ventilator in a timely manner, causing extended ICU stays.

This drives surgeons crazy. They want to avoid pneumonia, and other hospital acquired infections for their patients. They want them out of bed, moving around, and discharged home as soon as possible.

When a surgeon accumulates enough bad experiences with the third kind of nurse, distrust ensues. This distrust leads to a habit of withholding orders, and under medicating for pain. In a twisted way, this surgeon believes he or she is protecting their patients by withholding narcotics.

Clearly, further pain management education for such a nurse and surgeon combination is needed. Meanwhile, the rest of us suffer.

***

Early in the evening, my patient begins complaining of pain. I give her acetaminophen along with the spit in the bucket dose of IV morphine ordered. She quiets down a bit, but an hour later her whimpers turn to howls, and her parents demand I treat her pain. I agree.

I call Dr. Polk, who’s in the call room, and he comes in to assess the patient. Then we go to the nurse’s desk to talk.

“I’m going to start a Fentanyl drip for the night, so she can get some sleep Niki, but you know Eubanks will discontinue it the moment he rounds in the morning. If the kid spends another night in PICU, I won’t be able to repeat this.”

“I know. I won’t over sedate her, I promise. Thanks Dr. Polk.”

I start the IV infusion, and shortly, the child is comfortable. She watches a DVD with her parents before falling asleep. Dad goes home for the night. Her mom says, “Thank you,” before settling into the window seat bed in the room. I turn the lights low, and pull the room’s curtain so they can rest.

It’s a happy shift.

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Something Goes Wrong (Nice families always have the sickest kids)

Chapter 8

Besides my fourteen year-old head trauma there is only one other patient in the PICU.  Because that one is stable and expected to transfer to the regular pediatric unit in the morning, staffing for our night shift dropped down to two nurses, Kathy, and myself.

The fourteen year old’s parents had been at the bedside since his return from the OR. Throughout the evening his siblings, grandparents, and extended family visited two at a time until visiting hours were over at nine o’clock.  His parents, who really are very nice, took advantage of our empty waiting room across the hall, deciding to spend the night sleeping on the sofas. Kathy and I outfitted them with sheets, blankets, and a couple pillows. I promised to wake them if anything happened.

Around two am, Corey came up from the ER on his break. “Hey Niki, let’s have breakfast after our shifts in the morning, okay?”

“Sure Corey. That sounds great.”

Corey and I met at New Employee Orientation when we were hired. He’s married with two small kids. He’s become one of my best buddies at work. We regularly go out for breakfast after our shifts.

***

The shift nearly passed without mishap.

Around six am, I was taking vital signs on the fourteen year-old. Nothing changed all night. I charted the oxygen saturation and TCO2 monitor readings to check against the results of the arterial blood gas I’d just drawn with his morning labs. Suddenly the monitor alarmed loudly.  Glancing at the screen, I see the ICP numbers are rising, and then out of the corner of my eye I see bright red blood pulsating inside the clear plastic ICP device in the kid’s head and backing up into the tubing it connects to. What the Hell?

Then I shout,

“I NEED HELP!”

Kathy runs in, sees the blood, and says, “Oh my God, what’s happening?”

“I don’t know! I’m not even sure what to do. Should his head go up or down?”

I pondered this while quickly verifying his peripheral pulses and blood pressure manually. I take him off of the vent and begin hand-bagging him, hoping to control the rising ICP. Then I hit the code button. Meanwhile, the boy starts seizing.

Immediately, Gerald, the respiratory therapist runs in. The blood pressure and pulse are high, not low, so we don’t begin chest compressions, but Gerald takes over the hand bagging.  Dr. Polk runs in from the call room as the dayshift nurses begin to arrive.

Dr. Polk orders ativan and a loading dose of phosphyenatoin, which I run to retrieve from the automated drug dispenser.

Immediately, Kris is at the bedside:

“Keep his head up! Call CAT scan. Tell them we’re coming down NOW, this is an emergency. Draw a type and match too,” she commands.

Dr. Polk is entering orders for the scan, and phones the neurosurgeon.

“Should we clamp the ICP tubing?” Kathy asks.

“NO!” both Kris and Dr. Polk yell out.

Dr. Polk asks, “Niki, what happened?”

“Nothing. He was stable all night, then this.”

Meanwhile, the rest of day shift arrives, and a team of nurses flurry into action, transferring the boy’s monitor leads to a portable unit, drawing more labs, and gathering equipment. A green O2 tank is slid into a rack on the bed for the ambu bag. Gerald continues hand-bagging him for the trip downstairs. Another respiratory therapist appears to roll the ventilator down with us.

“Has anyone told the parents yet?”

I awaken them in the waiting room, and bring them back to the PICU. When we get there the team has already wheeled the boy in his bed out the door, with Kris at the helm. Trailing behind, I explain what’s happening. The three of us take a second elevator to CAT scan. Once the parents are seated in the anteroom, I help Kris and the radiology techs transfer the boy onto the narrow table that slides into the tube-like machine.

Behind me, Dr. Polk and the neurosurgeon view the black and white images with grave expressions. The neurosurgeon makes a phone call and instructs OR to prepare a suite.

The CAT scan reveals the cause of the bleeding is an ateriovenous malformation, an AVM, deep in the boy’s brain. Most likely, it’s lurked there undetected since birth. Though no one knows for sure, it’s assumed that when the boy hit his head against the wall, the AVM began leaking, causing the original small bleed, but wasn’t picked up on the original CT. Apparently the bleeding continued, the pressure building until the AVM blew like an old rubber inner tube.

The boy is rushed to OR. I return to the PICU, where I struggle to grasp the medical terms I need to document the incident in the nurse’s note. My adrenaline level is so high, I have difficulty concentrating and keeping the events in order.

Kris comes back up for report. “You did okay, Nik. It wasn’t anything you could control.”

“Thanks Kris. I appreciate that, and your help too. I really do.”

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The Center of This Body’s Universe (Niki needs caffeine and meets a nice family in the PICU)

Chapter 7

I can’t tell if my headache is caused by too much sleep or not enough.

Without coffee my night shift tuned body doesn’t know whether to wake up, or go to bed, since neither daylight nor darkness have circadian relevance anymore. Caffeine, not the sun,  is the center of this body’s Universe.

I fill the coffee maker and hit “start.”

Maddie is still asleep. Pausing in the doorway of her room I watch the even rise and fall of her chest. She is perfect, her skin creamy and unblemished. I’m constantly wonderstruck by her healthy color, unlike that of the sick children in the PICU.

Silently, I count the blessings: Despite her premature birth, we’ve made it safely past Sudden Infant Death Syndrome, and without childhood febrile seizures. Her bout with Chicken Pox was mild. Maddie’s learned to swim, and is forbidden from riding her bike without a helmet. I calculate my next bout of parental anxiety will begin when she’s old enough to drive.

Although I fix breakfast for Maddie and Simon, I only have coffee. I pack Maddie’s lunch while Simon showers before they leave for school together.

Simon got the teaching position at Woodman middle school, which Maddie will attend this fall. He’ll even supplement his pay by coaching after school, which he’s excited about.

This takes a lot of stress off of me, and things are better in our marriage. In fact, Simon and I have planned a weekend getaway to Coronado for our anniversary in a few weeks. We booked a luxury suite with an ocean view. Maddie’s staying with my sister and her family while we’re away. Simon and I haven’t taken a trip in years. I’m hoping this will refresh our marriage. Things are stale lately; actually it’s been longer than lately.

After Simon and Maddie left, I dressed in riding gear and rode my bike along the beach on the Strand, almost to Santa Monica. It’s not too crowded on a weekday. This morning the sun is out, and sunspots sparkled and danced on the ocean. I love how bicycle riding provides an opportunity to both see and interact with my surroundings.

The rest of the day I spent cleaning the house, followed by a short nap. There’s enough time for a quick dinner with my family before I leave for work.

In the PICU, Kris gives me report on an intubated fourteen year-old boy with an ICP bolt surgically implanted in his skull. It’s recording the pressure in his brain, which is represented as a number on the monitor screen overhead. During report, the number is normal. I assume that’s because he’s sedated.

“No ma’m, no sedation,” Kris informs me. “That’s the problem. He was at basketball practice and took a header into a wall. The coach and his teammates witnessed it. According to them, he didn’t hit the wall all that hard, but he lost consciousness. He’s roused a little, but he’s in and out, mostly out. The CAT scan showed a small bleed, which neuro removed in surgery, but he still isn’t coming to. He has a MRI tomorrow morning. In the meantime, they bolted him, just in case. This is a weird one.”

“It is weird. Is his family in the waiting room? I asked.

“Yeah,” said Kris. “They’re the nicest family.”

Of course they are. The nicest families always have the sickest kids. When a PICU nurse starts report by saying, “This is the nicest family,” you know something is going to go wrong.

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Little Earthquakes (Niki has a stress dream and learns about earthquake kits)

Chapter 5

I pulled into the driveway of our rented house. Simon’s left, so I park in the garage, closing the door. I removed the groceries from the backseat and set them on the washing machine before sliding off my scrubs, dumping them into the laundry hamper. I’m always worried about bringing home germs from the hospital, and spreading them to Maddie. I put on the robe I keep on a hook before entering the kitchen with the groceries.

Simon’s left the dirty dishes from last night’s dinner in the sink, and the wastebasket is brimming on the edge of overflow. Its contents defy gravity. Although exasperated, I admire Simon’s flair for sculptural design.

He’s left a sticky note in his methodical printing on the counter:

“I’ll take care of the dishes and trash when I get back.”

I put the groceries away, and then wash the dishes, but leave the trash. I’ll sleep better the less Simon clanks around in the kitchen. I’ll clean the rest of the house tonight when I wake up. Last night was my third twelve-hour shift in a row. I’m off tonight.

I take a quick shower, towel off dry and practically fall into the unmade bed in our darkened bedroom. In minutes, I am unconscious.

I dream I’m still at work. The monitor and pulse ox alarms are going off in a patient’s room. I go in and look at the baby lying in the warmer. He’s naked and uncovered. His skin is blue. I am terrified that I forgot he was my patient, and ignored him all shift. I can’t revive the baby, and the alarms keep ringing…

My heart is pounding from the dream when I wake up at two-thirty. It takes a minute to realize I’m not at work. In the still darkened room I feel around the foot of the bed, groping for the soft grey sweats and tee shirt I left there yesterday. I put them on, sliding my feet into rubber flip-flops before traipsing into the kitchen. The trash is still there from this morning. The sink is again full with the dirty utensils Simon used to make macaroni and cheese.

I maneuver the teakettle around the dirty dishes, filling it with water before setting it on a burner, and adjusting the blue flame to high. I drop a teabag, fragrant with cardamom, into my favorite mug and wait for the kettle to boil.

In the family room, I hit the random play button on the CD player before settling into the old rocker recliner. Rocking gently, sipping tea, my brain slowly rises from its fuzziness, much like the Southern California coast has emerged from the morning fog, which I notice burned off while I was asleep.

Twenty minutes later, Simon’s car pulls into the driveway. Two car doors slam shut, and I hear Maddie laughing as she runs into the house.

“Mom! We practiced earthquake safety at school today. We crouched under the desks and covered our heads with our hands. I have a note from Mrs. Marrs. Everybody has to bring an earthquake kit to school.”

“What’s an earthquake kit?”

I set down the mug as Maddie holds out a piece of folded paper. Sure enough, it’s from her teacher, explaining that every student needs an earthquake kit at school, in case of emergency. Each kit must be packaged in 2-quart Ziploc bags, double-bagged. The bags can’t be larger than 2 quarts because of space limitations in the classroom. The required contents of the kit are listed in bullets:

  • A lightweight hoodie sweatshirt
  • A packaged (not homemade) granola bar or snack
  • A juice box
  • A list of allergies, if any
  • Your child’s name, and the address of both parents, including home, work, and cell phone numbers on an index card
  • The name and cell phone number of a local, alternative emergency contact

I cringe; thinking, “Would I be able to get to Maddie if an earthquake happens while I’m at work?” then quickly dismiss the thought. I set the paper next to my mug on the table, reaching for Maddie to give her a hug.

Maddie cuddles into my chest. I touch her cheek with mine before kissing the top of her head. She says, “I can always tell when you worked Mom, because you wear the same old crusty clothes, drink tea, and rock.”

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Myopia (What happens when a Child’s Only Access to Health Care is The ER)

Chapter 3

“Fuck! Liz, get in here! I need more light.”

Dr. Polk, the PICU intensive care doctor is renowned throughout the hospital for his skill at inserting central lines into even the smallest child, and also for his use of colorful language. Middle-aged, however, his eyesight is worsening. This makes the placement of central venous catheters a challenge for all of us. Tonight, the patient is a three year-old in hypovolemic shock we picked up from the ER.

Corey brought him up, and gave me report.

“Dr. Polk, this is a pediatric unit. Watch your mouth,” Liz scolded while setting up a freestanding light used in these situations. The room had an overhead light for this purpose, but whoever designed the rooms placed it in the center of the ceiling instead of towards the wall containing the oxygen and electrical outlets where the head of the bed goes, rendering it useless.

“Yeah, yeah, I remember,” he mumbled. “Get that light a little more to the left, would ya? Yeah, right there, that’s it.”

After that the line went in smoothly. Using a curved needle that flashed and glittered in the light, Dr. Polk tethered the CVC to the child’s skin with two silky black sutures before stepping out of the room. Then I took over, sterilely dressing the site while Liz ordered a portable chest x-ray.

Once the X-ray confirmed placement I switched the bag of IV fluids from a peripheral IV to the central line.  I charted another set of vital signs, then got to work straightening up the mess left by Dr. Polk.

Carefully, so as not to stick myself, I picked out each needle and blade from the used central line kit cluttering the bedside table before throwing away the packaging. The sharps went into a red puncture-proof container. I straightened the bedding under the motionless child, lying on the stainless steel crib. I covered him with a pink and blue bunny blanket, which looked out of place in the ICU setting.

Next to the crib, a pair of corrugated blue and white ducts snake from the ventilator through the crib railing, connecting to a breathing tube inserted down the boy’s throat. Next to the ventilator three small infusion pumps were clamped to a single pole and piggybacked medications into the maintenance fluid. One kept him still so he wouldn’t pull out any tubes. Another kept him calm, and induced mild amnesia. The third, a narcotic, blunted the pain of his ordeal. Like Goldilocks, I hoped the combination would be just right. I rolled up two washcloths, and placed one in each of his hands to prevent his inactive fingers from curling. I checked the monitor alarm settings one more time before stepping out of the room for a moment.

At the nurses’ station, Dr. Polk had brought the boy’s mother in from the waiting room. Her eyes were red from crying. Animatedly, she told him about the events leading up to this admission. The child had been sick with a fever for five days, the last three of which he began vomiting, and refused to eat or drink anything. He started sleeping a lot too. She brought him to the ER this evening after she couldn’t get him to wake up for dinner.

It’s amazing how sick a child can become from fever, nausea and vomiting. Maybe if he’d seen a doctor sooner, the trauma and expense of this ICU admission could have been avoided.

“Why didn’t you bring him in when he first got sick? Why did you wait to see a doctor?” he asked, but Dr. Polk, Liz, and I already knew the answer.

“I no have insurance. I no have money.”

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A Good Shift (Niki introduces two coworkers)

Chapter 2

One good thing about working twelve-hour night shifts in a Southern California hospital is driving against traffic for the commute. Californians don’t measure commutes in miles, but by how long it takes them to get there. Everyone knows to stay off the freeways, and take surface streets.

I pull into the hospital staff parking lot ten minutes before starting time, unwrap my stethoscope from around the rear-view mirror, and grab my sack lunch from the passenger seat. Then I sprint to the PICU for change of shift report.

Unconsciously, my nose wrinkles when I see on the assignment board I’m taking report from Kris. She’s nearing fifty, and thinks this gives her the right to treat me like I’m still a student, but I see through her. Her aging makes my youth threatening. Blonde hair, overly tanned skin; she’s so thin I’m sure she has an eating disorder. Last year she had a boob job, and when she returned from medical leave she pulled every one of us into an empty patient room for show and tell.  She’s currently dating the bass player of a struggling rock band that practices in her garage. Kris doesn’t have relationships with men, or girlfriends for that matter, only superficial encounters of varying lengths; it’s a frequent source of gossip among the nurses in our unit. However, she’s been a nurse almost thirty years. She’s worked ER, OR, and adult ICU. Even I have to admit she’s nursing muscle.

I brighten when I see I’m working with Liz tonight, and she’s charge nurse. Every bit as skilled a nurse as Kris, she’s a completely different type of person. She doesn’t hold my inexperience against me. Instead, she sees me as an opportunity to develop a coworker she can depend on. She understands I’m looking for the chance to sharpen my skills. Liz doesn’t wear any make up, and laughs too loud, but she is the rock star nurse in this pediatric intensive care unit. The doctors ask her opinion of their patients’ progress before they write their orders.

It’s going to be a good shift. I start every shift thinking it will be good. That’s how new I am to nursing.