how much is too much? when i started on the floor over 2 years ago, i swore i wasn't going to be one of those people who used our floor as a stepping stone to get experience. i DEFINITELY wasn't going to be one of those superior ICU nurses who tossed around words like 'rapid sequence intubation' and 'dopamine drip'. but now, i admit, i've been wavering lately. the main problem is this: too many patients, too sick, not enough me to make sure that they're all breathing, not to mention actually doing any "extras".
like last night: i'll say it, I'M SUCH A SUCKER. so when the floor called to ask me to pick up a half shift PM, i agreed. i felt bad, because our floor is hard enough when we're staffed, and when we're not it turns into a nightmare. so here we are: 31 patients, 8 nurses. appropriate according to our grid. except that my assignment is horrible. not on purpose, not that anyone else had a cake walk, but still horrible. the rundown:
1. a trached, confused man with NJ tube feeds, on flat bedrest, just came back from dialysis
2. a small bowel obstruction woman with a ton of mental health issues, psych meds, and a leaky NG
3. a trauma patient who just also happens to have cancer with mets to the brain. foley, rectal tube, C diff positive, a strange accordian drain i have never seen before, both legs in immobilizers and CRABBY
4. an ortho patient who can't pee, so i bolus her, all the sudden she can pee and she's calling for the bedpan every 5 minutes, taking herself on and off of it, then spilling urine all over requiring THREE complete bed changes in 6 hours
i started to think about where i would rather work right about the time that my trach guy started vomiting green mucousy grossness from both his trach and his mouth. because the night's not truly bad until somebody gets aspiration pneumonia. i'm way behind, i've now got a patient with a compromised airway, and still no one will leave me alone. i fielded three phone calls from family members in about an hour. every ten minutes i'm in with miss no bladder control trying to pry the bedpan out of her hands and convince her to call for help. my tech seems to have disappeared, and i find myself emptying all the drains and clearing all my iv pumps alone. as i strip the tubing on my patient's leg drain, she begins to swing at me because it hurts, finally grabbing my hand and DIGGING HER DAGGER NAILS into my flesh. the guy across the hall is irate because no one has repositioned him 'all day' and why did i forget to bring him that menu? and i haven't been in to check on the lady with the leaky NG in at least a few hours because she is the only one that i feel can handle being left alone for more that five minutes.
the conclusion: i need less patients. or ones that can do things by themselves. such as get up out of bed. or eat. or go to the bathroom IN THE BATHROOM.
this is not going to happen. thus: i need a new job.
Friday, September 17, 2010
Monday, September 13, 2010
failure to rescue
they tell you when you start on the floor that you always have resources. that if you need help, people will come. that if something is really wrong, you can get all the right 'players' there in a matter of minutes.
i'm beginning to think that is a lie.
monday: uneventful PM, just about to wrap things up when at 2200 (of course) i hear the float nurse talking about her patient who's suddenly tachycardic. he's got multiple stab wounds, courtesy of his baby mama and her sister, and also has a chest tube in. so i started to ask her questions, when she casually mentions that his heart rate is 170 and she just can't figure out why. 170 is not ok. EVER. so i run down to the room and hook the guy up to the pulse ox. 65. 80. 120. 140. 165. 180. the numbers kept climbing, and by the time we got to 180 i was on my phone calling my other nurses to come help and yelling out into the hall for someone to call a rapid response and call trauma. the next time i turned around to look at him, his face crumpled and his eyes got glassy. the last time i saw that look, i watched a person die in front of me. so at this point, i'm yelling for the code cart, people are streaming in and everyone is pulling at lines and hooking up suction and attaching monitors. the patient is minimally responding to all of us shaking him and telling him to stay with us. his heart rate is now over 200. by this time, the rapid response team is in full swing, but no trauma. we page and page, at least half a dozen times. the pages are increasingly less polite, until we're sending borderline-threatening texts to both the junior and senior residents. about THIRTY MINUTES into the rapid response, we finally get a reply. there were three traumas in the trauma bay!! all coding at once!! we were doing chest compressions on three people!! and as usual, the patients on the floor come in last.
sunday: finishing up a long hard week. the bounceback admissions to the ICU have been BAD, because the team is sending out people who are simply not ready to be out on the floor. we get an ICU transfer at 1200, and by 1300 it's obvious that he's not at all stable. he's breathing at 45 respirations a minute, his heart rate is up in the 120s, and his oxygen saturations are in the 80s and falling. we put him on a face mask, then on a nonrebreather at 15 liters of oxygen which finally helps him maintain his sats. unfortunately, he's still panting like a dog and over the next hour, his heart rate rises to the 140s. we call for respiratory treatments and suctioning, which don't help. we page the trauma team who (of course) is in the ED and ignores us for the first several pages. finally the chief resident, the only one who seems at all concerned, comes up with the attending in tow. the attending pats the patient on the shoulder and tells him that he needs to take some deep breaths and rushes off the floor to the OR. at this point, we have been watching the patient struggle for almost 3 hours, and no one is doing anything about it. trauma tosses us a few meds to give and an order for a chest xray to placate the angry nurses, then completely disappears from the floor. at this point, the respiratory therapist asks me to go grab the ambu bag. we all think that he's going to get tired of breathing soon, and there's nothing we can do about it because none of the doctors will do a thing to help us. so we wait, until someone finally realizes that any more indecision will probably kill this man and someone finally calls a rapid response. suddenly, it's easy. there's a doctor who will order fluids and blood cultures and an efficient administrative representative who will find us an ICU bed. and not a moment too soon, because the patient's respiratory rate is now 75 and he's going up to the unit to get intubated.
so the week ended just the way it started: in a hot mess. and the only way to describe how i feel about it is disheartened. this is definitely not the way that things are supposed to go. and it's scary to think that the utter lack of action and flippant attitudes in the face of an obvious emergency went all the way to the top.
and nobody who was supposed to care seemed to be able to muster up any concern
i'm beginning to think that is a lie.
monday: uneventful PM, just about to wrap things up when at 2200 (of course) i hear the float nurse talking about her patient who's suddenly tachycardic. he's got multiple stab wounds, courtesy of his baby mama and her sister, and also has a chest tube in. so i started to ask her questions, when she casually mentions that his heart rate is 170 and she just can't figure out why. 170 is not ok. EVER. so i run down to the room and hook the guy up to the pulse ox. 65. 80. 120. 140. 165. 180. the numbers kept climbing, and by the time we got to 180 i was on my phone calling my other nurses to come help and yelling out into the hall for someone to call a rapid response and call trauma. the next time i turned around to look at him, his face crumpled and his eyes got glassy. the last time i saw that look, i watched a person die in front of me. so at this point, i'm yelling for the code cart, people are streaming in and everyone is pulling at lines and hooking up suction and attaching monitors. the patient is minimally responding to all of us shaking him and telling him to stay with us. his heart rate is now over 200. by this time, the rapid response team is in full swing, but no trauma. we page and page, at least half a dozen times. the pages are increasingly less polite, until we're sending borderline-threatening texts to both the junior and senior residents. about THIRTY MINUTES into the rapid response, we finally get a reply. there were three traumas in the trauma bay!! all coding at once!! we were doing chest compressions on three people!! and as usual, the patients on the floor come in last.
sunday: finishing up a long hard week. the bounceback admissions to the ICU have been BAD, because the team is sending out people who are simply not ready to be out on the floor. we get an ICU transfer at 1200, and by 1300 it's obvious that he's not at all stable. he's breathing at 45 respirations a minute, his heart rate is up in the 120s, and his oxygen saturations are in the 80s and falling. we put him on a face mask, then on a nonrebreather at 15 liters of oxygen which finally helps him maintain his sats. unfortunately, he's still panting like a dog and over the next hour, his heart rate rises to the 140s. we call for respiratory treatments and suctioning, which don't help. we page the trauma team who (of course) is in the ED and ignores us for the first several pages. finally the chief resident, the only one who seems at all concerned, comes up with the attending in tow. the attending pats the patient on the shoulder and tells him that he needs to take some deep breaths and rushes off the floor to the OR. at this point, we have been watching the patient struggle for almost 3 hours, and no one is doing anything about it. trauma tosses us a few meds to give and an order for a chest xray to placate the angry nurses, then completely disappears from the floor. at this point, the respiratory therapist asks me to go grab the ambu bag. we all think that he's going to get tired of breathing soon, and there's nothing we can do about it because none of the doctors will do a thing to help us. so we wait, until someone finally realizes that any more indecision will probably kill this man and someone finally calls a rapid response. suddenly, it's easy. there's a doctor who will order fluids and blood cultures and an efficient administrative representative who will find us an ICU bed. and not a moment too soon, because the patient's respiratory rate is now 75 and he's going up to the unit to get intubated.
so the week ended just the way it started: in a hot mess. and the only way to describe how i feel about it is disheartened. this is definitely not the way that things are supposed to go. and it's scary to think that the utter lack of action and flippant attitudes in the face of an obvious emergency went all the way to the top.
and nobody who was supposed to care seemed to be able to muster up any concern
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