Pediatric Dream To Pediatric Nightmare

I went to nursing school for one reason. I wanted to be a pediatric nurse for the rest of my life.  I loved my pediatrics rotation in nursing school, and the time I spent volunteering on the pediatric floor on Sundays (also during nursing school).  I babysat a lot as a teenager, and worked in the church nursery for 11 years. Then the real world and real life happened.

I moved away from the Midwest to Texas in late 1985.  The hospitals there didn’t have pediatric floors at that time where I lived, so whatever the kid had wrong with them, they went to the floor that dealt with that problem.  I worked in neurology/neurosurgery, so I got the kids who were neurologically impaired/sick.  A four year old near-drowning was my first ‘real’ sick kid.  She’d never recover.  At four years old her life was over.

The next 16 years, I worked with various types of patients, including adolescent psych and general medical surgical patients in a community hospital.  In adolescent psych, it was rarely the kid who was the train wreck, considering what they came from.  I timed contractions on a 12 year old who was carrying her dad’s baby.  She was terrified (understandably) and would never be able to erase that part of her life.  I also worked with a kid whose step-dad bit his finger off because he got upset with the kid.  The kid was remarkably pleasant, and didn’t have a resentful or  defiant personality.  Wow. Survivor.

When I moved back to the Midwest for family reasons, I was thrilled to be offered a full-time job on a pediatric floor.  Once I’d finished orientation, I’d be floating to the Pediatric Intensive Care Unit (PICU) for any critically ill child, and also Neonatal Intensive Care Unit (NICU) with the preemies.  I couldn’t wait to get started.  After 17 1/5 years of being a nurse, I was finally getting to do what I’d really wanted to do.  My previous experience was incredibly helpful, so it wasn’t a wasted 17  1/2 years. Not by a long shot.

I hadn’t anticipated the horrendous circumstances surrounding the majority of babies and children I encountered.  The congenital limb deformities, ambiguous genitalia (can’t tell for sure if they were girls or boys), organ failure (and the skin color literally that of Kermit the Frog in bright sunlight), the horrendous abuse cases on babies as young as a month old, and other terrible accidents and neglect.  We did have the ‘routine’ tonsils and appendix removals, but those weren’t the norm- most of them don’t get admitted for those surgeries anymore.   Most of the kids that came through there were going to be permanently disfigured or chronically ill.  Some ended up in the local children’s nursing home.  And those NICU babies that had permanent disorders from being premature had to go somewhere when they got sick. Again.

A ten week old baby shouldn’t have a broken leg (in a tiny cast) because mom’s boyfriend got mad and tossed it off of the couch after twisting its leg.  A six pound, one month old baby who had weighed more at birth, and gone through heart surgery, shouldn’t be left in a room, tended to mostly by the household pet who would react differently when the baby smelled too much, thus alerting the ‘parent’.  A fifteen year old shouldn’t be twisted in muscle contractions, in a vegetative state due to some fluke illness years earlier.  A first-grader shouldn’t have the skin tone of a kiwi fruit because of a failing liver. A toddler shouldn’t have part of its scalp torn off from a very random accident involving a hot tailpipe, and not being seen when the car was backing up. That kid actually was lucky in a bunch of ways… staying alive with no permanent brain damage was pretty significant.  If it was on the news, I met the baby/kid in the story.

Babies shouldn’t be born three months early.  They shouldn’t be considered ‘big’ at four pounds (but considering the babies that weighed 1/4 of that, they were huge in that NICU environment). They shouldn’t be born with only parts of their heads formed, and not visited by their parents like the ‘normal’ preemies. They needed to be held and cuddled, too.  Even if they’re a mess.  They still can respond by calming down, and nestling into the arms of a stranger called a float nurse.  Don’t they deserve that?  Why did the charge nurse thank me for just treating that little partially-formed headed baby like a b a b y ?

A two year old shouldn’t have scalded genitals and buttocks because another boyfriend of the mom decided to dunk it in hot water, and hold it there. That two year old should have cried during dressing changes. The kid had no skin left on that part of its body.  The kid had already learned that crying was pointless.  That kid should have been laughing and smiling when interacting with adults- not looking for some sign of impending abuse. At least that kid was loved by the staff- and before leaving was guzzling juice and eating all the Cheerios he/she could eat.  The kid was very good at hollering and directing traffic in a high chair at the nurses’ station before being discharged to foster care.  That was a good thing. The kid got some ‘normal’ before leaving.  It’s sad that ‘normal’ didn’t happen until being in the hospital as a crime victim… at age two.

I hated when I got a call that social services was bringing a mom up for a supervised visit. This would be a mom that allowed her boyfriend to abuse her baby.  This would mean I’d have to be there to defend the baby. I hated when she showed up and was not much more than a kid herself, and had the ‘deer in the headlights’ look on her face.  She didn’t really know what was OK to do to a kid, or what her boyfriend was capable of doing. She’d probably been raked over the coals when she was a kid. That never excused anything, but it could explain some things. And for those moms, there was usually more hope in that she was teachable.  The interaction with the babies I saw was positive, when the moms bothered to show up at all. But mom was damaged as well.  It was lousy all around. I hated that my anger wasn’t justified by some monster showing up.  I just had more ‘kids’  to be angry about.

I ended up leaving for many reasons (one was my own declining health; another  huge one being the cut in hours in the summer when the kids weren’t in school giving each other all sorts of contagious diseases).  The abuse was a factor.  Injuring a child just didn’t mesh in my head.  I got very protective of those little kids.  Their crime was existing, and that’s not good enough to justify their reasons for being hospitalized. Nothing is good enough to explain hurting a kid.

Pediatrics was a good experience in that I got the experience, but overall it was a tragic mingling of chromosomes run amok, congenital mayhem, and sociopathic people in the kids’ lives.  I’m glad I worked there, and saw what is out there.  But my dream job ended up being a horrific showing of the worst of things that can happen, either biologically or by psychopathy, with an innocent baby or child on the receiving end.

I have a lot of respect for the vast majority of the nurses I worked with on that pediatric floor, the PICU, and the NICU.  It tore me up.  I know those other nurses cared as much as I did, but they handled it differently.  Most had their own families.  I was single and didn’t have kids, so there was no ‘balance’ of how kids should be, living at home.  I didn’t have distractions to make my life less one-sided.  It was all about those babies and kids.

Something for the nursing students and new nurses out there: You don’t see the full job when you are a student.  When you are new, everything feels crazy for up to several years (there is a LOT of information to put together to make you a fully functioning, competent nurse).  Don’t judge what you think you want to do based on what you think it really is.  Wait until you know your strengths before deciding what is the best place for you.  I spent 11 years working in a church nursery, and went to nursing school wanting to take care of precious babies.  I just hadn’t anticipated how they got to the hospital.  Keep an open mind about where you fit in the nursing profession.  It’s never how nursing school shows it.  I hated geriatrics in school, and loved my nursing home jobs as an RN.  I didn’t think much of drug and alcohol rehab or psych when I was in school, but truly enjoyed my five years combined of both.

You don’t know what you will like until you really know what it is you’ll have to do. 🙂

Why I Didn’t Die During Nursing School…

I was 19 years old when I started RN school.  And a very young nineteen.  I’d grown up in a conservative church, and was an only child.  I really wanted to be a nurse, and was determined to get through it, but I’m not sure how that actually ended up happening.  I was horribly shy when it came to dealing with the patients when I was a student.  My first semester of clinical classes began in September 1983.  A lot has changed since then…

My first several patients during clinicals were hemorrhoidectomy  patients.  There I was, never  having seen a naked person, and I had to look at their butts.  WAY into their butts.  Uh huh.  I’m sure nothing about me exuded confidence, so starting with the butt was probably a safe place to put me, but I was mortified, especially since most of them were men.  Butts and balls to a naive nineteen year old was almost the death of me.  I finally had a chat with my instructor (a very nice instructor, but she was also intimidating with her knowledge).   I needed a different view.

I asked if I could possibly have a different type of patient.  She said sure. No problem. So when I picked up my next assignment to prepare my careplan, I saw the words ‘esophageal varices’ in an elderly woman.  That meant that blood vessels in her esophagus had ‘blown’ and she’d likely been critically sick from blood loss.  I was sure my mere presence in the room would have her spewing forth all that kept her alive, and I’d kill her within minutes, even if indirectly.  I was terrified.  I asked my neighbor (a pediatric cardiologist) about said varices. He told me that it was possible she could bleed to death in minutes if they reopened.  Not helpful.  I got busy with my careplan,  and  every horrible thing I’d already heard or read was confirmed.  The woman was doomed.

The morning came for me to actually go talk to this lady (this was back  in the day when we did all care for the morning for our assigned patient- not following someone  else around while they did it).  I stood in the doorway trying not to pass out.  My instructor came up behind me and physically pushed me into the room, whispering “You actually have to talk to them”…. I was thinking ‘ just shoot me now’.

What I found was a very alert, sweet woman who was cooperative, and didn’t have any signs of getting ready to exsanguinate in front of me.  I said hello, and she didn’t die.  I did my nursing student assessment, and the woman didn’t seem to suffer any ill effects.  Huh.  So I’d been a bit more freaked out than necessary.  I had the same lady three different days. I even ended up washing and rolling her hair- which she loved.  Anybody who knows me is rolling over in hysterical laughter at the thought of me doing anything positive for someone’s hair. I can barely keep mine brushed.

The next horrifying event was bathing a comatose MAN.  I’d have to TOUCH him.  My instructor seemed to sense my incomprehensible stupidity (inexperience?) and was in the room during the whole process. I didn’t kill him either.  The familiar lightheadedness was with ME the whole time, but most importantly the patient didn’t get worse.  OK. Check that off the list.

On to the big stuff.  I had to give an enema. The ‘serious’  kind with the little soap packet and the big bag that got hung on an IV pole.  My instructor was in on this as well.  I got the soap into the bag, and was getting the water to the right temperature before I filled said bag. I had the clamp on, so nothing would leak before it was supposed to find its way into the lady’s back door.  I put the little packet of lube on the  business end of the tubing.  Gee, this was going well !

Then my instructor suggested it might be more comfortable for the patient  if I let the air out of the tubing before I brought it out to the patient.  Well, that sure seemed like a good idea- no point in giving the woman gas. SO, I unclamped the clamp on the tubing, and waited for the air to exit.  What I didn’t expect was the lube packet being shot across the room from the force of an entire length of tubing full of air.  It was like sniper training in its force and trajectory.  I don’t know where that packet ended up, but I know I was ready to die.  My instructor was very professional, but I think I remember a slight grin. The patient looked a bit nervous, along with slightly relieved to know that everything was being supervised, and this nineteen year old pre-rookie wasn’t being turned loose on anyone.  I got more lube, and the enema went in, and came out, just fine.

I got through my fundamentals class  without killing anyone.  THAT is why I didn’t die in nursing school.  Nobody got worse as a result of my care.  I started out with a negative confidence score, and got to the point where I didn’t anticipate disaster.  That was the biggest perk in getting through fundies.  I had a shot at becoming competent !  All nursing school really teaches is how not to kill someone on purpose.  The experience and finesse come later.  I was at least on track !  I’d gotten through the checklist of skills, and passed tests with solid grades (anything below %85 was a D; I was usually in the %90s).

In the 20 years I worked as an RN before becoming disabled, I got past the shyness fairly quickly.  I just didn’t have time for it.  I needed to get in, get information, give care, and get out.  On to the next patient.  Asking about the color and consistency of someone’s poop was as much a part of my day as parking the car.  I had entered an ‘intimate’ profession.  I had to know things about the patients that they didn’t tell anyone but their closest friends and relatives- and some things that they didn’t even (or especially) tell them.  I had the book knowledge, and I fairly quickly got through the ‘people skills’ that make nursing work.  Without them, there’s no chance at giving good care.  Without getting up in someone’s business, I couldn’t know what they needed.  That trumped my insecurities EVERY time.  🙂

Diss Auto Gnome Ee Ya….. So there !

Dysautonomia.  Fancy word that means my autonomic nervous system (‘automatic’ functions; nothing that is controlled by me) is whacked.  I was formally diagnosed in 1996 when I flunked a tilt table test. My blood pressure tanked to 44/16, and I was still not totally unconscious. The doc told me that when I completely passed out (which had led me to the testing) my heart may have just taken a break for a second or two, and the thud on the floor jumpstarted me again…scary thought).

My blood pressure, heart rate, respiratory rate, and temperature regulation are all messed up. Pain and  being overheated are the biggest triggers, although having anything get the ‘fight or flight’ response going makes it go weird.  I’m not much fun when that happens.  Tipping over got me put on disability, which was (and is) the pits. I miss being a  working nurse (I keep my license active; I earned it, and it’s mine!).  I do not like being a patient (and I’m not that good at it, in spite of a fair amount of experience).  I tend to take care of any nursing ‘jobs’ I can when I’m a patient, and the nurses aren’t always that thrilled. I’ve gotten better about that…sorta.

Nobody is for sure what has caused this.  Some types of this disorder go along with other diseases, like Parkinsons or multiple sclerosis. Sometimes head injured patients have ‘brain stem storms’ which are similar, but those are generally confined to those with serious, life altering brain injuries.  Autonomic dysreflexia is similar. Diabetics can get autonomic neuropathy and have similar symptoms. Sometimes nobody knows.  Sometimes it progresses until the person dies (Johnny Cash), and sometimes it just sort of coasts along.  It looks weird regardless.

I was living with a co-worker in a house with no central air conditioning (in Texas) and hardwood floors when I started having symptoms that were enough to be noticably abnormal (i.e. passing out and hitting said floors about 10 times in two weeks). I had a bedroom window AC unit, but during the day, it was box fans or bust. In July.  I initially blew them off as ‘stress’. My co-worker (another RN) told me there was nothing ‘stress’ about what was going on- I had something physically  wrong, and needed to get it diagnosed and treated before I ended up getting really hurt.  Up until then, I bounced fairly well, and aside from some bruises and a concussion, I would just wake up on the floor, usually with my co-worker sitting on the floor next to me after being awakened in her room down the hall from my body whacking the floor.  She said I looked like someone was beating me, and since she was the only person around me on a consistent basis, it didn’t look good for her !!

So, off to the neurologist, who did some tests, and then to an electrophysiologist in San Antonio (60 miles from home, where I’d drive myself back and forth for the consults with a cardiologist, another neurologist, and the electrophysiologist…. basically they were looking for heart rhythm and brain abnormalities).   The electrophysiologist figured out the problem with passing out, and my neurologist back where I lived figured out some medications to help me keep working. Things had been pretty dicey with that, and my boss was ready to cut me loose. I was horrified.  I was tested for all sorts of things, but dysautonomia was the official word.  There are various types, and I seemed to have a mixed bag with neurocardiogenic syncope (I keel over if my blood vessels in my legs dilate and suck the blood from my brain (more  or less) , causing me to pass out), and some orthostatic tachycardia issues (POTS for the informed) where my heart rate goes up abnormally when I stand upright for too long.  Then there’s the strange stuff with heat that makes my blood vessels swell, and there’s no compensation with my heart rate, and I eventually keel over, after a very patriotic display of bright red cheeks, white around my mouth, and  bluish lips. If I don’t get it controlled at that point, I’m out for the day. It’s all quite exhausting.

It’s weird.  It’s misunderstood, and it’s taken my main sense of purpose – working as a registered nurse. I have been an RN for 27 years, and miss it terribly.  In some ways, it’s been good I’ve got that license to make sense of my own stuff.  But since 2004, I haven’t been able to work, and I do well to get the basic things dealt with at home. Laundry and cooking are quite painful, so it all gets done in ‘batches’.  But, it could be worse. I’m not in some retirement home.

At my last job, I was shipped to the ER between 10-12 times in the last 6 weeks or so that I worked there. Finally enough was enough (and the ER they sent me to was really snarky; if they didn’t understand it, it must not exist, so I was treated like the dreaded frequent flyer – even though I hadn’t sent myself there, my boss had. They were  very cruel at times).  My primary doc agreed that work wasn’t working. There was no way to know when I’d be more prone to having the episodes happen, and since I was (and am) in constant pain, there was always that trigger waiting to blow up.  If the thermostat was comfortable for everyone else, chances are I’d be burning up.  I now have an ice vest that I wear to leave home on the days I have MD appointments, or the one day a month I do major grocery shopping, which finishes me off for the rest of the day because of the pain that causes.

But I’m still relatively independent. That’s important to me. Even when I was getting chemo for leukemia, I’d drive myself to the chemo appointments and Neupogen/Neulasta shots. I wanted to do it on my own.  I’ve had to call my dad for enough stuff, that if I can take care of something, I prefer to do so (he would help in  a second if I asked him).  I rarely drive (have killed two batteries for lack of use), and know if it’s not a good day to go.  I shop in the middle of the night, so it’s cooler. I’ve had to make some adjustments, but that’s OK.

Anyway, if you see someone who has weird symptoms, encourage them to get help.  I got another 8 years of work from the right medications. That is priceless.  Don’t assume that just because you don’t understand it, it must not exist.  Too many people do that.  That can be dangerous.

I Miss Nursing, Really, I DO !!

When I was still working as a registered nurse, I don’t know how many times I heard, or how many times I said, “I wish I could retire NOW”.  I graduated in 1985 from an ADN program, and very soon after getting my license (we had to wait for snail mail back then) moved away from home to begin my career in a state/city 1200 miles from home.  I was so excited!

At first, I was the typical newbie. I was idealistic and knew just enough to not kill someone on purpose. That’s all nursing school teaches. It takes experience to make someone ‘good’, and that takes time and enough brain cells rubbing together to ignite a spark now and then.  Those first few years, I loved all of my patients, and everything they did was something to learn from.  The poop and puke, not so much, but I had a good gag reflex, and could smile through anything.  I didn’t even mind being elbow deep in someone’s butt sore if that’s what needed doing. And I was a supervisor’s dream- not married, no kids, and phone always turned on with no answering machine.  Yep. A huge target from the get-go; I’d pick up extra shifts, even at the last minute if I was home and answered the phone.

Then I grew up. Many things became decidedly less amusing.  The call-light jockey topped the list. When I found out that the spiel in nursing school about the call light meaning I didn’t ‘meet my patient’s needs well enough’ was a bunch of hooey, I learned to hate that thing. Some people are just so scared, or so regressed into the self-centric view of the world when they’re sick, that they need some sort of contact, a LOT.  I never minded the legitimate things patients needed, or even wanted.  But there was always some nitwit who had the audacity to complain about the brand of orange juice the hospital served.  Really?  And I can do WHAT exactly, at 2:00 a.m., about that particular life-threatening issue?  Maybe run out and grab a few nice juice oranges, and get to fresh squeezing them for ya? Eh?

Most patient families were very nice, and appreciative. They knew the real reason they were there- to support someone in getting well.  And then there were the invaders.  These are the families that send out messages to all known living relatives within a single day’s flight away that there’s free coffee in Junior’s room, and the nurses have nothing else to do but bring refills.  Though they do complain about the lack of service when there’s a Code Blue in the next bed. Go figure. Lack of pulse? Lack of coffee?  Tough call.  I’ll get back on that one.  But spell my name right if you’re going to take it to the supervisor, got it?  Thanks a bunch! 

 Doctors were another part of the equation. Most were great to work with, and knew if I was calling at 2:47 a.m. that it wasn’t to keep me awake;  something wasn’t good, and it couldn’t wait for 3 hours when he/she might start drifting in to do rounds.  I couldn’t just leave a note on the chart. One or two didn’t return my calls at all. That would make me so mad. Easy enough to fix that one- call the doctor he/she had ordered a consult from, and let them know that I knew  they weren’t the primary doc, but since he/she wasn’t returning my calls, did they want to do something about the guy having seizures who had never seized before? No? Well OK, just thought I’d ask.  That usually got the doc I really wanted to discuss the matter with to call back (after a brief call from their ‘real’ colleague)  apologizing for the phone upstairs not working right.  Uh huh.  Blame the phone. It worked when the other doctor called…

There was the one neurosurgeon who had a vast reputation as both a superior physician and world class asswipe.  One of his patients had the hiccups as a side effect of one of the IV meds we had to give them.  And every last doc but him would order a bit of a sedative to get rid of them; they’d go on for hours if nothing was done, and it was cruel and unnecessary.  But I had to call and report the hiccups anyway (even knowing the patient wouldn’t get anything to help) since  it was the patient who was miserable.  The asswipe doc told me there was nothing to do for hiccups but put a paper bag on someone’s head. SO, I wrote the telephone order, IN THE CHART, “Paper bag to head as needed for hiccups”, and signed/dated it.  He had to cosign that order. He’d given it.  He was still a jerk after that, but at least he’d address his patients’ needs a bit better.  This is when we all still used pen and paper charts.

This was about the time I learned to clean up diarrhea from one end of the bed to another, and then go on dinner break and eat chili. No problem.  In a pinch, I’d use a little kidney-shaped puke pan to warm up my Lean Cuisine Chicken Chow Mein…kinda looked like it belonged in there, to be honest. Made the docs nuts to see me in the back room with a fork in a puke pan.  But then they got to know me, and they were glad that’s all I’d dreamed up.  🙂

One of my  horror docs was a real genius who thought if he didn’t know about something that meant nobody would call and bug him about it. *rolling eyes*  Picture this:  a very sweet, but cash strapped guy who was diabetic, and could either get his diabetic meds OR the test strips to check his blood sugar. He wasn’t non-compliant for fun. He chose to get the medicine.  He ends up in the ER with some nutso blood sugar in the 600’s, and the ER gives enough insulin to get it to the mid-400’s (should be about 70-100 for the normal person- and I’d taken care of many diabetics who ended up permanently vegetative for ultra high or low blood sugars; nothing to joke around about. This guy wasn’t in that range, but I wanted to keep him there). The guy is awake, and with the program, so stable enough for the floor. OK, fine. The dude gets to the floor and I’m checking orders. Nothing for blood sugar checks after getting IV insulin, and still not in a normal (or tolerable) range. Lab isn’t due for several hours to check the regular blood work.  And I’m supposed to sit on this guy not knowing if he’s tanking, or has bounced high again after the insulin’s duration maxed out?  I don’t think so!  SO I call Dr. Genius, and ask about blood sugars since I’d checked one on admission to the floor, and it was still rocking in the 400’s (he was a bit irked that I’d checked it). There was no sliding scale insulin (the dose depends on the blood sugar, taken right before giving it), no orders to check the blood sugar (which would be standard), and the guy was still too high.  The MD I would never subject a corpse to responds “If I don’t know about it, I don’t have to fix it”.  *crickets*  I got nothing for that one (aside from an immediate call to my supervisor to let her know).

People really need to know what nurses have to deal with on the phone with some doctors. It’s nuts. Then they’re supposed to be diplomatic to not make the doc ‘look bad’.  I learned that his image is not my problem. If a doc wouldn’t give an order to deal with something, I’d let the patient know. No problem.  Fortunately, the vast majority of doctors I worked with knew that it was a team effort, and I was the part of the team that meant THEY didn’t have to wipe butts, serve coffee, have their arm halfway to Mars inside someone’s butt sore, get spit on, duck flying objects, referee family fights about Grandma being resuscitated until she turned inside out, not be able to pee for 8 hours easy, and sometimes 10-12, and on and on. Most doctors knew that the nurses had their backs.  I was up all night, it didn’t make any difference to me if I had to call someone, but the good ones left me orders for a lot of the ‘what if’ situations, so they knew that if I was on the phone, something wasn’t OK.  I didn’t send him/her to med school, and it wasn’t my fault he/she was on call!

But I miss those nights (and days).  They were my life.  Once a nurse, always a nurse.