my spidey senses are a-tinglin'

lets play a game!!  we will call this game 'is this patient appropriate for the floor?'  ready?  ok!!

30 year old.  known source of infection with worsening cellulitis.  BP 82/47 after 4 liters of saline.  no urine output as of yet.

is this patient appropriate for the floor?  the answer is...

NO!!  this patient is septic!!  this patient needs an ICU bed!!  this patient is not quite in florid sepsis at the moment, but that pressure after that much fluid says to me that he is going to be quite soon.  and i said as much to the doctor, with little-to-no verbal filter as always.  i told him in no uncertain terms: this patient is unit-bound, and septic, and i am willing to bet money.  actual money!!

so the night nurse texts this morning with the latest set of vitals.

T:104.8
HR: 145
BP: 80/54
RR: 30

after 7.5 liters of fluids.

is this patient appropriate for the floor?  NO!!  did this patient go to the ICU?  YES!!  should doctors listen to nursing instinct?  YES!!  but i'm not going to say i told you so...

...ok i am.  which is rather generous on my part, because i think he should actually be giving me money.

attrition

these are the days that wear you down.  i can think of nothing particularly good that i did today, not a moment where i felt like i had accomplished anything of value.  mainly i just ran myself into the ground.  two of my patients didn't have enough urine output.  two others had systolic BPs in the 90s. my 81 year old s/p fall wanted some vicodin, which i knew they wouldn't give to her, so i didn't even bother asking.  and then of course there was the typical routine of adversity: missing meds from pharmacy, rude medical students, a patient who repeatedly called after discharge, etc.  as i finished up all my charting, i listened as the night nurses paged doctors on three of my four patients.  and although i never stopped running during my shift, it was as if i had done nothing at all.  as i walked out to my car, wondering if i was going to cry before i started drinking or vice versa, i had to move aside for five nurses moving an ICU patient.  she was vented with about eight bags of fluids hanging, and the nurses that accompanied her moved with purpose.  like they do something worthwhile.  and when they put their own needs aside during the shift, and give way more than they have for the sake of someone else, i bet it's worth it.  to look at a patient that's more tubes than skin, and to think 'i am keeping this person alive'.  and i run around all day for what?  cups of ice and pillowcases.  and as i sit here, in quiet despair, i can't say that those things are worth feeling like this.

things i know, but wish i didn't.

sometimes i'm almost able to forget about how hard this job really is.  lately i've been efficient, comfortable, in the zone.  i do my thing, make it through, go home, and start it all over the next day.  

i almost forget that the things i see are not commonly seen.  there are horrors that live in my brain that aren't there for everyone.  

most day i operate on pure instinct.  so when i heard the crash tonight, and then the screaming, i ran towards the chaos and not away.  and i found a woman, not much older than i, absolutely hysterical, shattered dinner tray on the floor.  she was screaming, the kind of scream that i recognize because i've heard it before.  it means someone is dead.

not everybody knows that sound, i guess.  i've only heard it once before, when an ICU nurse came to the floor a few years ago to tell a patient that her husband had just died.  it was absolutely chilling.  

turns out the patient's house had been robbed, everything had been taken.  a cousin had walked in during the robbery and had been shot to death.  the patient had gotten a phone call telling her the news, and had come undone...flipped her dinner tray, ripped the cord out of the phone, and started stomping and sobbing and screaming.  

oh the screaming.  like someone had just ripped out her soul.  it's a sound that i still can't get out of my head, even as i sit here and try to cover tonight with wine.  

there are things that i've seen that i can't unsee.  things that i've heard that i can still hear, and that make me sick inside to think about.  it makes me long for a life of cubicles and happy hours, makes me want to be a normal 20-something instead of a nurse.  

attack of the clones

working in trauma, basically all i see is variations of a few things...MVC or MCC, shooting or stabbing,  and falls.  pretty much everything can get siphoned down into these categories, so it's not unusual for me to have some pretty similar patients.  but today was a little ridiculous.

today i had essentially the same patient.  four times.

four middle aged men.  all with rib fractures, thirty five (!) between them.  three MCCs, one fall.  two clavicle fractures.  three with chest tubes.  five chest tubes between the four of them.  two with epidurals.  two who required a VATS: one pre-op and one post-op.  got all that?

yeah, neither did i.

you'd think that all this repetition would make things easier for me.  it didn't.  all night long my head was spinning.  did i change that chest tube dressing?  well i know i changed somebody's....and marking all the chest tubes?  auditing the epidurals?  where are we on pain meds?  is everyone doing their IS?  who's on oxygen?  are everyone's sats ok?  my brain.  melting.

i'm still not sure if everything is done, and i left work a long time ago.

i cannot remember which side the rib fractures are on in my only patient without a chest tube, and i'm obsessing over it.  let's not lie, it's irrelevant to me now, but the fact that all these people are blending together is crazy-making.

it's to the point where i'm almost wishing for a nice GSW to break up the repetition, to free me from the monotony!!

almost.

zero tolerance.

in the past few years i've seen some pretty ridiculous things, but the events of the past week shocked even me.  i am no stranger to those with the entitlement mentality, but this weekend we had a family who put even these people to shame.

 this particular family began their reign of terror by bringing a dozen people into the room, including grandma with the double-wide wheeled walker, whom they parked right in front of the door.  they came up to the nurse's station repeatedly demanding ice and water, so much so that the final cup count in the room at the end of the shift was over 40.  one child had sunburn, and the patient's mother demanded antibiotic cream for her.  the nurse went out of her way to get something to put on the sunburn, telling the child "i know that it hurts, i have fair skin and i get burned too", the patient's mother got up in her face and accused her of being racist, yelling "you ain't the only race that get sunburned!!".  on the way out the door, the nurse was stopped by another member of the family who told her that she was going to "beat her ass to a bloody pulp".

at this point management and security was called and a standoff began.  the family continued to be rude, belligerent, and threatening to them, so the sheriff was called.  the entire family was escorted off the floor, and we were told to call security to walk us to our cars at the end of the night. 

the next day, the antics continued.  the nurse who had been threatened spent the night hiding out in the back hall, far away from this family and their drama.  we also learned that the family had called patient relations and complained about the nurse...i'm sure leaving out the part about the threats of bodily harm that were made to her.  as the night wore on, the patient's sister came up to the nurse's station demanding personal information about the nurse, including her last name and the hours that she works. when told that we would not be giving out that information, she spent an hour yelling at then threatening management, leading the entire family to be removed from the floor by security and the sheriff for a second night in a row.  

at this point we were told that the patient's family was banned, and his room was moved so that they couldn't get to him.  we all breathed a collective sigh of relief and went about our business.  

but sure enough, the next day the family showed up AGAIN.  they harassed the secretary for awhile, demanding to know where the patient was.  when she held her ground and called security, the patient's mother walked around the unit and looked in every single patient room until she found him.  the family was removed from the unit by security for the third time.  

no less than 15 minutes later, the house supervisor waltzed in with 3 family members and delivered them to the room.  at this point i was done, and paged both of my managers to deal with the situation.  sadly, it was too late.  the family got their foot back in the door and the ban was over.  

i am LIVID about this.

this is how i feel:

you would not be able to walk into a walmart and act this way, you would be dragged out the door by their off duty police officers and not allowed back.  if you tried to pull something like this FOUR DAYS IN A ROW, you would probably be arrested.  but walk into a hospital and act a fool?  you can do whatever you want, apparently.  and everyone is willing to make excuses because "it's a stressful time" and "people are in pain and scared" or whatever it is, but i'm going to say this: IT'S NOT OK.  ever.  i don't give a crap about all the rationale, you don't get to threaten another person with bodily harm, especially not someone who is taking care of a member of your family.

so here's what i'm proposing.  ZERO TOLERANCE for this kind of nonsense.  you decide to threaten a staff member?  you are gone.  no questions asked.  and you can't come back.  seriously, eight year olds who bully other kids get punished harshly in today's society.  there are policies in place in schools, why not in the hospital?  i should not have to come to work and be threatened.  this kind of behavior is not ok, should not be tolerated, and should definitely not be normalized.

i said as much, to my managers, the house supervisor who brought the family in, and to her boss.  and i was disappointed but not surprised, when they acted like the idea of zero tolerance for threats was absolutely crazy.  as i want to keep my job still make money, i decided to keep my mouth shut, but what i wanted to yell is YOU ARE THE PROBLEM!!!  this kind of acceptance of violence is ridiculous.  everyone kept piping in with things like "i've been hit before" and "if i had a penny for every time someone got in my face", like this kind of behavior is just par for the course.

at this point, i don't think any of the powers that be will give a damn about this until somebody actually gets hurt.  how sad is that?  i'll have to actually get punched in the face before anyone will listen to what i'm saying.  and, while we're being honest, we'll be lucky if it's just a fistfight.  in the land of trauma, where people don't hesitate to shoot/stab their problems away, does anybody really think that they'll think twice about attacking a nurse?

let me spell it out:
*i don't care if nurses do get threatened/abused on a regular basis, we shouldn't.
*i don't care if it's happened to all of us, maybe it's time to say NO MORE.
*most of the time, i like my job.  but i wouldn't take a bullet for it.

and you can say i'm being overdramatic, but i'll enjoy the 'i told you so' when an angry visitor pulls a gun.  or at least i'll enjoy it if i'm still alive.

on walking away.

i have always practiced nursing a certain way.  obsessive.  controlling, at times.  vigilant.  i sense impending doom regularly.  i rely on my gut to tell me when i need to worry, which it tells me is quite often.  i have never been one who can ignore labs that are off, or who accepts "it's a chronic problem, don't worry about it" as an answer.  i have no use for timelines...if my patient starts doing something weird a half hour after my shift i don't care that i should go home, i'll be there until we figure out what's going on or until the night nurse pushes me out the door.

but we've been under the microscope lately, and overtime isn't cheap.  and after an hour long meeting with the bosses, you start to try to figure out what to cut to get out on time.  and it's actually kind of nice to have the ok to pass some problems along, to be able to walk away and say 'your turn now'.  and when management is telling you "you need to say NO", you start to think that maybe everyone else has the right idea.  walk away.  your shift is done.  what's the worst thing that could happen?

tonight i had a very stable rib fracture patient.  he was walking, talking, eating, and his pain was well controlled.  i gave him pain meds at 2205, and tucked him in.  i reported off and was finishing some charting when i heard another nurse tell Very Capable Night Nurse that the patient was saying he had chest tightness.  it was 2235, and i am supposed to be punching out at 2300.  the last half hour of my shift is supposed to be dedicated to charting, and i'm supposed to be off the floor.  the old me would have gone down to his room.  the new me thought that nights should handle it.  the night nurse asked me if i had heard about the chest tightness, to which i replied, "he's FINE.  he just has rib fractures".  

so she took her time finishing report, and i punched out 3 minutes early and waited for a coworker.  until i heard someone scream to call a code.  

wouldn't you know?  

i ran to the room and things were flying and compressions were going and everyone was running, and for once instead of jumping in i walked away.  i made all the calls, and i pointed the code team in the right direction, and i ran supplies back and forth.  but i didn't do it to be a team player, i did it because i couldn't stand to see the patient.  

why?  because i failed him.  i turned off my instincts and i toed the party line.  and now i know for sure what i always thought, there is no NO.  you do not loosen up, you do not relax.  it does not matter that there are three shifts.  Very Capable Night Nurse will go home tomorrow and sleep well, knowing that she did a good job.  and here i am, (not) sleeping in the bed that i made for myself by being a sell-out.  

so to escape my guilt, i ran as far away as i could, which turned out to be to the stat lab with a vial of blood for a code panel.  and just as the labs were done, my patient came rolling down the hall to the ICU.  i followed the bed in and stood in the corner while they hooked him up, looking like a crazy catatonic person, i'm sure.  they sat him up, and he was able to tell them his name and where he was.  

it is because he is awake and alive that i can function at all.

Very Capable Night Nurse is going to call me with an update when they figure out what happened.  i'm sure i'll still be here, awake, turning everything over and over in my head.  thinking about how i really CAN'T ever let my guard down, and i can't lighten up, and i can't ever forget what the magnitude of this job really is...that people's lives do literally depend on me every single day.  

because this is what happens when i do.  

***

Very Capable Night Nurse just called.  the patient died overnight in the ICU.  at this point we have no idea why, every test they ran up there came back fine.

and i know these things are going to happen.  and i know that this outcome isn't because of anything that i did, or anything that i didn't do.  in my head i know.  in my head.   

living the life.

humanity has been really disappointing me as of late.  the gunshots are rolling in by the dozens...six came in to the ED before noon yesterday alone.  and with them comes the inevitable drama....the three dozen entitled family members, the dueling baby mamas, and the endless string of detectives coming for interviews.

and for the first day or so of the hospitalization, the patients are scared straight, just a little.  before the gunshot wounds become badges of honor, they're just holes pouring blood.  and it hurts, and it's scary.  

but by day two, it's almost always the same.  the cell phones come out and the calls go out to all the homies, who then show up in droves to sit at the bedside and talk about how many times everyone in the room has been shot and where.  typically the conversation will turn to the shooter...and they usually know exactly who did it even though they usually tell the police it was just "some guy".  and to be honest i don't know why they all get shot, but i'm inclined to believe that most of the time it was a little their fault.  not because anyone deserves to be shot, but because these patients are reaping the rewards of their lifestyle.

i want to scream it from the rooftops.  MAKE GOOD CHOICES!!

is it really that hard?  stop selling drugs.  stop doing drugs too.  don't hang around shady people.  have a job, and go to work.  don't be in a gang.  don't make people who are in gangs angry.  stop being a pimp.  stop glorifying the hood lifestyle.  you are not 50 cent.  you are 29 and you've been shot twice now and just maybe it's time to sit down and look at your life and why these things keep happening to you.  

and i watch every day as the next generation of little gangstas are indoctrinated into the lifestyle.  they grow up coming to the hospital and visiting various relatives and acquaintances who have been shot or stabbed.  they sit quietly in the rooms while rap music blares, talking about "carrying 9s" and "doing your bid".  

i'm tired of acting like all this is normal.  THIS IS NOT NORMAL.  this is sick, and it's wrong, and i'm tired of rolling 19 year olds off of blood soaked sheets and trying to count entrance wounds.  what kind of evil does it take to look at another human being, then fire a gun at them?  9 GSWs is not a warning.

and right now i'm exhausted, but i really think that this is true: it's never going to change.  i've set myself up to spend the next 40 years of my life watching this community try to destroy itself.  and it's frustrating.  and it's typical.  but most of all, it's sad.  

it's really, really sad.

fentanyl, you are dead to me.

my patient is in for pancreatitis, which is ridiculously and notoriously painful.  unfortunately my patient, although very nice, is no stranger to narcotics.  therefore no normal medication doses were helping his pain.  as a result, the generous doctors at my day spa hospital decided to give him a fentanyl PCA with a basal dose.  first of all, you can take your basal rate and shove it, to me it screams "get the narcan".  secondly, fentanyl, really?  it's more sedation that medication, and i've had more than one bad experience with it.

so i went to this patient's room to obsessively check his breathing, and found him with a heart rate of 45.  i didn't love this, so i called the doctor and after a very typical patronizing conversation (where she insisted that fentanyl does not cause bradycardia...ha, and it doesn't cause hypotension or respiratory depression either...), we decided to take the basal out of the PCA.  naturally i didn't want to tell the patient that we were giving him less narcotic than before, so i sneakily reprogramed the pump and returned to check him again.  this time the heart rate was in the 30s.

weeeeeeell, we seem to have a little problem here.

this time, we decided to DC the PCA altogether and put the patient on some percocet and toradol (apparently the spirit of generosity in pain meds had left the building).  unfortunately, the fentanyl was still hanging around in my patient's system and his low heart rate in combination with his high blood pressure was wreaking havoc.

he started to complain of blurred vision, chest pain, dizziness, and shortness of breath.  i spent the better part of an hour running around pushing blood pressure meds, getting stat labs, and coordinating the EKG and chest xray.  i called the doctor who by this point was very sick of me, and suffered through another condescending conversation about how my patient was fine.  (funny, how an hour ago fentanyl did not cause bradycardia and now all of these very concerning symptoms are "just the fentanyl".)  then i called the STAT RN to come to assess.

of course by this time, the chest pain and shortness of breath vanished, and i was left looking like a big exaggerator.  but no matter!!  the crisis had passed (as had any hope that i would ever get a lunch break) and i returned to the issue at hand: pancreatitis patient now has crap for pain meds.

the saga continued on for a few more hours, ending with the patient dramatically vomiting up all of those great oral pain meds he was on.  at this point the patient was begging for that "Dilontin...it works for me!!" and i was pretty much at the end of my patience.  i called the doctor and got his pain meds switched to dilaudid and finally there was peace in the world.

i kid you not, 10 minutes later my phone rang.  it was my tech.  "he wants to get disconnected from his IV so he can go outside".  oh hell to the no, i know you DO NOT THINK you are going outside to smoke after everything that happened in the past five hours.  so i did what any good nurse would do.  first i avoided him until i thought i could interact with him and not rip his head off, and then i guilted him into staying in his room for another hour before i finally caved and hooked his IV machine on his wheelchair.

this situation has reminded me of several key nursing truths:
*they always want dilaudid.  ALWAYS.
*people can be half dead and still drag their nearly lifeless bodies outside to smoke
*medicine doctors are mean
*just because a patient is nice doesn't mean that they're not manipulative

and most importantly:
*fentanyl is evil and never to be trusted

um.

actual patient conversation:

visitor: "do he have restrictions?"
me: "restrictions...you mean like activity?"
visitor: "like can he have sex?"
me: "um...no.  he can't have sex here in the hospital with his chest tube in."
patient: "aww yeah, i did that last time i got shot and ripped some staples out!!  look my scar!!" (lifts up gown and exposes self to everyone in room)

seriously?  seriously.

second chances, or lack thereof part 2

remember this?   last week, my patient walked down from the rehab floor with her parents to tell us that she was being discharged.  she was talking normally, dressed in t-shirt and a pair of shorts like a typical 20 something.  the only evidence of her accident was her brace and the healing roadrash that covered her arms and legs.  her parents updated us on her recovery, and thanked us for everything that we did for her.  the whole family looked so happy, and the relief was obvious.  they had dodged a bullet and they wouldn't soon forget.  as we all hugged goodbye, her mother looked at me and the day nurse very seriously.  "we've been all over this hospital" she said, " and there is no one else like the two of you".  it was the best thank you they could have offered me, simple words to help me get through the days when it feels like nothing i do really matters at all.

once again, we have living breathing proof that people are ridiculously, incredibly resilient.  and as cynical as this job makes me sometimes, i'm reminded that second chances do exist after all.

past & present

there are certain moments in life that change you.  three years ago, a perfectly healthy 43 year old trauma patient suddenly coded and died under my care.  it's something that i've alluded to, something that certainly made me different, but also something i've never been able to bring myself to talk about.

my patient was in a rollover car accident with multiple orthopedic injuries.  he had come out of the ICU earlier that day and had promptly gotten out of bed and fallen on the floor.  he was tachy, but otherwise stable.  his chest xray was clear, so we put him on telemetry and gave him IV metoprolol.  i sat with him as i pushed his evening dose, giving it over 5 minutes exactly because i was a new nurse and that's how it was supposed to be done.  we watched the ten o'clock news together.  he was confused, but pleasantly so.  he called me baby, and i tucked him in for the night, setting his bed alarm in case he had any ideas about attempting another escape.  i left his room and sat in the nurse's station to get report on an ED admission.  as i was on the phone, his bed alarm sounded, and our aide responded.  i wrapped up report, and she came to get me.  "something's wrong with him", she said.  i went into his room and he was hyperventilating, eyes wide.  it looked like a panic attack, or a nightmare.  i asked him where he was, and he told me "jail".  he had a criminal history, so with his confusion i thought he was freaking out because he thought he was locked up.  but something still wasn't right, so i called for someone to bring me a dynamap for vitals and i called the doctor and the STAT RN.  i hooked him up to the machine and started to get vitals, turning to the doorway to yell for a coworker to grab me some more equipment.  as i listed off what i needed to her, she got a panicked look on her face.  "is he breathing?".  no, he wasn't breathing.  

i wish i remember what happened next.  i'm sure we got the ambu bag and bagged him.  and i know that someone started compressions.  the room got so packed that i couldn't move.  people were shouting out questions, only some of which i knew the answers to as i had only had the patient for that day.  at some point, the code team decided to pace him.  this is the part that i wish i could forget.  it was, to this day, the worst thing i've ever seen.  and then? nothing.  no pulse.  no respirations.  they decided to call it.  

i cried.  everyone shot me sympathetic looks on the way out of the room.  i stood, staring, against the sink while the two doctors listened for a heartbeat, then pronounced him.  my coworkers came in and helped me clean him up.  i almost told them to be careful for his broken hip.  as if it mattered.  

his family showed up, his father looked horrible.  he kept asking us what happened, and it just sounded so accusatory.  the doctors didn't know, they weren't there.  so i told him.  i told him that he was fine, and then he wasn't.  and i told him that we tried everything and it didn't work.  and i told him that it was quick, and that i was there the whole time.

it was hours after my shift, and i sat charting, trying to make sense of what had happened.  i had to call the donor network to report the death.  i had to fill out additional paperwork because he was in a vest restraint when he died.  i sat in the physician room charting while the doctors discussed the paperwork they needed to do, and the chief resident shot me a dirty look, probably wondering why i didn't work in my own space.  but i couldn't, because i couldn't stand the way my coworkers' eyes felt on me, and i couldn't handle their sympathy.  they all filed out one by one, after coming to hug me and make sure i was alright and see if they could do anything else for me.  "i'm fine" is what i told them.  i wasn't fine, and i wouldn't be fine again for quite awhile.  

i cried all the way home, then laid awake for awhile.  i slept some, and then called my parents.  then i cried some more.  then i had to go in and rehash the entire thing with the nursing director.  i cried then too.  my manager was off that day, but had heard what happened and called me on my cell phone to check up on me.  she told me that her heart sank when she heard that it was my patient who had died.  i guess she knew before i did that i wouldn't be able to handle it.    

we all know death is hard, that it makes you consider your own mortality, think uncomfortable thoughts, etc.  i was prepared for that.  what i didn't expect was the crushing guilt.  the night it happened, i actually had some peace, the feeling that everything happens for a reason and we don't get to chose the things that happen to us.  the peace was short lived.  i replayed that code in my head every day, for months.  i could see the way my patient's body twitched when he was paced, and i could hear the horrible grunting breaths that he got with the ambu bag.  i could picture his father's face, and the parade of devastated family members that came to sit at his bedside.  i remembered his two daughters who had come to visit him that day, and the way that his wife braided his hair and asked me if it was ok to use her hair cream, she didn't want to hurt anything.  and i felt horrible.  like i should have known what was going on from the moment i saw him.  like i should have done something faster, like i let my patient down. 

and slowly, the fear of seeing that kind of horror again crept into my everyday life.  no longer were things as they appeared to be.  death could be lurking around any corner.  any one of my well-appearing patients could be a ticking time bomb, just waiting to code without warning.  i freaked out about everything.  i cried all the time.  i held vigils around sick patients, afraid to leave them for fear that they would die when i was gone.  i cleared furniture from their rooms, unconsciously making more room for the code team.  i remember one patient who was tachycardic in the 140s who had a clear chest xray.  i was sure that it was a PE (this ended up being the cause of death of my patient: massive bilateral pulmonary emboli), and the doctor thought he was dry.  i looked him straight in the eye and said, "that was what you thought about ____".

it took awhile, but i got to be ok again.  time and distance from that awful code took away some of the guilt and some of the horror, but i know that i'll never forget that man.  which is why when my ED admission got called up today and the patient had the same last name, it took me back.  and i told myself that it was bound to happen sooner or later, that it was a coincidence, that i needed to not dwell on it.  my admission came up, and i settled him.  i honestly don't really know what happened to him, as the story kept changing...just that his arm had "accidentally" been cut, severing an artery.  his reputation preceded him, and i was wary the second he rolled through the door.  sure enough, the first thing he did was pick up the phone and start screaming about going to court and child support.  i did my assessment and listened to his conversation at the same time, trying to see if i could learn what actually happened to him.  he told the person on the other end of the phone where he was at, followed by "i don't even want to be here.  this is where my uncle ____ died".

i froze.  i mean what are the odds, really?  as past and present collided, i had the overwhelming urge to tell this patient that i will never forget his uncle, and to see if the family blames the hospital, blames ME for his death.  but of course i didn't.  i just went about my night like usual.

i used to wish that i could forget the night of that code, that i could wipe that man from my memory altogether.  i feel differently now.  that patient changed me.  he made me a better nurse, one who can handle the things that are terrible.  so when i came home, i took a minute to remember.

it's the least i can do.