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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!

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Simon’s Turn (Simon talks back)

Chapter 21

“Yes you are, Niki.  You’re wrecking our home.”

Simon, seated across from me in the family room hadn’t moved a muscle, but the power of his words hit me like a punch to the stomach: breathless, and unable to speak. My bravado was gone. Defeated, I crumpled into the chair, fighting back tears.

“I don’t have the strength to do this,” it occurred to me.

Before I recovered, Simon’s shoulders dropped. His energy changed. He looked down at his hands in his lap before looking into my eyes, and said,

“I’m not angry at you for wanting a divorce Niki.  I’m angry that you gave up on us before I did.”

Puzzled, I stared at him.

“Our marriage hasn’t worked for me for a long time. I don’t know when the magic stopped, but you’re different now Nik.

You used to be fun. We used to go to games together. You were as big a fan as me. Now you don’t want to be in the crowd in the bleachers anymore. You’re not interested in watching on TV either.

You take everything so literally. You used to have a sense of humor and laugh. Now I have to explain, ‘I’m just kidding,’ so you know it’s a joke.

When we go to movies or concerts, the first thing you do is locate all the emergency exits. Everything is always worst-case scenario with you. You’re too intense. When was the last time we laughed?”

I couldn’t think of an answer to this. Simon used my pause to continue.

“When you talk about work, and the drugs you give to those kids, all I can think about is, “Jesus, she knows how to kill someone!”

“I like to think I know how to save lives, Simon.”

“The point is Niki, I don’t know you anymore. You’re not the fun girl I met in college. It’s like saving the world is your only concern. I married a wife, not a super hero.”

Simon bit his lip then clenched his jaw. His eyes were red-rimmed, and moist. Then he pulled his finger out of the dike, and it burst open, changing the landscape of our lives forever.

“Niki, I want a divorce too. This doesn’t have to be a bad thing. You’re a good person, and I’m glad we share Maddie, but I don’t love you anymore.”

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It’s Not Like You Work Five Days a Week (Twelve-hour night shifts are hard on marriages)

Chapter 14 

For the third night in a row, I returned to the PICU. Shortly after shift report, the father of the child I told how to ask for pain meds for his kid walks in carrying three large boxes of pizzas. He sets them in front of me, on top of the nurses’ desk.

“My wife and I want to thank you PICU nurses for the extraordinary care our daughter received while she was a patient in this unit, and we are  treating you to a pizza dinner.”  He looked at me.

“So how is your daughter doing tonight?” I ventured.

“Great!” Her surgeon talked to us by phone. He wanted to make sure her pain medications kept her comfortable. We really appreciate his concern for her well being. She had a very good day, and we’re going home tomorrow.”

“That’s great news,” I told him. “Thanks for the update, and the pizzas.”

“It’s our pleasure,” he replied. “Enjoy!”

After he left, Liz looks at me quizzically, but only says, “Well Niki, you certainly excel at the ‘concierge service’ the hospital keeps pushing on us. Obviously that family thinks you’re the bomb. Way to score pizza! Thanks!”

***

At breakfast the next morning I swear Corey to secrecy, and tell him about Dr. Eubanks, the dad, and the pizzas. It was two of us, because Liz had to take her mother to a doctor’s appointment.

“That’s awesome, Niki. Way to advocate for your patient. I’m tired of being told to ‘manage up’ without a way to honestly speak up when I see something wrong. What administrator’s going to support a nurse’s concern about an under medicated patient over a surgeon’s insistence that his patients don’t need it? Nurses are hospital employees, and in most cases, doctors are not.”

“I think nurses could push on an issue like this in nurse council, but it takes forever to change hospital policy. My patients can’t wait that long for help. It’s a problem.”

“Amen,” agrees Corey.

The server brings Corey’s breakfast. I only ordered coffee because of the pizza I ate last night, but Corey’s ordered bacon, eggs, hash browns, and his usual beer. The bacon smells so good, and Corey notices me eyeing his.

“Go ahead Niki, have a piece.”

“Oh no. I ate all that pizza last night. I don’t need any more calories. Plus it’s your breakfast.”

“No, really have some,” he insists, placing a couple strips of bacon on my plate with his fork.

Corey watches me eat the bacon. It tastes heavenly. I love bacon.

A smile breaks across his dimpled face, making him adorable. I smile back.

“So, Niki, maybe it’s none of my business, but last time we had breakfast with the gang, it sounded like maybe there’s trouble at home.”

“Oh I don’t know… No, that’s not true. Maybe I expect too much from Simon. I mean he’s a good man, and an affectionate father. He was out of work for a while, but now he’s teaching again. You’d think that would get us back on track, but when he tells me about his day, like normal people do, I try to be sympathetic, but I’m thinking, “When I have a bad day at work, somebody’s child died.” He doesn’t understand why I can’t let my work go when I get home, like he does. How about you Corey? You didn’t say much about your marriage.

“My wife, Sheila, is beautiful. When I met her, she was a high-powered realtor selling spectacular homes for the wealthy. She was so girly, you know: blonde hair, pumps, always wore dresses. I fell hard.

I think I’m a big disappointment to her. I know she doesn’t consider three 12-hour nights shifts a week in a trauma center full time employment. She actually says that out loud,

‘You know, Corey, it’s not like you work five days a week like my friends’ husbands. They don’t sleep all day either.’”

“When the bottom fell out of the real estate market, Sheila went on hiatus. She’s home with the kids while I work, “single mothering it,’ as she calls it. On my days off I get the girls ready for school, drop them off, pick them up, shuttle them to and from dance classes, and then start dinner. Sheila leaves the house early in the morning for a full day of Pilates, a pedicure, her book club or shopping, and then happy hour with her girlfriends, but not before making a ‘honey do’ list of repairs around the house for me. Occasionally she texts me something she forgot. It’s pretty clear she doesn’t respect nursing as a career for a man.”

“Corey, I’m sorry. Your wife should spend a night watching you work in the ER. A lot of people are alive because you’re a great nurse.”

“Sheila would never willingly enter a hospital. She doesn’t want to know about the ‘blood and guts’ of my job. When I try to explain it to her, she tells me it’s not an appropriate conversation for our daughters to overhear.

“So, I pick up as much overtime as I can handle. I don’t know if it’s for the extra money, or to avoid being home anymore, but I get a lot of satisfaction from nursing. I’m part of a team there. It’s like I matter to something larger than myself.”

Corey and I have a silent moment of eye contact. He reaches across the table and touches my hand.

“Thanks Niki.”

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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.

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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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No Good Deed Goes Unpunished (Niki gets a speeding ticket)

Chapter 9

After charting on the fourteen-year-old boy with the AVM, I left the PICU to the well wishes of my coworkers: “Get some sleep, Niki. Good job.”

As usual, I leave through the Emergency Department exit, glancing around before remembering that it’s after eight-thirty; Corey went home over an hour ago, and I stood him up for breakfast. He probably heard what happened in PICU from radiology. It’s not that large of a hospital.

The sun is almost blinding this time of morning. After wrapping my stethoscope around the rearview mirror, I search the glove compartment until I find my sunglasses, and put them on. Pulling out of the hospital’s parking lot, I head for home on surface streets. During prime time morning traffic they are congested, requiring my concentration.

While driving home, I relive the shift in my head, wondering if the boy will survive (he doesn’t), and if I’d missed any signs during the night, which may have gotten him help sooner. Lost in thought, I suddenly realize I’m driving in front of an elementary school as I careen a crosswalk at 35 miles an hour. On the curb stands a crossing guard wearing a neon green vest with several school-age children huddled around her.

“Oh shit,” I hiss at myself.

In the rearview mirror I see the flashing lights of a motorcycle officer pulling away from the curb after me. I signal, and pull over. From the mirror, I watch him note my license number, and call something in over his radio. He’s already writing the ticket as he approaches. By the time he gets to the passenger door, I have the window down, and am apologizing profusely. He asks for my driver’s license.

“Officer, I’m so sorry. I didn’t see the crosswalk. I forgot what time it is.”

“Ma’am, you were going thirty-five in a school zone. You just missed taking out a group of children and a crossing guard.”

“I realize that sir. I’m really sorry. I just got off work and I’m really tired. I know that’s no excuse. I’m really, really sorry.”

He contemplates what I just said, and takes a look into my car. I see him take note of my green scrubs, and notice the stethoscope hanging on the rearview mirror.

“Do you work at the hospital a few blocks from here?”

“Yes sir.”

“Are you a nurse?”

“Yes sir.”

“Dammit!” he says. Do you work night shift? Are you getting off late?”

“Yes. We had a bad last few hours.”

“Dammit!” he repeats. “I don’t ticket doctors or nurses. It’s bad Karma. For all I know, I may be a trauma patient in your hospital one day, but I already started writing the ticket. I can’t make it go away once I start writing a ticket.” He looked genuinely worried.

“Ticketing me won’t affect your Karma, Officer. Really. I deserve the ticket. I almost hit a group of kids. I was lucky this time. It doesn’t matter how tired I am, I need to be more careful.”

“Are you sure?”

“I’m sure. Give me the ticket.”

“Alright, well. I’m checking the box that says it’s okay for you to go to traffic school though. That way, it won’t affect your insurance premiums.”

“Thank you, Officer.”

He handed me the ticket.

I rolled up the window, and slowly drove away. When I was out of his sight, I pulled into a large commercial parking lot, locked the doors, and cried.

I didn’t go to traffic school. I wrote a check and paid the ticket.

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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.