Why I Do the Things I Do...

The page came two hours into my shift.  

I had been ill all weekend and couldn't sleep so I had arrived at work tired and sick.  We only had a few patients, some experienced PICU nurses along with a couple of newer ones, and finally, we had both a secretary and a tech.  I rounded on all the patients, families, and nurses, did some paperwork and then sat down and hoped for a calm quiet night.  

Not to be.  

I looked at my pager and saw..."Code Blue Jr ETA ED <5".>

After alerting my staff and giving some directions to our new tech, I called the ED and grabbed some pumps they requested and flew down the endless hall, down the stairs (4 flights!), down 2 more halls and into the ER.  I always run with a knot in my stomach for two reasons (other than the fact that I'm 100 pounds overweight and out of shape!)...first, even though I have been in (and sometimes even ran) countless codes and have proven I have the needed skills, I am ALWAYS ALWAYS terrified.  Second, I pray the child will not be anyone I know.  I mentally run through everyone and note who has sick kids, whose kids might have been out and about and I pray without ceasing all while I'm runningand wish for the 10 millionth time that my friend Donna was with me (Donna was my ANM and friend when I started as a tech but she moved away before we ever got to work together as nurses and she taught me more than any professor...I always see and hear her when I am in a code and wish for her at my side)...

In the ER, I see a crowded trauma room and hear the beeps and buzzers and murmurs of a code in progress.  Out of the corner of my eye, I note a policeman talking to a hysterical mom and weeping dad.  As always, I think of our Noah and Jean and Jeff and fight back tears.  He is always with me in codes these days.  I feel his presence and can almost see his smile.  I force back tears because there is no time for them now. But they will come later...they always do.  I hand over the pumps and ask for an update (so I can go back and prepare to receive the child into our unit if the child is stabilized).  The resident holds out a square of paper and I see terrible horrible no good numbers.  I note a baby being intubated and nod my head.  It will not be good.  

Back through the halls and up the elevator this time (adrenaline is my friend but it too has limits!!), I return to update my staff and take a phone call from our attending.  He is on his way in and asks my opinion.  I relate the numbers and he is grim.  He asks if he can bring the baby up forthwith when he arrives in about 3 minutes and I agree as if it is nothing.  Then, I hang up the phone and we all spring into action.  Like ants from a trampled antpile, we scramble in different directions, setting up the room, pulling over the code cart, drawing up drugs, hooking up a ventilator, getting out procedure carts and needed supplies.  I estimate the baby's weight and print a code sheet that gives correct doses of "code drugs".  I remember the phones will be out hospital-wide for 6 hours starting at 10 pm.  It is almost 9:30...I call pharmacy and beg for drips of things we might need, giving a verbal order and knowing the docs will write for them later.  Then I stop for a moment to utter a prayer and steel myself for the drama to come...

Down the hall comes a stretcher and surrounding it are ER nurses, RTs (respiratory therapists), residents, and THANK GOODNESS, Dr Hubbird!!!!  He is already shouting orders to me..I nod over and over and repeat "yes sir, yes sir, yes sir" praying I will not forget one!  I hand off the orders to the waiting fabulous PICU nurses and for the first time look at the patient.  A beautiful, chubby infant.  She is gray...and cold (92 degrees)...but her heart is beating with the help of an epinepherine drip and we are artificially breathing for her.  

I wonder if anyone who hasn't done it knows of the intense physical labor it takes to care for a child this sick.  It was now 9:30 and the nurse I assigned to this patient, the docs, and I would not leave that room for the next 6 hours (except for brief runs across the hall for supplies or drugs).  From time to time, I looked out and asked how our other sick patients were and checked on my nurses.  About 11, I asked our secretary to call in another nurse to help out.  Charge nurses from other floors heard what we were doing and came to offer help.  I love the staff at Palmetto Health Children's Hospital.  They are the best in the world.  

So what did we do?  We hooked the baby up to machines and monitoring devices.  We administered drugs and strung and started fluids, pushed boluses of more fluids, calculated epi and dobutamine to micrograms per Kg per minute and programed our pumps.  We pulled up versed and fentanyl and calculated milligrams per Kg per hour and programed more pumps. We manually bagged oxygen as the ventilator couldn't keep the baby's sats above 50.  We gowned up and assisted our attending and then our surgeon in placing arterial and central venous lines.  We pulled air off the tummy through a nasogastric tube.  We inserted a foley catheter and assisted with multiple x-rays.  We carefully repositioned the child for each procedure, always protecting that fragile airway.  We labeled the many lines of IV tubing and when the central line was in, we took out the IO (a device that gets pushed into the bone beneath your knee in a code to open an access line for drugs and fluids.  And yes, it is as painful as it sounds but anyone getting one probably isn't aware at the time!), cleaned the baby and the bed over and over, bagged some more, assisted in more procedures, unearthed everything the docs needed, working in a tight space and weaving in and out and under each other...all the while succeeding in keeping sterile fields sterile! We constantly assessed pulses, color, heart rate and rhythm, oxygen sats (percentage of blood that is saturated with oxygen), blood pressure...alerting the docs who were concentrating on their procedures, and obeying their orders, making adjustments in drips, recalculating mcgs/kg/min and mg/kg/hour, relaying orders to our secretary for tests, procedures, meds, and supplies.  We kept a careful written record of vital signs during each procedure, calling "time out" and checking patient identification and assuring everyone was following procedure at all times (that is my job...yuck yuck but necessary!).  We drew blood, filled out lab slips and tubed down samples to the lab for a multitude of tests.  We did glucometer checks and started an insulin drip (more calculations and double checks)!!!  We talked, we instructed, we learned, we silently prayed.  I took a few minutes to meet the parents at the elevator when the security guard escorted them up and settled them in an empty room on our back hall.  I couldn't take but a moment but I hugged Mom and promised that we were working as hard as we could and that her child was alive but that I had to go back to her bedside.  I promised to return, update and bring them to the bedside as soon as I could.  They broke my heart.  It always humbles me to see the complete trust these parents place in me and I cry inside to hear them beg, "Please do everything you can..she was so healthy..she is my sweet baby girl...please please save my baby."  I am always glad I am only the nurse and not the doctor!

The room is a mess.  The floor is littered with wrappings from syringues, sterile towels, packaging from tubing, discarded alcohol pads, and so much more.  I help the tech pick up, throw away, organize...I help the nurse rearrange, clean the baby and bed..and then alarms sound and we start all over...and so it goes until morning.  We bring the family back in a short lull in the action and update, get a history and hear what happened.  An accident.  A terrible horrible accident.  I shudder to realize (as I have many times) how easily this could be my child or anyone else's.  Things get worse and we switch to an oscillator (a ventilator that is capable of forcing oxygen into the lungs at rates upward of 500 times a minute..yes, it sounds like a jackhammer!).  Even the oscillator can't keep the sats up.  The mood is grim and the tension is thick.  No one is talking now.  We are in a serious fight for this child's life.  Most of us know though, that even if we win, barring a miracle, this baby will never talk, walk, run, play..or even make conscious movements or smile..or worse, be able to tell us she is hurting.  Still, we work without thought of anything but the here and now.  Dr Hubbird is amazing.  He never leaves the bedside.  He helps in all that we do, always directing, teaching, supporting and encouraging.  He tells us to prone her.  In a last ditch effort, we will flip the baby (which creates a nightmarish tangle of cords, lines, tubing, etc) to her tummy and reconnect the oscillator.  It is complicated to explain but in short, gravity will pull fluid, etc away from the airpockets in the back of the lungs allowing oxygen to enter.  It is a tedious procedure because we have to note every wire and line and plan the flip carefully because we cannot disconnect the lines carrying the epi and dobutamine...even a second off those can have disastrous effects.  

But, we do it, we eventually untangle, rearrange, clean up the baby, the bed, the floor, the tables, organize and restock AGAIN and YES!  Proning is working for now.  The sats began to climb.  For now, the blood pressure is stable.  There are many many obstacles yet in our path but for the immediate future, we can breathe...grab a drink and visit the restroom...albeit one at a time!

It is 4:30 am.  Leaving the child's primary nurse in charge of this patient, I make rounds, checking on and thanking the nurses who took care of their patients with no help from me and also constantly aided those of us in the heat of battle.  I spoke to parents, gave some direction to our tech and praised her for her help.  I talked at length with Dr Hubbird and the resident about concerns and parameters for making changes in drips and treatments.  Then, I sat with the baby's nurse and we compared notes, gathered all the orders and made sure we had written orders for everything that had been done and that everything was charted correctlty.  She is a newer nurse and I told her how impressed I was with her work and how proud I was of her.  

Then, at 5:30 (an hour late!) I left the floor to "huddle" with the other Children's Hospital charge nurses so we could talk about what was going on on each floor, what patient might transfer where and what the concerns would be, who might need an extra nurse and who might have an extra nurse, etc.  I have come to love that time as it brings about a solidarity to our hospital as we become a true team.  At 6:15, I sit down at the charge desk for the first time since 9 pm.    I get ready to give report to the day Charge who will arrive in 30 minutes.  The night is over.  I long for my bed.  As adrenaline seeps away, I ache in every muscle and bone and I start to shiver and realize I am still sick.  How thankful I am that Pete is picking me up because I could not drive home.  Day shift arrives and I give report with a voice that is now hoarse and my hands are noticably shaking from exhaustion. Someone hands me orange juice and I gratefully accept it.  

I again thank my staff and visit with the Mom, hugging her and trying to bolster her and love on her because she is blaming herself.  "No", I repeat, "it was an accident and it could have happened to anyone.  It was only an accident."  I know she will never forgive herself but I pray her family will support her.  I clock out and sadly realize that once again, I will be too exhausted to attend Church.  That's when the tears come.  I miss the Saints.  I miss sitting with my family.  I miss Noah.  I love my husband and my children and my eternal family.  And even though it is hard, I love being able to do what I do.