trauma tries to kill (ok, maim) people, chapter 982374

trauma: a team that combines stupidity with arrogance to the point where it actually frightens me.  i am SO SICK of these people thinking that they have any business managing anything besides bellies and rib fractures.  tonight's comedy of overconfidence?  trauma thinking that they can play urology.

the backstory is as follows.  the patient is young, shot, shackled to the bed because he did something real stupid, screwed his whole life up, and now is being charged with murder.  he has a big (like baseball sized) hematoma in his bladder, and trauma thinks that it's NBD that he's peeing straight blood.  well, that is it wasn't a big deal until yesterday, when they decided to have me jam a garden hose of a foley up him and do intermittent bladder irrigations.  

do you know what that is?  that is 20 frenches of hell.  and the young men folk hate anyone messing around in their special place as it is.  but too bad, in it went and i tried to irrigate.  

tried.  

i could flush in, but not pull back.  and when i flushed the patient would shake and break out in cold sweats.  then his bladder would spasm and bloody drainage would pour out from around the foley.  then he would stand up and fluid would pour into the catheter, as well as all over his gown, sheets, and the floor.  

EVERY. TWO.  HOURS.  

torture.  it was torture.  i told trauma that the first day and begged for urology.  but no, we're going to go with this as a "first step".  and i told the chief resident later in the day that it still wasn't working.  no response.  then i told the NP the next day in rounds.  no response.  then i told the intern after dinner.  no response.

and then, i lost it.  because the situation was RIDICULOUS, their management of the patient was not ok, and i was over playing nice.  

so i called my ladies over on the uro/gyn unit and had a little pow-wow.  then i bladder scanned the patient and found that he had over 600ccs in his bladder.  at this point i could irrigate and nothing would even come out into the foley bag.  so i called the intern on call and told him that we needed a urology consult, NOW.  but he was in the trauma bay, and someone was dying, and he needed to talk to his chief...blah blah blah.  

so i politely ended the conversation and paged the urologist myself.  

and he came in from home with his man-bag chock full of catheters and irrigated 3 liters into the patient and finally managed to suck out 300ccs of clot and 500ccs of urine.  and then he took out my garden hose foley and put in one that was 2 sizes bigger.  he tried to put the patient on continuous bladder irrigation, but the clots were so bad that the tubing kept getting clogged.  so he irrigated some more.  

i stayed in that room with the urologist for over and hour.  there was blood EVERYWHERE.  we soaked towels, all the bedding, the floor...blood was in urinals full of irrigation fluid and graduated cylinders  and 60cc syringes and all over the patient.  the MD would push in a syringe of fluid and pull back nothing but solid clot. (while we're on the subject of bleeding out of ones bladder, do you think that trauma would order an H&H?  nah...)  

but, don't worry guys, trauma can handle this.  pssh.  

and tomorrow, urology will come back and decide what's next.  most likely a clot removal under anesthesia.  

so tonight, trauma, i curse your name.  i curse your arrogance, and your neglect, and the fact that you would not listen to me, and we are NOT FRIENDS.  no we are not.  i am friends with urology, and that doctor is lucky that i did not kiss his face because i almost did, i really almost did.  

and THAT, ladies and gentlemen, is sadly what it takes to get things done on the trauma service...namely, going around the trauma service.  

***and for the record, the next day the patient got a clot evacuation with urology and came back to the floor with a civilized sized foley and perfect clear yellow urine.  the day after that, he was discharged to jail.  you're welcome, trauma.  you're welcome.  ***

hierarchical feeding...

...aka, when the surgery attending climbs down off his holy mountain and proceeds to eat you.  alive.  in front of his entire service.

i must have missed the day in nursing school that said putting an SCD on a patient who's anticoagulated   is sick and irresponsible.  sheesh, you would have thought i put the thing around the guy's neck...

and then there was the fact that his brace was rubbing his leg and it was all my fault because i had no idea where the stump sock was.  um. well maybe it was in dialysis.  seeing as how that was where the patient had been FOR THE PAST FIVE HOURS.

so excuse me if every pillow is not fluffed quite so, and if there are extra linens at the foot of the bed (gasp!) but i was more worried about the fact that the patient has been repeatedly attempting to drink from an imaginary cup.

oh and also he's oriented x1 and his eyes are doing that rolly "i'm 'bouts to code" thing and frankly we have bigger problems than feng shui-ing his room.

so after i listened to all that noise which was a total waste of my time, we got down to business.  the plan of care.  i'm thinking sepsis: altered mental status, downtrending pressures, known source of infection...easy.  but he had been worked up pretty good and nothing came back.  CXR was negative.  blood cultures negative.  head CT negative.  UA was pointless because he's colonized with VRE.

which leaves us with the last 2 things.  the lactic acid and the ABGs.

i knew what i was getting into before i opened my mouth, and i almost didn't say anything because i was tired of being patronized, but that's just the way that the patient advocacy cookie crumbles sometimes.

did you know that "lactic acid is a $200 pointless test that tells you absolutely nothing and should be removed from the lab".  and that "oxygen saturations via pulse ox are 99.9% accurate and you don't need ABGs to tell you what you already know"?  well that goes against everything i have ever been taught and more than one case that i've seen, but oh well.

so that was that.

and then 2 hours later the patient bottomed his pressures out to 70/40 and got all hypoxic and started doing this weird staring at the ceiling thing with his mouth open that looked a whole lot like dying.  so i packed him up, took him to the ICU, and watched them do all those expensive "pointless" tests that i had requested.

well i tried.


*i later found out that this patient eventually had a MI and died in the ICU.  nursing instinct people...not to be ignored.*

medicine

well the floor is a complete show right now, like BAD.  why?  two words: medicine overflow.  I'm talking weird aseptic meningitis/west nile, neutropenic cancer patients, every other room getting pumped full of blood products, grey people who don't look compatible with life, bad.  people who belong in the ICU, but can't go because they are not quite 75% dead yet, which is the threshold for admission through the pearly gates, bad.

SERIOUSLY.  it is easier to get into heaven than into the medical ICU.  ACTUAL HEAVEN.

i mentioned that i'm a trauma nurse, right?  so you can take your chronically ill medicine patients and SHOVE THEM.

things that don't interest me, a list:

• your fibromyalgia/chronic back pain that means that you either a. call me every 10 minutes for meds or b. spend the entire shift passed out in your bed with a half-eaten sandwich hanging from your mouth. 
• CHF.  seriously.  it is dead to me.  core measures?  dead. to. me.  
• toileting elderly people with UTIs.  over it.
• your 3020928345 meds for your 35 documented chronic conditions, and trying to figure out what your dialysis days are and where your access is and which of your limbs are missing and if you are blind or not and managing your 300s blood sugars.  not for me.
• syncope cardiac workups that obviously aren't cardiac and are actually just a waste of my time.
• arguing with you about your cardiac/renal/diabetic diet.  if it bothers you that much, go to the vending machine or have your family bring you chicken wings like everybody else does and leave me out of it.
• the "history of" isolations.  they inconvenience me.
• trying to locate your particular medicine doctor out of the 23490 medicine teams
• pointless labs for obscure antigens and swabbing every orifice for parasites and pertussis and AIDS, and then
• wondering if i have parasites/pertussis/AIDS from being exposed to you and your inevitable disgusting hacking cough you will cough right in my face.

in other words, i am not interested in medicine patients AT ALL.  which is why i became a surgical nurse.  so, unless your 80 year old with altered mental status also happened to get shot, kindly return her to the nearest medicine unit and send me someone with a suture line.  k thanks.  

needs.

do you know what gets really old?  putting my needs last.  all the time.  apparently this is the career path that i've chosen: the road to selflessness.  in a word?  overrated.

is it really so much to ask that i get an uninterrupted half hour at some point during the shift so i can eat?  that's all i want!!  thirty minutes.  instead, today i crammed my dinner down my face in approximately five minutes and returned to running around the floor.

and speaking of uninterrupted, always being available is ridiculously annoying.  all day long i wear a phone clipped to my neck.  convenient, you say!  not so.  this is a torture device invented by 'the man' to make sure that i am operating at max productivity.  because it's not good enough that i do three things at once, i now can take multitasking to the next level by being available to field phone calls at all times.

it's enough to drive me to drink.  which i am, by the way.  i am trying to cover my anger with wine and it's clearly not working.

i come to work and feel like i'm set up for failure most days.  who's brilliant idea was it to remove half the staff from the floor all at once to go to meetings?  as if it's not bad enough that i have to keep my own four patients alive, now i have become responsible for "watching" three other patients who i know nothing about.  i dread the beginning of the shift, because it's chaos, all the time.  forget seeing any of my patients, i spend the first two hours of the shift toileting the masses.

here's what i want:  to feel like i'm actually accomplishing anything instead of just spinning my wheels. to get to eat lunch.  to get to go to the bathroom once in awhile.  to spend time with my patients and not constantly be interrupted by phone calls.  to have someone help me every now and then so i don't feel like i'm being eaten alive.

because i have needs, too.

best discharge teaching ever

chief complaint: narcotic overdose.

"stop taking percocet that is not prescribed to you"

well that about sums things up, now doesn't it.