Burned out?

How can I go from energetic, enthusiastic--albeit realistic-- to grouchy, tired, and jaded so damn fast? Yesterday at work I had last pick of assignments, and I got the bad pair. Well, not the only bad pair, but the worst one. The guy who has been there forever (we're talking five months and around 20 trips to the OR), belly still open, who along with his family is exceptionally needy (and who could blame them?). Then, two doors down, we had the 70-something gal with stage IV cancer (recently diagnosed after the breast cancer came through her skin) who is on a ventilator. Seems that "everyone" knew she would not be weanable, and the pulmonary team tried to share this with her and her family pre-intubation, but then the gallant oncologists swept in and announced their chemo could surely work wonders, a few chest tubes would "fix" those pleural effusions, and she'd be a breathing champ again. The ventilator would be a temporary thing, and before long she would be sailing out in a wheelchair.

After many a trial, her spontaneous tidal volumes remain around 120-150mL, which means she has to breathe about fifty times a minute to get a decent minute volume. Those chest tubes continuously drain large amount of serous fluid, which come from endless springs within her cancer-ridden lungs. Is she supposed to wander around with those things sticking out of her and bubbling away for the rest of her *long* life?

To top off the whacked-out-ness of the situation, the oncology team is starting to think realistically about her inability to wean from the vent. What do they say?

"Time to talk to the family."

"We should really talk to her family before we do more chemo as planned today."

Hello?!? This woman is totally awake and completely alert and oriented. She writes us complex notes all day long. I reminded our pulmonary attending of this and he said, "Okay, well does she have a living will or power of attorney?"

"Maybe, but it doesn't matter right now because she can tell us what to do!" I reminded him.

People seem to think that just because a patient is on a ventilator, they are incapacitated. This is not true! I reiterate this during rounds and the resident says he'll come back and talk to her.

A few hours later, he and the fellow enter her room. They explain her situation briefly, including the fact that she may need a tracheostomy if she is going to stay on the vent much longer. They say, "What do you think?"

I count about three seconds before they turn to me and say, "She's overwhelmed. She's not processing. We'll come back another time."

"She hasn't even had time to get her Sharpie in hand!" I exclaim. "Give the woman a few minutes!"

It is hard to be patient in the hospital, when there is so much to do. Patients to be admitted, lines to be placed and changed, families to be updated, films to review. But sometimes you must be patient, stand at the bedside, and wait the necessary time for the patient to find her voice.

For me, it is morally distressing on many levels to care for an elderly patient with advanced cancer who is being mechanically ventilated. From the questions they ask me, it is obvious that she and her family do not have a sense of the big picture of her total health. I try to give it to them piece by piece, but if it doesn't jive with what the various teams of physicians are saying, that only serves to confuse them more. Even framing it as, "Here are some questions you might want to ask... Here are some things to be thinking about... etc" seems like banging one's head against a brick wall.

Yesterday at work, several people commented that I was not my usual cheerful self. Usually when I announce that I'm feeling grouchy, my colleagues say things like, "You're never grouchy," "Impossible," etc. Not yesterday. I hope it's just a passing thing, but the fact is these things weigh heavily on a person.

Probably what makes it the hardest is that only about forty percent of our nursing staff seems to recognize that we must share these burdens together. The other sixty percent just does everything they can to stay away. This doesn't feel very cooperative or facilitate feelings of happy, we can do it team-ness!

This isn't my best writing today, this is just a tired, frustrated nurse who wonders sometimes how to keep going at all, much less with a good attitude. Part of this may be coming from the fact that I'm currently reading Suzanne Gordon's awesome book, "Nursing Against the Odds." The book illuminates so many complex issues in our health care system and examines them specifically as they relate to nursing. While at times it is uplifting and inspiring, it sometimes reads like a laundry list of (seemingly) unfixable problems that are enough to make any nurse crawl under a rock and not come out! Anyhow, I highly recommend the book and hopefully will have some forthcoming more thoughtful posts born out of this good reading.