"Have You Examined the Patient!?"

Surgeons tend to get a bad rap amongst nurses.  Not necessarily in my institution necessarily (or consistently), but in life, in general. 

They can be known for bad bedside manners. They can be known for being short (in personality, not stature).  They can be known for talking down to all non-surgeon personelle. 

And then there are the rare but fine (oh so fine!)  moments, when one of them just says something utterly ridiculous that you can call them out on!

What was even sweeter about my interaction with a particular surgeon this week, was there were 3 of my collegues listening in on my phone conversation.  As I hung up, they all bust out laughing, and couldn't believe what they had heard.

So enough setting up the story...onto the good stuff!

I had been caring for a four year old girl who had cerebral palsy and several other medical problems. She was severely mentally and physically disabled, was completely non-verbal, can't fix or follow objects, and was definitely on the small side of the growth curve.  I know that's a lot of info, but it comes to be important in a bit.

She came in for pneumonia, but I noticed that she was malnourished, and recommended consulting Pediatric Surgery for a G-Tube for feedings. I was actually shocked that up until this point she had been fed by mouth for so long!

Looking through her chart, she had previously had a swallow study showing that she was aspirating (which was just as I suspected), so this further built my case for needing a GT.

I placed the call, told the surgeon why we were consulting, and he said he would go see the patient later in the day and get back to me.

Just as I was getting ready to leave work, I get a phone call. Reluctantly I picked up, and was so glad I did. 

The conversation went like this:

Surgeon:  "So I went and evaluated your patient.  I also talked with the mother for a bit, and we are not going to place a GT.  She doesn't need it."

Me:  "Umm, I'm sorry, why do you not think that she needs it.  She is malnourished, she has a swallow study showing that she aspirates, and given her underlying medical problems, none of this is going to change anytime soon."

Surgeon:  "Well the mother says that the patient is able to tell her when she is thirsty, and mom gives her water to drink.  She also says when she is hungry and she will get an apple and eat it. She's been doing this for the last four years, and while she may be on the smaller side, perhaps the mother isn't giving her enough nutrition which we can educate her on." 

Me:  (let me preface that I was BAFFLED at this response!) I simply stated "I understand that you had a conversation with the mother and were given that information, but did you examine the patient!?"

This took him back a bit, and he stumbled over a few words and then said, "Well, yes I saw her." 

More adamently I said, "This patient is completely non-verbal...why would we think that she is verbally telling her mother that she is hungry or thirsty!?  She is severely contracted and does not have purposeful movements, so why would we think she would say she wants an apple, reach for it, and then feed herself!?  I understand what the mother told you, but if you spent five minutes evaluating the actual patient, you would understand the reality very clearly."

*This was the point in which my co-workers were laughing b/c I was so in awe of his ridiculous reasoning that I was definitely firm, but remained very calm*

He didn't particularly like this (I'm assumming), because he got really quiet, then didn't really say too much. 

At the end of the conversation, I gently reminded him to go back to the patient, do a thorough evaluation, and then come to a conclusion on whether this child was safe to eat by mouth, and more importantly able to take in the appropriate nutrition that way. 

He agreed, and then said that he would talk to his attending and call me in the morning.

The next morning I get a text page from him saying "Discussed with attending. We will place GT in 4 weeks.  She will need imaging prior to that."

Short, sweet and to the point.

And yet such a sweet, sweet point made by me! 

Just another lesson learned in the importance of truly evaluating your patient. And yes, while parents are a wealth of information most times, sometimes they don't live in a full reality.  It takes our medical evaluation, studies, and judgement to help determine what is best for these patients.

Score one for the Nurse Practitioners...lesson learned for the Surgeons! 

Exhaustion: PICU vs Pregnant!

Hi friends!  I know, I know...I've definitely fallen off the blog wagon. 

The holidays came and went so fast (don't they always), and now I'm still here thinking now's the time to jump back on.

But then work happens and it's been SO crazy lately!  Tons of sick kids equals tons of crazy busy shifts. Which leaves me just flat out exhausted on my days off.

Oh, that and the fact that I'm pregnant!!  Really, I think that's the major contributor the extreme exhaustion, but still...the job isn't completely innocent : )

For those of you that personally know me, you know this has been a very long journey to motherhood.  Four years of dreaming, planning, praying and hoping.  Four years of countless doctor appointments, about a trillion blood draws and medications, and a hormone imbalance and severe clotting disorder diagnosis later, and here we are!! 

So of course I had to start a pregnancy blog that I hope to continue onward and document our little one has he or she grows.

And when I sit down after a really long day in the PICU, I can either get on and blog about how I didn't sit, eat or pee for the last 12 hours, or I can relish in the fact that I'm pregnant and document that amazing journey.

Yeah, guess which one generally wins!?!? (if you're interested: www.littlelerma.blogspot.com)

But regardless, I still love my first blog baby.  And I am still madly in love with the PICU.  So while I may not be as present, or have as many fun or funny stories, I'm not going anywhere. 

Just thought you should know.  Because really I know how patient you all are. And since most of my readers are either family or other nurses, I'm grateful that you just get it.

Shoot, my nursing and APN friends probably log on every great once and awhile thinking, "Oh my schedule is so crazy...I don't have time to read blogs!" only to find out, neither does the writer.  So at least we are on the same page ; )

I do have some stories in the back of my head that I want to share.  And I do have some topics that keep getting asked about (eg: DNP, picking grad schools, studying for boards, etc) that I want to address as well.

So stick with me and we'll get through this crazy, busy life together...one slowly written blog post at a time.  And if you're in the PICU like me, you wouldn't want it any other way!  What's life without some busy, without some crazy!?!? That's PICU at its finest!

Merry Christmas!

Last year I had to work Christmas Eve and Christmas Day, both 12 hours shifts that turned into about 15 each. 

This year I got a better deal and just had to do Christma Eve.  It was supposed to be a ten hour shift but in true PICU Christmas fashion, it turned into a 14 hour. 

I don't know what it is about the holiday times, but the week or two leading up to it seems so chill.  And I think, "Oh nice, for one year the PICU will be quiet on Christmas!"  And then the holiday hits and it almost knocks you out.

Yesterday was one of the top 3 worst days of my APN career (only in competition with last Christmas Eve in which we had 16 patients with no other APN or fellow to help me out, and a day last November that 3 of my patients died in 12 hours!). 

It's rough having bad days at work.  It's hard not being able to eat, drink or pee for such a long time.  And yet I always have to be reminded of what it is that I'm doing.

I'm working in a PICU that is filled with sick kids, and families that are hurting.  At a time when they would love more than nothing else to be home with their little ones opening presents, drinking hot chocolate, and watching Christmas movies, they are instead in a hospital.  In a PICU nonetheless.

And so it makes my horrible day so much less horrible.  It's all about persceptive.  And it's important to keep that in mind.

So with that, I hope you have a Very Merry Christmas!! And a special thought goes out to my co-workers who are taking care of our precious little ones today in the PICU.  You are truly a light in this world!

Old PICU Friend, New PICU Role

For the last week I've been taking care of a 4 year old, who I was his primary nurse from the time he was 6 months old!  He was in and out of the hospital (more in than out) from the time he was 6 months until he was 3 years old.  And I absolutely loved taking care of him, watching him grow, and helping him get better each time.

So I was really excited to see him last week when he was admitted to the PICU (although sad he had to be there for health reasons).

And let me tell you, while I have been very aware of the differences between my role as a Nurse Practitioner, and my role as it was as a nurse, this week made those differences even more obvious.

When my boy came in I was able to spend 12 hours at a time with him.  We read a lot of books. We watched a lot of Sponge Bob.  We took walks in the halls.  We just spent a lot of time together.

But now my role is so different.  Even though I may be in the unit for 10 or 12 hours each day that I work, I don't get to spend it exclusively with him.  And some days when other kids are much more sick and need much more of my time, I may spend 20 minutes with him at most!

What a difference!!  While nurse practitioner may share the word "nurse" it truly is a different world than bedside nursing.  And while I do love my job as an APN, there are some things, certain things, just like spending time with this sweet boy, that make me miss being at the bedside.

So on the days that it seems like I'm not able to impact this one boy in the same way that I once was, being able to make him smile and laugh when nobody else could, I have to remind myself that with this new role comes new ways to make impacts. 

And while I'm still trying to figure out what that exactly means, I will continue to enjoy my role as an APN...and squeeze in any extra minute I can to read Dr Suess books with my precious little boy!

Customer service at its finest

I love great service. I love giving great service.  And I get even more proud when I see great service at work.

Since I've been working so many 4pm to midnight shifts lately, which typically means I'm leaving the hospital around 1 or 2 am, I've been taking the free shuttle from the hospital to the parking garage.

I work in an inner city hospital and while it's not in a "bad" part of the city, it definitely has its moments of crime there.  So anytime I can not have to walk the 0.6 miles to the parking garage in the middle of the night, the better.

There are several different shuttle drivers that work the night shift.  But lately I have found my favorite.  His name is George, and he is the friendliest, older gentleman.  Not only does he pick me up at the front entrance and drives me to my garage, but he goes above and beyond.

Once we pull up to the garage he always asks what floor I'm parked on (I'm thinking b/c he wants to know approximately how much time to expect me to come out).  He then tells me, every time, that he is going to wait right at the entrance until he sees me pulling out.

And everytime I pull my car out of the garage, there is he waiting...big smile on his face and waving his hand out of the window. 

It's nice to feel taken care of.  It's nice to have your own personal security guard taking you to your car, and making sure you get out safe.  It's just nice to get great service. 

And while great service is what we strive for at my hospital, truly great service is what is being given my George, the shuttle bus driver!!!  Thank you for all you do (this is a general thank you, b/c I'm positive he does not read my blog!).  You are a reminder to us all to not only provide good service, but to go the extra mile, go above and beyond, make a difference, and deliver exceptional service!

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!

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!