Thursday, November 28, 2013

Happy Thanksgiving

Happy Thanksgiving!  There is much to be thankful for this year.  And as I spend the day with family and friends, I will reflect on all that I am grateful for.

I hope that you all have a safe and blessed Thansksgiving, and year to come!

And for all my nursing and Nurse Practitioner friends who are giving of themselves in the PICU (and other units today), thank you! Thank you for your hard work, for your servatutde, and the way you selflessly give to patients and families on holidays like today, and everyday! You are much appreciated!

Monday, November 18, 2013

When PICU Parents Get in the Way

Ever taken care of a patient and you do everything you can for them??? Only to realize that the "everything" list is completely shortened because the parents just keep getting in the way!?

This hasn't happened to me in quite awhile...until last night.

Around midnight (yes, great timing...JUST as I was getting ready to leave!), I get a CAT page.  I think I've talked about our CAT calls before, but just a little refresher:

CAT = Critical Assessment Team

Anytime a physician, APN or nurse on any unit (outside of the PICU) feel that they want a "PICU Consult" or another set of eyes on their patient for recommendations, or perhaps a transfer to the PICU, they call a CAT call. 

Generally APNs in the PICU respond to these calls (although on some days that we are completely slammed, the fellows can step in if they are not swamped as well!).

We go up, evaluate the patient, and either decide that the patient needs to come down to the PICU, or they are stable enough for the floor service but we can give them further recommendations on what to do. 

While I really was terrified and hated these when I first started as an APN, I'm learning to love them more and more.  It really brings out the autonomy and critical thinking out in my practice.  And certainly as I become more knowledgeable, they get a bit easier.

Until last night!

As I said, I got the page right as I was getting ready to leave.  So of course, I wanted to get up there, decide if the patient needed to come down, and get out of there ASAP!

Almost 2 hours later, I was finally ready to leave for home : (

So what took so long for a process that typically takes 15-40 minutes???

The Parents of the Patient! That's what happened!!

The floor team called the CAT because they were concerned about the patient's neurological status that had been waxing and waning over the last 3 hours that the patient had been there.  I was getting the patient's history from the physician which included fevers, headache, neck pain, decreased appetite and overall lethargy for 4 days. 

My next question was what had been done in the ED and on the floor look into this.  The answer? "Weeeeelll.....not much."

I didn't really get it *what do you mean "not much" has been done??* so I re-phrased.  Off the top of my head, in a patient with these symptoms, I would be concerned about several things, but the top of my list would be meningitis.  Have you gotten a head CT, and done the LP?  What about antibiotics??

So this is where the story got interesting.  The ED apparently had to convince the parents of this patient (that sometimes woke up, sometimes not so much!) that he was actually sick!  Despite several attending physicians discussing at length with the family, they ultimately refused everything except the head CT (which was normal).

So no LP, no antibiotics, no further testing! Done.  They almost took the patient home, but the ED physicians said they would not allow that b/c their son truly was sick and needed medical attention.

So here I am, about 6 hours later doing a thorough neurological examination and determining that this patient now needs to go down to the PICU, mostly for hourly neuro checks (which is too much for our floor nurses when they have a larger patient load than PICU nurses). Ohhh boy, the parents did NOT like that!

Nor did they appreciate that I stated that he really did need an LP.  And antibiotics.  And once again, they flat out refused.

In their minds, their son was sick, but was something that he would need to fight out on his own.  And they though he truly wasn't that sick.  But he was!!

So it was a very long, very drawn out process to get the patient down to the ICU.  Ultimately, I wrote my CAT note (detailing very thoroughly what I had recommended, and that the parents were refusing most of it along the way), and had to hand off this hot mess to the team that would be there the remainder of the night.

So here are 2 parts of the PICU that can be hard or frustrating:

1.) When things are unfinished, or unresolved, it is so unsatisfying just leaving, and not really knowing the outcome right away.  But for the sake of my sanity, and the fact that I was exhausted, I did leave.

and 2.) When parents get in the way of doing what you know needs to be done medically for the patient.

So while I have no idea what happened today, I look forward to going back tomorrow night seeing what was ultimately decided among the family and the medical team.  That will help to resolve the frustration of #1.

As for frustration #2...unless we take over legal custody because the parents are truly harming the child (which is a much longer and drawn out process than sometimes seems necessary!), parents such as this will continue to be parents just like this.  And while I can't do anything to change them in the short term, I can continue to try my best to help them understand what medically would be best for their child.

And ultimately, I will continue to provide the best care that I possibly can for them.  Doing everything I possibly can to get this patient back to their healthy former self, and out of our PICU!

Tuesday, November 12, 2013

PICU Vices

I laugh at how frequently the topic of being a nurse practitioner and alcohol go hand and hand.

I remember when I was referred to a hematologist almost 2 years ago, I had just finished school and hadn't started as an APN yet.  I saw the heme APN and she asked, "So have you started drinking yet!? Because if you haven't now, you definitely will once you start working."

The question took me a little bit by surprise, so I just laughed. I mean Jon and I have always loved wine. Or an ice cold beer on a hot day.  Or a good dirty martini (see, I'm no stranger to alcohol!).

But then I started working as an APN and it definitely took on a whole new meaning.  The hematologist APN was right!

I also have a friend who is a mother of 2, in her 40s, who is now in the midst of nursing school and she recently posted on facebook a status that read something to the effect of "I don't know how I'd get through these classes without X, Y and Z friends...that and our good friend wine. If nursing school doesn't turn us into alcoholics..."

I laughed as I read it and then commented, "Just wait, if nursing school doesn't turn you into an alcoholic then your first year as a nurse will!"  Laugh, laugh.

And now my co-workers and I laugh at the end of a hard day about whether it was a "one or 2 glass sorta night."  Generally, the super hard days that involve note writing at home are the 2 glasses types of nights!

So it was particularly funny when one of my favorite co-workers called me last night to say that I would be proud of her.  While she was pouring a glass of wine after a long day, it was the first time in 4 or 5 days (yes, we celebrate the small victories!).  I told her that I indeed was impressed, and asked her what she replaced her wine vice with.  Because I KNOW it's not something you just toss to the side without a replacement.

While I was completely joking in asking this question, she sheepishly replied, "Yeah, I've taken up online shopping!"

We both laughed so hard!! Oh boy. 

She then replied, "I think I'm going to stick with the wine, because it's definitely cheaper!"

So I'm not sure what it is about nursing school, nursing in general, grad school or being an APN, but there is a direct correlation with that and wine consumption!  Now there's a smart research study waiting to be done!

Are you a wine drinker??? If not, what is your post-nursing/APN hard day vice???

Friday, November 8, 2013

Goodbye Three Things....

OK, after 2 short weeks, and one of them not even being on time, I've decided 3 Things Thursday is over. 

YUP, this is coming as no surprise to me...remember what I told you my journals and diaries used to look like? I'm telling ya, a ten year span can fit in about the front 1/3 of a very small notebook!

I just realized that I don't have the kind of job that I can guarantee to blog on one particular day of the week! 

So instead, as I come up with them, I can do a 3 things here and there. 

Since I started this blog to document the many fun and crazy things that happen in the PICU I don't want to start feeling stressed or obligated to produce something.  That's definitely not needed!

So Happy Friday instead!  I'm working this weekend and am looking forward to it (as much as you can look forward to working on a weekend!). 

I spent 2 days last week spending time with the Neuro Critical Care APN and the remainder of my last several shifts have been evening/nights so I'm excited just to get back into the regular swing of daytime PICU.

My one true career love...days in the ICU! 

But tonight, it's a date night in with my man.  Nothing can beat that!

What are you doing this weekend???

Friday, November 1, 2013

Happy Halloween!

In leiu of Three Things Thursday today (since it became Three Things Tuesday this week!), I am simply wishing you a very Happy Halloween! 

Since I don't have kiddos of my own yet, it's always a blast to work on Halloween and see the kids of the PICU dress up.  Most kids in the PICU are too sick to participate, but the few that do definitely bring huge smiles to all of us! 

And since I can't post pics of those kids without getting consents and legal stuff, blah blah blah, I will leave you with some pictures of Halloween the Lerma style. 

Horrible lighting, I know...sorry! But we started the night with amazing loaded baked potatoe soup...YUM!
Super excited about carving the pumpkin...and determined not to overcut the top so it falls right in like last year : )

My spooky dollar store skeletons on our kitchen ledge

Ewww. guts, guts, guts! (Sadly, this is the SAME face I've made on halloween for the past 8 years...some things never change apparently!)