there is multitasking and then there is nursing

i know when my job is really bad, because i honestly consider taking off my stethoscope, turning off my phone, and walking out. this week has been a little like that. ok, a LOT like that. my biggest problem is that the patients have me outnumbered. there are four of them, one of me. this works out ok sometimes, but when everyone decides to be sick at once, we have a problem.

thursday: i had four patients. one was a suicide attempt who's super stable and waiting for placement, one was a brain injured 81 year old who thinks we're on a cruise ship, one was a multiple GSW to the abdomen who has one of the worst infections i have ever seen, and one was a post-op bezoar removal (aka giant food ball stuck in stomach...i swear this stuff exists). so i got my post-op settled and took some vitals. her BP was 78/54. i didn't want that to be right, so i took it again on the opposite arm. 80/53. no no no no no. the woman was white as a sheet and breathing at 12 resps a minute...kind of slow for my liking. to be perfectly honest, she looked like she was dead or well on the way, and it was creeping me out. as i was decided what i was going to do, the door flew open and one of the aides yells that my lady with the brain injury was having chest pain. i HATE chest pain. it almost never means anything on our floor, but you still have to call the doctor and get a bunch of tests and stat labs. so i'm supposed to be 2 places at once, and no one is stable and did i mention that my abdominal infection guy sprang a leak in his belly? poop in open wounds is usually very very bad. so i'm waiting for the OR to call for him and praying he doesn't go septic (that is more septic than he already is) before they do. and i need to fix the ghostly white hypotensive patient. and make sure that my cute grandma isn't having a heart attack. i would like to say that i handled this with grace. in reality, first i had a small freak out, barked orders at my coworkers, then snapped at an aide for asking me for something. then i gave blood pressure lady a fluid bolus, had someone else call the doctor about the chest pain, and made sure vitals were taken on my pre-op abdomen guy. then i apologized for being mean. eventually the blood pressure came up, the chest pain turned out to be rib fracture pain, and OR called for my abdominal infection. but by this point, the night was beyond saving. i punched out an hour late, and STILL managed to leave the hospital feeling like i accomplished nothing at all. so i called up a friend and cried all the way home.

friday: after all that drama i wanted, no NEEDED, a good night. i went in to get my assignment, told the powers that be that i couldn't handle all those people at once, and gave up the bezoar patient to another nurse. my day started out fine, but when i got back from lunch all hell broke loose. i had a discharge, so i was up for the admission. "just an ortho patient" i was told. then i was pressured into giving up my 81 year old who had actually been behaving herself to take back the bezoar patient who wasn't getting along with her new nurse. i didn't like it, but i said yes and went to go check on her. her NG wasn't working, i was supposed to give her 2 enemas, and she burped poop breath (literally) in my face. yay. then i had to meet my new admission. my "just an ortho patient" was really an ortho oncology patient with a white blood cell count of 23,000 (normal 5-10,000) who was bright yellow. he was sick. in the real world, sick means that you have a cold or a headache or want a day off of work. in the hospital world, when you say a patient is sick you mean REALLY sick. so i picked up my second septic patient of the night, and immediately got bombarded with orders for blood cultures and urine samples and a chest xray and abdominal CT. the attending surgeon called me probably 5 times to keep me posted on the plan and give me more verbal orders. in between asking the 234234098 admission questions, i was drawing labs and fielding phone calls. somewhere during the melee, my patient with the bad abdominal infection who had gone to surgery the night before called me to say that his dressing was leaking. i was so busy that i pretty much ran past his room and told him i'd be back in a few minutes. maybe a half hour later i finally remembered him and went to assess the dressing. i had seen the doctors change it earlier, so i knew what i was going to do and grabbed an aide who's in nursing school to come help me. i had been warned that the wound was pretty wet, but i was surprised to see the whole dressing was saturated. as i peeled off layers, i got more and more alarmed. when i pulled the packing out of the wound, bile started running down the patient's belly. bile doesn't belong sloshing around in the abdominal cavity. i calmly asked the aide to go grab the doctor out of my other patient's room and started to soak up the drainage. the on call doctor walked in, looked at the belly, and walked out. then came the chief resident. by this time it was clear the patient was going back to surgery for the second night in a row. over the patient's open belly, the on call doctor told me that he had tried to fix the bezoar patient's NG tube and couldn't...i had to put in a new one. yes. i also had to prep this patient for surgery and make sure that my septic admit wasn't crashing. first i died a little inside. then i called the STAT nurse to put the NG in, finished my preop checklist, and sent my ortho patient to CT. i honestly don't remember the rest of the night too well...just that it ended with me punching out an hour and a half late and cursing the day i decided to become a nurse.

saturday: i got to work and both bezoar lady and abdominal infection man were in the ICU. turns out that's where people are supposed to go for one on one nursing care. who knew.

my brain hurts from so much multitasking. but everyone is still alive. success.

hello and welcome to my ICU

this semester i'm teaching a nursing student. she follows me around, and i explain why we're doing what we're doing, then troll for exciting thing for her to see. as the patients on our floor can get sick fast, more than once i've set her up in the corner of a room and told her to just stay there and watch. personally, i've learned the most from being in rapid responses and codes, even if that is where i often feel most scared and generally like i want to go cry in a corner. for the sake of all of my student's clinical paperwork, we have been calling these incidents "critical situations". and it seems like we didn't go a day last week without having one. some of the highlights:

my medicine patient went into status asthmaticus...basically a really bad asthma attack that doesn't respond to the usual treatments. now i can handle a lot of things. if you're bleeding, i can stop it. intestines coming out of your belly? seen that, we're ok. but asthma? i have NO idea what to do with asthma. so i gave the lady her rescue inhaler and grabbed the respiratory therapist. well after a nebulizer, things usually get better. not so much. so she got another neb. and another. and another. and then we called the rapid response team to come see her, because she was barking like a seal and we still couldn't get her to stop coughing. the MICU resident came down to join our party, and ordered continuous nebulizers. this is a floor no-no. along with the nebs we got an order for q 15 minute vital signs (seriously?) and to run some magnesium in IV really really fast( pharmacist's quote after seeing the doctor's order "no no, we do not run it that fast even during a code". oh great.). my thoughts? this lady needed to go to the ICU. she can't breathe, and i can't leave her long enough to check on any of my other patients. fortunately i work with some amazing nurses, who graciously took over the care of my other patients so i could help fix this lady. after TEN nebulizers in a row, countless sets of vitals, and a bag of mag, the patient was cured!! unfortunately, it also took two and a half hours, during which time i never saw another patient. i like to refer to this phenomenon as "running my own ICU", and despite the fact that we don't have the time or resources to do this on the floor, it happens all the time. i feel that certain doctors see ICU transfers as failures. they don't want to sent their patients to the unit under ANY circumstances, so you have to basically be dying to enter the holy gates. which doesn't put me in a good position when i'm trying to care for an unstable patient as well as 3-4 other people. but i digress.

so on sunday, we get a patient out of the ICU. he's sitting up in the wheelchair, looking pretty good for someone who just got transferred out of the unit. until the nurse realizes that his epidural catheter is snapped in half and leaking pain medication out onto the floor. and he gets nauseated. and dizzy. and dry heaves. until his heartrate goes down to 38. and then passes out. still in the wheelchair. have i mentioned that he's over 350 pounds? the next hour was a blur of running up and down the halls, calling the rapid response team, hooking him up to the monitor, jabbing various tubes and needles in him, bolusing, etc etc. once again, his nurse wasn't able to leave the room to see her other patients for several hours. but of course, despite the fact that this patient required 1:1 nursing care, he was not sick enough for the ICU.

so, in summary: my nursing student learned a lot. i am exhausted. and i may not officially work in an ICU, but then again some days i do.