THE NIGHTINGALE JOURNALS

A/N: I'm finally admitting to the world that I'm a First Class Dork. I'm the only one in the fandom who does silly A/N at the beginning of the story anymore, so for the sake of being less dorky, this will be the last one I do. I may be a dork, but I don't want to be that dorky.

Things I own: Customized Alice in Wonderland Keds flats that my bb sister gave me for Christmas, based on the Tenniel sketches. PERFECTION.

Things I don't own: Anything Twilight. It all belongs to Stephenie Meyer.

Thanks to my beta, Trinity/TFX, who loves Rob in navy blue as much as I do, and to my pre-reader Ladyeire72 for making sure I don't go overboard with the heavy. Thanks also to lupin4tonks for trying to beat the difference between lay/lie into my head, with little success.

CHAPTER TWENTY-FOUR: I NEED A LIFESAVER

It's one of my rare days apart from Bella; she has Pediatric Advanced Life Support renewal certification today. She grumbled loudly when the alarm went off this morning, muttering curses about it being insane to try to function at this time of day. Since I have to go in early for rounds, I'm up and almost out the door by the time I guarantee that she is genuinely no longer sleeping. I wouldn't exactly call her awake, but she's as good as she's going to get without caffeine pumping through her veins. I bring her venti Americano to the bedside, and sit beside her as she stretches.

"Cullen, you got me Starbucks? Really? God, you spoil me. You must want sexual favors or something."

"Have I ever had to bribe you for sex, baby?" I chuckle into her ear as I kiss her neck.

Instantly, her hand finds its way into my hair, pulling me closer to her. "Can I just sex you up in bed, stop your heart, do CPR, and then get recertified? Do I really have to spend the day at PALS?"

"Well, I'm a little larger than your average child, and you won't be able to intubate me or put in an intraosseous line."

"Sure I could. I bet you'd hold still for me."

It's way too early to be laughing this hard; how can she be this funny when she isn't even awake?

"I'd do just about anything for you after you glamorize me with one of your kisses."

So what does she fucking do? She gives me one of those kisses. The kind that make me forget everything I know, and focus on nothing but the sensation of her lips on mine.

"Keep that in mind when I drag my ass home after this day of hell. I'm going to need some good, hard, Dr. Cullen brand TLC."

"Oh, I can handle the hard part. Nothing to worry about there."

She kisses me again, and I feel her hand patting around my lap, looking for my cock. I grab her hand and put it right where she wants it to be—right where I need it to be—and I press down. We moan simultaneously.

I'm already cutting it a little close this morning. Typically, I like to get in before all the residents, in case they have questions, and to make sure that I'm prepared for rounds. I pride myself on my ability to give brief but thorough reports on each patient. I review strategy in my head.

I know the patients really well right now. There were no admits last night. It isn't the end of the world if I'm not there to answer every question the residents have. I have a few extra minutes.

"Edward? Are you all right?"

I must have paused a bit too long. I gently take the cup of coffee from her hand, set it aside, and lay her down on the bed. Quickies can be good, too. She looks at me with a mischievous grin, and it's all over.

~xXx~

As we move through rounds, I keep getting texts from Bella. They're naughty, of course, but also hilarious. It's all I can do to keep my erection well hidden. Once again, I'm incredibly grateful for the fact that I get to wear a long lab coat to work, or everyone would know my little secret. Well, maybe not little, but hopefully still secret.

I feel my phone buzz over my ass, and I quickly pull it out to read her latest naughtiness. She is going to be so sorry tonight for teasing me so agonizingly. Vixen.

OMG, E, DY-ING

I quirk an eyebrow in response, waiting for her next text to explain.

Quote: New rules say all compressions s/b HARD + FAST + DEEP. Their words! Srsly! Trying SO hard not to lol!

As I listen to the cardiologists drone on about their latest miracle patient, I quickly reply to her.

Phew. We're both safe. 'Cos that's EXACTLY HOW WE ROLL!

I smirk to myself and wait.

Better be hard-fast-deep in about 6h 2min.

Have I ever NOT been?

How the fuck do u make me want u via txt? Perv.

Look in the mirror, Swan.

THEY JUST SAID MAKE SURE 2 USE FEEDBACK-CLOSED LOOP COMM! I HAVE SOME FEEDBACK 2 GIVE U. RN. JS.

U r an evil harpy. I'm in rounds! Ttlly hard. Jesus.

I need your compressions. Right fucking now.

5h, 57 min.

NOW.

Pay attn. You'll need those skillz l8tr. JS.

I fucking hope so. :)

Bet on it. Now, pay attn.

Yes, doctor.

God, it makes me hard when u say that.

RAWR. Bye, hotstuff.

ILY. JSYK.

Samesies.

I glance at the time on my phone. I can't fucking wait another five hours. I take a deep sigh, and steer my direction back toward the cardiologist. I smile secretly to myself and realize I haven't really missed a thing.

~xXx~

A few hours later, I'm in the dictation room, reviewing my tape. Just being in this room once again is enough to make me want Bella. I remember her flushed, excited face when I pulled her in through the door, and the way she dove at me in the chair. I do my best to sequester those thoughts in another part of my brain, with minimal success. I press play on the recorder. I'm surprised when the voice that erupts from the speaker is not my own.

Edward, you were so naughty earlier, making me want you so badly.

Bad boys do not get what they deserve.

I, however, am a very good girl, so I get exactly what I deserve, and that would be you.

Her voice is laced with this sexy rasp, and suddenly I'm rock hard, imagining that Bella is sucking on my cock once again. Christ that woman is building me up so much I'm going to come like an atom bomb when I see her! I almost feel like I need to apologize to her in advance, because we are not going to have a gentle lovemaking session.

I'm going to make it as hard/fast/deep as I possibly can.

She isn't going to know what hit her.

I give up on dictation, because that is so not happening right now. I check the time; it's too early for Bella to be done with her session, but late enough that I can head home. I let McCarty know he can page me if he needs me, and I'm out of there in less than five minutes.

As I drive the Volvo toward home, I realize that I'm taking advantage of my time apart from Bella by thinking of Bella, and plotting about Bella, and doing things for Bella. It's pretty safe to say that I don't really have time without Bella, because I feel as though she's always next to me, even when I can't see her. That sounds a little creepy, but the woman has wormed her way into my soul, and I have learned to accept that this is simply how things work now. I have no choice in the matter any more; in fact, I never have.

I decided a few weeks ago to create a playlist for Bella's iPod. I want her to hear all the songs that remind me of her. We enjoy a lot of the same types of music, and for those times when we're apart, I want her to understand that she is always foremost in my mind. In essence, I want it to communicate all the things I'm never quite eloquent enough to say on my own. I start running down my mental list of songs, all of my favorites that capture who she is and what she means to me. By the time I get to my Mac, I have a long mental list, and I try in vain to remember all of them. I scroll through my iPhone to jog my memory, and use it to get more ideas. I create a playlist and start dragging the songs over. I notice that Bella has conveniently left her iPod at home, so I can mess with it. When I finish loading the playlist, I glance at the time and notice that she's going to be here any minute.

I don't want to jump her bones the second she walks through the door, but I'm so wound up I'm not sure I can resist. I try to keep myself calm by grabbing some takeout menus; we're going to need to eat at some point. I know that whenever I have PALS, or any other kind of certification, my brain is totally wiped out afterward, so I'm trying to make things as easy as possible for her.

Shit, what if she's too tired to do anything tonight?

God, I'm a selfish bastard.

If she's too tired tonight, you just sit and snuggle for christ's sake. It isn't like your cock is going to fall off from lack of use.

I run my hands through my hair, which for some reason helps me calm down and think more clearly. I glance at the menus, but nothing stands out. That's probably because I'm still thinking of Bella, even though I'm supposed to be focused on the menus, and I'm still hard as a rock. Will I ever want her less than I do now? I hope so, or I will be unemployed in short order.

Finally, I hear keys jingling outside the door, and it's like she is the spark that sets all my senses on fire. I'm at the door and have it open before Bella can even put her key in the lock. I must be faster than I realize, because I hear a sharp gasp of surprise once the door opens.

"Oh! Edward!"

She's incredibly attractive with her owl eyes, and I cannot possibly resist her, so I don't. I merely yank her inside and shut the door with my foot. Before I can do anything else, though, she twists this tryst right around. She manages to get me on the ground, and she is hovering above me.

"Wha—"

"Shhh!" She commands.

"But…" her mouth is on mine before I can say anything else.

I'm confused. I expect a Bella who dragged herself home, who is sleepy, and simply wants some food and to have some quality cuddle time. What I have is a Bella who is most definitely devouring me.

A-fucking-men.

We don't waste any time getting down to business. Bella is literally writhing on top of me, we're both fully clothed. In between kisses, when she comes to the surface for a breath, she starts mumbling words to me.

"Fucking hard-fast-deep…"

"SO horny, need you now…"

"Teamwork... critical… need feedback…"

I have no idea what the hell she is talking about, but when Bella Swan is dry humping you for all she's worth, you don't stop to ask questions, you just let the beauty unfold in front of you.

She's managed to pull off half of her scrubs, and is working on my shirt. She stops to swear when she realizes that in order to take off my shirt, she needs to remove her mouth from mine.

"Goddammit!" she yells in complete frustration.

The second my shirt is over my head, she suddenly stops. Her eyes brighten, and I know she is up to no good.

What?

She flips over so she's lying on the floor, and whips off her scrubs. Naturally, she's wearing a thong. God forbid she should wear sensible underwear to an all-day certification session.

I hope to god she was wearing scrubs that give her full ass coverage, or the guys in the session would have been tormented for 8 hours straight.

Bella is lying on her back, on the floor, clad only in a bra and thong. She turns to me and says with fluttering eyelids, "Oh, Dr. Cullen—I'm coding and I need your help!" She fans her face as if she is a damsel in distress.

What the fuck?

Duh, Cullen. Mouth to mouth. Hard and fast and deep. I get it.

I run to my bedroom to find my stethoscope. Bella plays it up for all she's worth, gasping and choking, adding in a "HELP!" every minute or two.

I run up to her body, pretending I'm at the scene of an accident. It's the scenario we're always given in PALS certification. I'm on my knees, next to her body, and I shake her to see if she is conscious.

"Bella, Bella, are you okay? Are you okay?"

Stop. Look. Listen. Airway. Breathing. Circulation.

I put my hand on her chest, right in her cleavage to feel if her rib cage is moving.

Hell yes, it's moving. Maybe even fluttering a little bit.

I know I can't call 911 on my own; I need to give 2 minutes of CPR care before I call for help.

So I do exactly that.

I bend over, pretending that I'm going to give Bella mouth to mouth. The minute my lips touch hers, she talks while our lips are still connected.

"Mmmm, fuck yes. Help me breathe."

I can't really talk, so I just hum out an "Mmmhmmm."

I take my time to really explore Bella Swan's mouth, making sure there aren't any anomalies to be concerned about. Everything checks out perfectly, of course. In fact, her tongue is actually quite extraordinary, and my tongue spends time with it, trying to convey how much I appreciate its sublime beauty via my touch. Although I haven't spoken a word, I'm convinced that Bella understands what I'm trying to say.

"Edward, check my pulse. I'm not sure if my heart is still beating."

"You know, it kind of ruins the whole drill if the victim is intent on telling the rescuer what to do."

"I'm not telling you what to do. It's my conscience. Talking to your conscience. I swear."

I kiss her again, just because she's wonderful and funny and her lips are right there. It would almost be a cardinal sin of advanced life support basics to overlook lips like these.

Without my brain actively engaging my hands to do something useful, they start to travel on their own. Much to my happy delight, they happen upon Bella's breasts, and that just has to be part of any lifesaving equation. Well, any lifesaving occasion that involves Bella Swan and myself, that is.

"CPR compressions are done over the sternum, not the tits."

"Again, victim isn't supposed to be telling rescuer the steps. Unless, of course, there are new rules I need to learn."

"Modified CPR is acceptable in this case. The victim seems to be arousing."

I slide my hand down from her breast and carefully slip it into her barely there thong. As I suspected, she's already soaking wet.

God, I love this woman!

"Yes, I concur with the victim, she is definitely getting aroused."

"Are you using the Cullen-Modified CPR technique again?"

Her eyes are closed, but a huge grin spreads over her lips.

"Yes, I need to make sure the victim is adequately prepared for the hard-fast-deep compressions I'm about to initiate."

"Fuck, that is so hot!" she says, under her breath.

I carefully dip my finger inside of her, and she moans. Her hips thrust in an attempt to get my finger even deeper.

"I think it is safe to say that it's time for compressions."

Grabbing Bella's legs by the knees, I fold them up toward her shoulders so that her hips are raised off of the ground. I grab her thong and fling it off. Once she is naked, her pussy is right in front of me; I take a moment to just marvel at how beautiful and sexy she is.

"I don't tell you this often enough, but your pussy is a work of art, Swan." I run a finger up and down her slit, appreciating the view.

She waggles her hips with impatience. "Compressions," she breathes out.

I grin at her, loving it that she wants me as much as I want her. I put her knees over my shoulders and thrust into her in the same motion.

"Remember, hard-fast-deep," she chides.

"Oh, I remember."

I recite the words over and over in my head, in time with my thrusts.

Hard-fast-deep, pause. Hard-fast-deep, pause.

Bella unexpectedly grabs the back of my head and pulls my lips to hers. She attacks my mouth with the same level of intensity as my thrusts. Her breathing pattern sounds almost staccato, because a small breath escapes every time our skin slaps together.

I'm so fucking close, but I want her to come with me, so I shift position slightly. I hook my arms around the back of her shoulders so that I'm able to pull her into me more deeply with every thrust. Her eyes pop open suddenly, and our mouths part. She's there, perfect timing.

"Fuck! Edward!" I come as she screams my name.

"I think I'm going to like the new PALS recommendations. Hard-fast-deep is a very winning combo," I pant out, trying to recover my breath.

"Dr. Cullen, your resuscitation skills are the stuff of legend."

We lie together on the floor, still floating from our incredible sex.

"I never thought I'd have to worry about having too much sex, but I swear to god, I want you all the time. I wonder if that will always be the case for us," I explain, feeling a little badly for fucking her in my doorway without so much as a hello.

"How many times do I have to tell you? Sex every day is the only way to go."

"Yeah, but we usually have sex more than once a day."

"I can't believe you're complaining about that."

"Oh, trust me, I'm not complaining. I just can't believe I found someone who wants it as often as I do."

"I know. And it's not just that—I also get your incredible parka and your beautiful physique. I'm thinking I must have done something very good in a previous life to deserve you now."

"You stole my line, baby," I lean over and kiss her, pulling her body close to mine. "You hungry?"

"I am now. Should we order out? I'm not really up to making anything."

"I was actually planning to do that once you got here, until you attacked me at the front door."

"I attacked you? I think it is the other way around, Cullen."

"Rationalize all you want, but you can't keep your hands off me. It's okay, Bella. You can admit it. It's all part of the irresistible Cullen charm."

She rolls her eyes at me. I love to get her goat, it's so much fun.

We order Thai and sit next to eat other, fishing food out of the cartons with our chopsticks. We take turns feeding each other. As I watch her tongue snake around a bite I'm giving her, it suddenly dawns on me that it feels like the most natural thing in the world to have Bella sitting at my kitchen table with me, eating the dinner that I'm feeding her.

Unexpectedly, I feel her snuggle into my side. I wrap my arm around her, pulling her as close as she can get.

"When I first met you, I never imagined you were a cuddler."

"I'm not. I just can't stand not being close to you when you're right here. I can't explain it, other than it feels wrong to have any airspace in between us. I think the phenomenon is Cullen-specific."

"Remind me to keep you away from my dad, then," I laugh.

"I meant Edward Cullen-specific!" she whacks me on the side.

As our laughter dies down, I lean over and rub the tip of my nose on her temple. I love the way she smells.

"Edward?" She breaks the quiet, and her voice sounds a little nervous.

"What is it, baby?"

She buries her head in my shoulder. I set my chopsticks down on the table and circle my arms around her. Her arms quickly follow suit, but she shakes her head.

I kiss the top of her head. "What? You can say it. It's just me."

"Promise not to freak out?"

"Bella, there is nothing you could say that would freak me out. Unless you want to break up, that is."

She looks up at me, alarm written all over her face.

"God, no! Never! How could you say that?"

"I was just trying to tell you that you never be afraid to tell me something, good or bad. If you love someone, you accept the whole shebang."

"I keep waiting for the thing that's going to convince you that you don't really like me as much as you thought you did. That somehow, I'll prove to you that I don't belong in your life."

"Oh my… of all the crazy—how have you failed to see how much I fucking adore you? I'd be devastated if you weren't in my life, Bella. Make no mistake about it. I can't even think about how much it would kill me. You have to know that."

She reaches up and puts her hands on my cheeks, then kisses me softly on the lips. "Oh, Edward," she sighs softly. "It just feels so perfectly right to be here at your table, eating dinner after a day at work. I was going to say that it feels like I belong here, but I didn't want to be presumptuous."

"What would you think if I told you that I was pondering that exact same sentiment about three minutes ago?"

"I'd think you were just trying to make me feel better."

"No way, you need to believe it. There's nothing better than having you here at my house. In fact, it makes my heart do funny things whenever I think about your not being here. You've already changed the whole energy of this place, just by your mere presence. I'd like you to think about staying here."

"For how long?"

"For as long as you'll have me."

"You'll get tired of me. Eventually, you won't want me here anymore."

"What the hell makes you say something like that? Are you fucking blind? Bella, you are my life now—the thought of you being anywhere else, with anyone else, makes me crazy. If I'm completely honest with myself, I'm afraid that you won't want me anymore."

"But I'll always want you; you know that!"

"All right then, let's make a deal with each other, here and now—we both want to be here, we both want to be together, and that's the way we're going to stay."

I put out my hand for her to shake, to make it official. She puts her hand in mine willingly.

"Deal."

"You know what? I have something I need to give you. This will describe my feelings far better than I can."

I take her hand and lead her to the bedroom.

"Uh, Cullen, we just had sex. Not that I'm complaining…"

"You know, beds serve other purposes aside from a place to have sexual activity."

"Really?" she says, like a smartass.

"Lie down," I tell her, as I grab her iPod and earbuds. "Now close your eyes."

"What are you going to do?"

"Just trust me. Put this earbud on."

She looks at me warily as I hand it to her. "Please? This will explain everything."

She slides it into her ear, and I put the other end into mine. I select the playlist, and we lie next to each other, cuddled up. The music fills my ears, and images of Bella dancing flood my brain.

Fuck, yes.

She tries to grab the iPod from me, probably to read the playlist.

"No," I tell her. "I want you to experience this with your ears and your brain. So everything is fresh and you don't know what to expect."

For once, she just agrees, and closes her eyes. As she listens to the first few songs, she opens her eyes and looks at me, her face a picture of beauty and serenity. I wish I had a camera right here, so I could capture that look, because she's never been this beautiful before.

She grabs hold of my hand, kisses it, and whispers "Thank you."

It doesn't take long before her breathing slows, and I can tell she's fallen asleep. I grin to myself, knowing that she did so listening to all the ways I love her. I carefully take the bud out of her ear and set the iPod aside, then resume my cuddling position with her.

In this moment, with the two of us wrapped closely together, my entire world is complete. My reason for being is right here; I'm so fucking lucky that I found Bella Swan all those years ago. I fall asleep with a sense of utter peace.

~xXx~

Bella is resting with her body form fitted to mine, her head tucked into the space below my chin. I know she's awake, because she grabbed my arm and pulled it even closer to her body. I love this position, because I can smell her hair and kiss her head freely, and it all just feels so right. Like it's been preordained.

"You know I'm a vampire, right?"

Trust Bella to completely distract me with something ridiculous.

"What the fuck are you talking about, Swan? Do you need some caffeine or something?"

"No! Listen. I'm up all night, I take children's blood, and I'm allergic to sunlight. You've seen how much sunscreen I need to use, and I still turn into a tomato."

"Uh-huh. You've thought about that one for a while, haven't you?"

"Yep."

"Well, I guess that I'm a vamp, too, then."

"Naw, you're up all day and night. You're just a vamp wannabe."

"I'm pretty sure if we mated, that we'd have vampire children. I mean, look at my mom and dad—they mated and spawned a vampire wannabe."

"Do you want vampire children?" Her voice sounds so small and unsure.

"Well, I haven't given it serious consideration before. I always just assumed I would—I fucking love kids. I'm not gonna lie, though, Swan—I'd want your children, no matter what they are."

"Really?"

"Of course! You'll be an awesome vampire mom. I'm sure of it."

She giggles, then spanks me playfully. "Well, no matter what, we can't make vampire babies right now, because we need to get our asses to work."

"Well, vampires are known for their stealth and speed. I'm pretty certain I could attempt to make vampire babies right fucking now," I waggle my eyebrows at her.

"Yeah, but you're just a vampire wannabe, so that doesn't count. You just have slow, regular, boring human sex."

"Oh, so you've been bored by having sex with me? The 'Oh, fuck Cullen, don't you stop' screams you let out make me think otherwise."

I roll over on top of her, pressing my hard cock onto her thigh. I'm confident it can fight a convincing battle for me.

"Awfully sure of yourself…" she giggles beautifully in my ear.

I'm expecting her to move underneath me, but once again, Bella proves to me she has a mind of her own. She holds me tightly, and whispers in my ear, as if she is too shy to say it while looking directly in my face.

"More than anything, I want what your family has. I want to be Carlisle and Esme all over again. I want to give them grandchildren. I'm in love with your family, too, Cullen."

This woman who I love more than anything on this earth continues to amaze me. I cannot imagine loving her more deeply than I already do, but she proves me wrong every single time. I try to convey everything I'm feeling in my kiss, but it's never going to be enough. She's never going to understand exactly how much I love her, because it is infinite.

I slowly slide myself into her. "Bella, nothing would make me happier." We move together, in sync, taking our time to appreciate being together like this. When we come, we're looking at each other, and I've never felt closer to another human being in my entire life. It's perfect. She's perfect. I'll never want more than this—my Bella and our vampire children.

~xXx~

Since it's Friday, the start of the weekend, I'm going to be in charge tonight. McCarty will be available for paging, but I'm running the show. I absolutely love the challenge and feel completely ready for whatever the night brings.

I get a quick report from the resident about the more serious cases on the unit, and take some time to review the physician's notes on each patient. I'm on all weekend, so something is likely to go south. It always does.

At around 10:00, we get an unexpected admit from the ER. A 17 year-old kid tried to commit suicide when his girlfriend broke up with him. Apparently, their relationship wasn't true love in her eyes—the kid would never be as good as the character in her favorite romance novel. I grimace internally at the circumstances, and I feel awful for the poor guy. He still hasn't learned that some women you simply need to avoid. He took an entire bottle of Tylenol, then called 911 in a panic. The end result? He lived through the attempt, but the Tylenol poisoned his liver, so now he'll need a transplant. If there was one thing I could tell adolescents, it's to avoid Tylenol as a means of suicide. If it doesn't kill you outright, you'll wish you were dead anyhow. Liver failure is painful and miserable, and you invariably end up needing a transplant, just like my patient. Neither option is very pleasant. We get the kid stable and start him on a mucomyst drip to minimize the effects of Tylenol on his liver as much as possible. Regardless, we still need to get him on the transplant list. We track his liver enzyme values every two hours, and they continue to climb despite our interventions. I shake my head at the pointlessness of it all.

I'm just finishing up with the overdose patient when my pager goes off. A rapid response was called on the general peds floor. While not technically a code blue, it is still an urgent situation—we need to get there quickly to assess a patient whose condition is rapidly deteriorating. I walk briskly to the patient's room. When I arrive, I find a kid who looks perfectly normal. I ask the charge nurse why the rapid response was called, and she tells me the patient's oxygen sats dropped to 50%. I grab my stethoscope and listen to the kid's lungs. Perfectly clear. Heart sounds are fine. Color is normal. She's breathing a little fast, but not labored. She's a little sweaty, but I'm told she's been running a low-grade fever. I want to see where the O2 sat probe is, and find that it is on her foot. When I remove her sock, I see that the probe is no longer attached to the patient—it was stuck to the inside of her sock. I'm more than a little frustrated, because I just wasted about 15 minutes assessing a patient who is perfectly fine, in the scheme of things. I ask the nurse to put on a new sat probe, and the patient's sats are 94%. I excuse myself and get back to the PICU.

As I'm walking toward the physician's room, I overhear Bella arguing with the resident, so I decide to check things out.

"Look, I don't care if you think 'this is what she does'! Her breathing pattern is irregular, and I cannot get a diastolic blood pressure!"

"We talked about it in rounds today, and we aren't going to do anything to intervene at this point. She's done this every day for the past few weeks."

"Hey, guys, what's going on?"

"Yeah, this is the patient we're just going to watch overnight. She's been having these unstable episodes, but then she recovers. No one is really sure what's going on with her, so we aren't doing anything."

Oh, hell. I've got a resident who thinks he knows better than an ICU nurse. If there is one thing I always try to impress upon a resident, it is that they should never argue with an ICU nurse. No matter how much they think they know, they never know more than the nurse. This is one of the ego-driven residents who thinks he's smarter than that.

Bella opens her mouth to rebut what the resident said, but I raise my hand to quiet her. She gives me a dirty look until I wink at her.

"Okay, Tyler, let's imagine that no one said anything in rounds today. You come in the room at the nurse's request, and find the patient has no measurable diastolic pressure, despite the fact that she has an arterial line that directly measures the blood pressure from inside the heart. On top of that, the bedside nurse has checked a cuffed blood pressure on both arms and legs, and still cannot get a diastolic reading. What does your expert judgment tell you that you should do in such a scenario?"

"Well, it really doesn't matter, does it? Because we said we wouldn't intervene."

"I told you to disregard that direction. What does having no pressure mean?"

"It could just be an error in the equipment."

"True, but how likely is that? If you have an a-line pressure and pressures on all four extremities?"

Tyler looks extremely annoyed, like he has better things to do than argue with a bedside nurse and a fellow. He crosses his arms and huffs. "Well, I guess it isn't that likely."

"Okay. So let's look at the other variables at play here. Nurse Swan tells us that the breathing pattern is irregular, even though this patient is on a ventilator. You have a heart that is getting assistance from all sorts of blood pressure medications, but you have no diastolic pressure. You have a ventilator doing all the breathing work for the patient, but she is still breathing with difficulty. You have a seasoned ICU nurse telling you that something isn't right. You have all this information in front of you, and your conclusion is still going to be to wait until morning?"

"I don't want to go against what the bone marrow transplant team decided."

"Fuck the BMT team. They aren't here, and you need to make a decision. That's what working in the PICU is about. Now, what are you going to do?"

"Well, we're maxed out on the amount of vasopressin we can infuse to increase her blood pressure."

"Okay, and?"

"Should we add a different blood pressure medication?"

"What do you think? Come on, you have to think fast! This patient is unstable, Tyler!"

"I'd like to add dopamine."

"Why?"

"Because it will help the blood pressure more."

I shake my head. "Nope. What else is going on here?"

"The breathing?"

"What about the breathing?"

"It's um, unusual. The nurse says it changed."

Now he listens to Bella! "Watch the way she's breathing. What does it look like?"

"Well, it's irregular. Sometimes fast, sometimes slow, sometimes deeper than others."

"We have a word for that. What is it?"

"Uh… is it stacked breathing?"

"No, Tyler. Ask Bella."

She smirks at me. She loves to show up a resident who didn't do their homework.

"Well, Dr. Cullen, I believe this patient is illustrating agonal breathing."

I'm not done quizzing him yet. "What is agonal breathing?"

"It's irregular."

I shake my head. If this patient had been actively dying, she would be dead by now. I have to step in and do Tyler's work for him. I hate it when residents are unprepared.

"Bella, will you call RT? We need to make some changes to the vent settings. Tyler, aside from being irregular, agonal breathing is not really breathing. It's a series of gasps or moans. We can't hear the patient because she is on a ventilator, so we have to watch her breathing. Do you see how her chest rises? How unusual it looks? That is agonal breathing. What is happening when a patient is breathing like that?"

"Uh, they're dying?"

"Right. So the fact that you have a patient who has agonal breathing and no diastolic blood pressure means that this patient is likely trying to die. It just took you 5 minutes for me to question you, and this patient could be dead by now. Obviously, I'm not going to let that happen, but you need to step up your game, dude. Big time. What else do you notice about this patient? Before anything else happens, what do you see?"

Tyler wipes his brow. He's nervous as hell, but he still needs to figure this out.

"I really don't know."

"Swan? Can you help him out?"

"The patient is DNR, Dr. Cullen."

"Okay, Tyler, you wanted to add another med to increase the patient's blood pressure. You would have been flying directly against the orders, and there would have been hell to pay for that. I'm going to tweak the vent settings and have the nurse send some labs, but you need to get on the phone and speak to the BMT team. You also need to let the charge nurse know this patient is heading south. My guess is that the patient will expire some time today. You need to get your ducks in a row and make sure everyone is prepared for that. If you aren't, you're going to get a brand new asshole chewed, by more than one person. Got it?"

"Yes?"

"Call the docs. Let the charge nurse know. Order STAT labs to be sent. Do your fucking homework next time you work all night with me. And never—I mean never—question the judgment of an ICU nurse again. They're always going to be smarter than you. Always. The sooner you learn that lesson, the easier your life will be."

Tyler practically runs out of the room, and Bella has a very pleased look on her face. I'm about to apologize for his being such an ignoramus, but my pager goes off.

Jasper.

I get to his room, and he looks dead serious.

What the fuck is wrong now? Haven't we had enough for one night?

He holds up a plastic Ziploc bag. When I look at the contents, I see several vials, some syringes and needles, and a blue rubber tourniquet. It takes a moment to recognize what Jasper is showing me.

"Was Mallory in this room before you?"

"Yes, Dr. Cullen, she was. I happened to find this bag taped behind the patient's supply cart. I suggest you take this evidence and have management review the videocam. I think she just shot herself in the foot."

SATURDAY, JULY 3, 2010

The Nightingale Journals

DOCTORS VERSUS NURSES

In the best of times, doctors and nurses work together, side by side, to save critically ill patients. When you are part of a seamless team, things come together without a hitch. You recognize that everyone is a part of that team, and no one member is better or worse than anyone else. In the worst of times, you have individuals out for their own gain, or held hostage by their own ego, and the patient is the one who suffers.

I'm the kind of nurse who likes to treat my colleagues with respect. We've all been through years of school, myriad challenges, and we've all passed our board certifications before we set foot on the job. Sometimes, however, I meet medical professionals who believe that nurses are merely individuals who weren't smart enough to get into medical school, so they became nurses instead. Their perspective is that nurses need to be told what to do.

ICU nurses are at a patient's bedside throughout an entire shift. We are the ones who keep track of a patient's vital signs. We can see subtle signs that a doctor wouldn't notice by simply reviewing the patient's latest lab results. While physicians focus on clinical evidence, nurses focus on the big picture. When we combine our knowledge together, we can accomplish incredible things. When we work against each other, we can sometimes miss critical pieces of information.

Tonight, I had a patient who was starting a long cascade toward death, but a resident refused to believe me. He didn't have any explanations, but he clung stubbornly to what he felt was the truth. It made me incredibly sad to recognize that even in this day and age, physician bias against nurses is alive and well. If I could impart one idea into every resident's head, it would be that united together, we stand, divided, we fall.

POSTED BY BELLALUNA AT 8:17 AM 0 COMMENTS

END NOTE: The actual songs from Bella's playlist are on my LJ page.

There are new guidelines for CPR, and I kid you not, the direction we are given is, "Give compressions hard and fast and deep." How could I ignore such great advice, I ask you?