so we get this lady from the ED. she's a bad COPDer with a crap ton of heath problems who was found down at home barely breathing and for some reason rushed to the ED. they can do basically nothing for her because she is a DNR/DNI. well, nothing except for bipap. and by golly!! it worked!!
unfortunately.
this woman was so crazy, that i wanted to hurt myself. that's right, not hurt her, but myself. self-destruct mode. three gallons of crazy in a two gallon bucket. cray.
it all started with her "running leg syndrome". ok, first of all ma'am, if you're planning on faking a disease, take the time to get the name right. now i'm not going to say that i don't believe in RLS. maybe i do, maybe i don't. but i know for a fact that restless leg does not make you buck around in bed to the point where i have to put seizure padding on your siderails. restless LEG. legs. not arms flailing and head twitching and an occasional seizure-like spasm for good measure.
also, your RLS becomes less credible when you tell me that ativan and oxycodone are the only things that can help you. the drug seeking seems obvious, yet i find these things on your home med list in obscene doses.
ooooooooohhhh, so your dealer...excuse me, your doctor, prescribes them for you. how thoughtful.
so she got half her home dose of meds for the RLS show: 1mg of ativan and 15(yes, she takes 30 at home) of oxycodone.
and oh, the sweet silence that ensued. until she became unresponsive. rock solid vitals, eyes open and looking around, but no one was home upstairs.
narcaning her was a crime against myself.
to make a long story short(er), she required 4 vials of narcan, 3 sets of STAT ABGs, and someone to hold her down so she didn't rip off her Bipap. and this is on half of the home dose.
so in the morning, when she sobered up, the true story came out. the patient couldn't sleep because of her restless legs, so she decided to take triple the amount of medication she was prescribed, a whopping 6 mg of ativan and 90 of oxycodone.
ninety milligrams of oxycodone. NINETY MILLIGRAMS OF OXYCODONE, to a woman who is approximately 115 pounds and can't breathe at baseline.
it makes me want to bang my head against the wall and not stop. self. destruct.
yes, people are that stupid. and yet somehow this stupidity is rewarded, and she gets to continue breathing even though she very well should have died because she was so stupid.
once again, if you have no regard for your own life, please do not come to the hospital and make your problems my problems. if you want to take enough drugs to kill yourself over a disease that is ALL IN YOUR HEAD, stay home and die.
yes, that's a horrible thought. it's cold and uncaring and mean and i should be ashamed of myself. but isn't it the truth?
is it so much to ask that fully functioning adults take some responsibility for their health? that they don't do blatantly stupid things like triple dose themselves on narcs and benzos?
i don't think so . do you?
Monday, December 31, 2012
Thursday, December 27, 2012
the jury is still out
...on whether or not my nursing spidey senses have once again prevailed.
the patient: middle aged, just "fell" on a drill bit square in his neck. odd for sure, but now odd and hypertensive and tachycardic and tremoring up a storm.
my thoughts? when you likey 4-6 tall boys every day (and i'm sure that this is a conservative estimate), you DT fast and you DT hard.
the chief resident? gave me my 2 mg IV ativan q 6, but says "he looks fine".
don't borrow trouble? maybe. but in my opinion, this will be an issue. a sweaty, seizure-y, run him up to the ICU issue if we're not pretty proactive.
so i'll keep you posted.
***
so i can't be sure, but i think that the fact that the ativan was up to q2 by this morning means that maybe the nurses were on to something...but, no worries!! we will never know for sure as the team has made sure to ship the patient over to psych before he can hardcore DT so they don't have to deal with it. another crisis of patient care narrowly averted.
***
the patient: middle aged, just "fell" on a drill bit square in his neck. odd for sure, but now odd and hypertensive and tachycardic and tremoring up a storm.
my thoughts? when you likey 4-6 tall boys every day (and i'm sure that this is a conservative estimate), you DT fast and you DT hard.
the chief resident? gave me my 2 mg IV ativan q 6, but says "he looks fine".
don't borrow trouble? maybe. but in my opinion, this will be an issue. a sweaty, seizure-y, run him up to the ICU issue if we're not pretty proactive.
so i'll keep you posted.
***
so i can't be sure, but i think that the fact that the ativan was up to q2 by this morning means that maybe the nurses were on to something...but, no worries!! we will never know for sure as the team has made sure to ship the patient over to psych before he can hardcore DT so they don't have to deal with it. another crisis of patient care narrowly averted.
***
Tuesday, December 18, 2012
the other side.
1/8/12
my grandma was in the hospital all week. it started with some bleeding, and a CT scan revealed some lesions on the liver and kidney. the liver was biopsied, so now we wait.
i love control. at work, in my real life, i like to be in charge. i like my routine, and i don't like change. i like being able to micromanage. with my patients, i like to be able to see all of their labs, read all of their notes, and quietly obsess over vitals and I+Os. i know when the creatinine is trending up that we need to DC the toradol, and i know when the K is borderline to get rid of it in the IV fluids. i can usually tell who we're going to need to transfuse, and I know who's going to be a problem child because their WBCs are so high.
but i don't know how to be a family member of a patient. i don't know how to wait for information that i'm used to looking up or paging someone until i get an answer. i don't know where i'm supposed to put this anxiety. and none of the platitudes that i offer to my patients and their families like "one day at a time" are working for me.
and if we don't know the results of the biopsy, then why does grandma need to meet with an oncologist on wednesday?
all that i've pictured for the last 4 days are the faces of the people that i've taken care of who have been dying of cancer. the patients that i've sent to hospice with only a few weeks left. and the black and white newspaper obituaries that sometimes get pinned to the bulletin board.
i am on the other side now. and i am terrified.
12/12/12.
my grandma died 5 days ago. i guess if i had to, i would say that it was a lot like i pictured it. at the end she didn't look like herself at all. my family told me she was "sleeping a lot", but really she was unresponsive for about 4 days before she died. and the other side? it's hard, for sure. the hospice part of it was hard. sitting for hours around the bed of someone who doesn't even know you're there. having to deal with the onslaught of well-meaning people who say nice things that only make you feel worse. 'there isn't anyone like your grandma anymore'. thanks for reminding me. and the nursing staff at the home where she died? don't even get me started. the LPN was so clearly terrified of the dying process that she practically ran in the room, shoved the syringe of liquid morphine down grandma's face, and ran out without so much as a "is there anything i can do for you?". some people apparently are too busy for compassion.
but i digress.
it's hard for me to believe that 11 months after i wrote this, grandma is gone. it seems like a long time, but also not nearly long enough. and i knew exactly what was coming, but it was all still, somehow, such a surprise.
cancer is a horrible thing. her's was "urothelial"...bladder but not bladder, kidney but not kidney. by the time they found it, it had mets to the liver and to the pelvis. i still am shocked at how it got so big with no symptoms at all.
or, if we're being honest, i look back on a UTI that i told my grandma to get checked out the easter before she was diagnosed and see that as "the sign". in 20/20 hindsight, i blame myself for not knowing, which is stupid, i know. but i digress again.
she did so well for awhile. not sick. didn't lose her hair. moved slower than usual, and couldn't do as many things, but still ok.
and we had such a nice summer...it was a cancer stay-cation. no chemo, no radiation, just a 3 month long pause to pretend like nothing was going on. and pretend i tried.
but then after that, the scans were worse. the liver met was 4 inches round. there were new lesions in the spine and the lungs.
and, one day, she couldn't walk to the bathroom.
that led us to 14 days in the hospital, which was pretty much hell. MY hospital, to be exact. who's surprised that i had a hard time giving up control of her care? no one? ok. to my credit, i did only helpful family member things and knew my place. i made suggestions when asked, but did not completely take over. and as hard and stressful as that time was, i felt like i knew what was going on. the nurses saw me come in, they knew who i was. they would talk with me honestly, and take my concerns seriously. the doctors were nothing but receptive and kind, and made sure that grandma got what she needed. so maybe it wasn't hell after all.
the nursing home on the other hand...now that could probably be considered hell. the nursing home is a book all it's own. as someone who had relatives in the home for years starting when i was young, i take issue with the environment as a whole.
first of all, why on earth is there a big bird cage in every home? birds are creepy, their eyes are blank, and when you park a bunch of drooling slumped over seniors in front of them...it's what horror movies are made of. also: nursing home smell? gross. shared rooms (especially when someone is dying), so awkward. and the barking cough of the guy across the hall? PERTUSSIS. i google-audioed it. seriously people, what's wrong with you.
and oh, the staff. lord have mercy the staff. my personal favorite would have to be the 'charge nurse' who told my mother that she really had to let them give grandma something for pain because "i just can't handle her screaming like that".
ok, lets back it up here for a second.
1. we did not say you couldn't give her anything for pain. we just didn't want you to give her the ridiculous amount of pain meds that made her hallucinate that she was dead and call my family at 3 am to tell them to call the funeral home because she was in heaven.
2. do you have something against senna? because i'm pretty sure that our pain issues have something to do with the fact that you have given her so many pain meds that she can't poop ever again.
3. this nurse also told my family that we wouldn't have to turn grandma anymore, because it was "too painful, and now you have that special air mattress so we don't have to worry about it". she's lucky i wasn't there for that one, or else i would have strongly considered punching her face.
4. also, i could care less what you CAN'T HANDLE. this is not about you, for the record.
(rant over)
so the end. the end was not as bad as i thought, and also kind of worse than i thought. i have seen people die before, this is true. it's different when it's someone you love. and if i had to describe the experience, i'd call it surreal. it feels like it happened to someone else.
i was there. i held her hand as she took her last breath. my mom was there too, and my aunt, but i was the only one who knew what was going on. i was the only one who could tell it was so close. when you're on the other side, you know too much. and also you forget that other people don't know as much. it's lonely.
i thought that "the moment" would be bigger than it was. it wasn't. to me, she was already gone. she was gone the minute she wasn't who she always was: my sassy, opinionated, fearless, strong grandma.
and now she's gone.
it's very strange. in a lot of ways, i feel the same. i have been grieving this loss for 11 months. i have been scared that her death would be so horrible that it would overshadow her life. that i wouldn't be able to remember the good times because my mind would be so full of the painful images of her last days. that she would become some sort of cancer-ridden "shell" person that would rob me of the woman i knew and loved.
but that didn't happen.
and i'm not scared anymore. just sad. really really sad.
i don't know how much of this is ok to say. i drafted the original post because it was "too personal", and i don't really do that. but this is the only way i know to get the feelings out. the only way i know to process this loss.
12/17/12
we buried my grandma today. she's no longer in pain. i'm no longer afraid. is it wrong to be so relieved? for the past year, i've been a little cynical, i must admit. cancer was constantly on my mind, and anything awful that happened in the world, whether it had anything to do with me or not, came as a personal attack. it felt like the world was dark, and just getting darker.
it makes no sense to me that now, ESPECIALLY now, with all the horrors of the past week, that suddenly i can see the good in the world.
but i am seeing it.
and after feeling so sick at heart for the past year, so scared of the unknown, already grieving for what was yet to come...for the first time in a LONG time, i feel some peace.
my grandma was in the hospital all week. it started with some bleeding, and a CT scan revealed some lesions on the liver and kidney. the liver was biopsied, so now we wait.
i love control. at work, in my real life, i like to be in charge. i like my routine, and i don't like change. i like being able to micromanage. with my patients, i like to be able to see all of their labs, read all of their notes, and quietly obsess over vitals and I+Os. i know when the creatinine is trending up that we need to DC the toradol, and i know when the K is borderline to get rid of it in the IV fluids. i can usually tell who we're going to need to transfuse, and I know who's going to be a problem child because their WBCs are so high.
but i don't know how to be a family member of a patient. i don't know how to wait for information that i'm used to looking up or paging someone until i get an answer. i don't know where i'm supposed to put this anxiety. and none of the platitudes that i offer to my patients and their families like "one day at a time" are working for me.
and if we don't know the results of the biopsy, then why does grandma need to meet with an oncologist on wednesday?
all that i've pictured for the last 4 days are the faces of the people that i've taken care of who have been dying of cancer. the patients that i've sent to hospice with only a few weeks left. and the black and white newspaper obituaries that sometimes get pinned to the bulletin board.
i am on the other side now. and i am terrified.
12/12/12.
my grandma died 5 days ago. i guess if i had to, i would say that it was a lot like i pictured it. at the end she didn't look like herself at all. my family told me she was "sleeping a lot", but really she was unresponsive for about 4 days before she died. and the other side? it's hard, for sure. the hospice part of it was hard. sitting for hours around the bed of someone who doesn't even know you're there. having to deal with the onslaught of well-meaning people who say nice things that only make you feel worse. 'there isn't anyone like your grandma anymore'. thanks for reminding me. and the nursing staff at the home where she died? don't even get me started. the LPN was so clearly terrified of the dying process that she practically ran in the room, shoved the syringe of liquid morphine down grandma's face, and ran out without so much as a "is there anything i can do for you?". some people apparently are too busy for compassion.
but i digress.
it's hard for me to believe that 11 months after i wrote this, grandma is gone. it seems like a long time, but also not nearly long enough. and i knew exactly what was coming, but it was all still, somehow, such a surprise.
cancer is a horrible thing. her's was "urothelial"...bladder but not bladder, kidney but not kidney. by the time they found it, it had mets to the liver and to the pelvis. i still am shocked at how it got so big with no symptoms at all.
or, if we're being honest, i look back on a UTI that i told my grandma to get checked out the easter before she was diagnosed and see that as "the sign". in 20/20 hindsight, i blame myself for not knowing, which is stupid, i know. but i digress again.
she did so well for awhile. not sick. didn't lose her hair. moved slower than usual, and couldn't do as many things, but still ok.
and we had such a nice summer...it was a cancer stay-cation. no chemo, no radiation, just a 3 month long pause to pretend like nothing was going on. and pretend i tried.
but then after that, the scans were worse. the liver met was 4 inches round. there were new lesions in the spine and the lungs.
and, one day, she couldn't walk to the bathroom.
that led us to 14 days in the hospital, which was pretty much hell. MY hospital, to be exact. who's surprised that i had a hard time giving up control of her care? no one? ok. to my credit, i did only helpful family member things and knew my place. i made suggestions when asked, but did not completely take over. and as hard and stressful as that time was, i felt like i knew what was going on. the nurses saw me come in, they knew who i was. they would talk with me honestly, and take my concerns seriously. the doctors were nothing but receptive and kind, and made sure that grandma got what she needed. so maybe it wasn't hell after all.
the nursing home on the other hand...now that could probably be considered hell. the nursing home is a book all it's own. as someone who had relatives in the home for years starting when i was young, i take issue with the environment as a whole.
first of all, why on earth is there a big bird cage in every home? birds are creepy, their eyes are blank, and when you park a bunch of drooling slumped over seniors in front of them...it's what horror movies are made of. also: nursing home smell? gross. shared rooms (especially when someone is dying), so awkward. and the barking cough of the guy across the hall? PERTUSSIS. i google-audioed it. seriously people, what's wrong with you.
and oh, the staff. lord have mercy the staff. my personal favorite would have to be the 'charge nurse' who told my mother that she really had to let them give grandma something for pain because "i just can't handle her screaming like that".
ok, lets back it up here for a second.
1. we did not say you couldn't give her anything for pain. we just didn't want you to give her the ridiculous amount of pain meds that made her hallucinate that she was dead and call my family at 3 am to tell them to call the funeral home because she was in heaven.
2. do you have something against senna? because i'm pretty sure that our pain issues have something to do with the fact that you have given her so many pain meds that she can't poop ever again.
3. this nurse also told my family that we wouldn't have to turn grandma anymore, because it was "too painful, and now you have that special air mattress so we don't have to worry about it". she's lucky i wasn't there for that one, or else i would have strongly considered punching her face.
4. also, i could care less what you CAN'T HANDLE. this is not about you, for the record.
(rant over)
so the end. the end was not as bad as i thought, and also kind of worse than i thought. i have seen people die before, this is true. it's different when it's someone you love. and if i had to describe the experience, i'd call it surreal. it feels like it happened to someone else.
i was there. i held her hand as she took her last breath. my mom was there too, and my aunt, but i was the only one who knew what was going on. i was the only one who could tell it was so close. when you're on the other side, you know too much. and also you forget that other people don't know as much. it's lonely.
i thought that "the moment" would be bigger than it was. it wasn't. to me, she was already gone. she was gone the minute she wasn't who she always was: my sassy, opinionated, fearless, strong grandma.
and now she's gone.
it's very strange. in a lot of ways, i feel the same. i have been grieving this loss for 11 months. i have been scared that her death would be so horrible that it would overshadow her life. that i wouldn't be able to remember the good times because my mind would be so full of the painful images of her last days. that she would become some sort of cancer-ridden "shell" person that would rob me of the woman i knew and loved.
but that didn't happen.
and i'm not scared anymore. just sad. really really sad.
i don't know how much of this is ok to say. i drafted the original post because it was "too personal", and i don't really do that. but this is the only way i know to get the feelings out. the only way i know to process this loss.
12/17/12
we buried my grandma today. she's no longer in pain. i'm no longer afraid. is it wrong to be so relieved? for the past year, i've been a little cynical, i must admit. cancer was constantly on my mind, and anything awful that happened in the world, whether it had anything to do with me or not, came as a personal attack. it felt like the world was dark, and just getting darker.
it makes no sense to me that now, ESPECIALLY now, with all the horrors of the past week, that suddenly i can see the good in the world.
but i am seeing it.
and after feeling so sick at heart for the past year, so scared of the unknown, already grieving for what was yet to come...for the first time in a LONG time, i feel some peace.
Friday, December 7, 2012
on overstepping.
nurses are just people like everybody else. so i guess it makes sense that not everyone is going to react to a situation the same way.
the patient was a man stabbed in the neck by his wife. he was immediately post op. he found out that his underaged child couldn't stay overnight, so he decided to leave AMA.
time to worry? for me, definitely. the guy just got out of surgery. the anesthesia is still hanging around, and lord knows it makes some people crazy. he shouldn't leave, or at least he shouldn't leave until the doctor could try to talk him out of it.
but his nurse saw it differently. she tried to talk him into staying and he wouldn't. she paged the doctor and he didn't call back. the patient was stable, he signed the AMA papers, she did all she could.
except call the chief resident. if one doctor isn't paying attention to you, you go above him. but when i suggested that she try that, she told me that she "wasn't really concerned about it".
well that made my blood boil. how could you not be concerned about a person who literally just got out of surgery with a stab wound to the neck up and leaving? she was WRONG.
so i paged the chief resident.
and the other nurse found out, and she was mad.
maybe it's because management is trying to push this idea of "all of our patients are all of our patients". they take that to mean that people can't walk past beeping IV pumps or bathroom call lights because "it's not my patient". but i take it a little differently. to me, it means that as a nurse on the floor, i have the responsibility to intervene in situations where i feel that a patient is not being provided with the care that they need. for example, if a patient looks sick and the primary nurse isn't doing anything about it, you jump in and start doing stuff, basically whether she likes it or not.
but it's a fine line to walk. and it's gone my way more than once. this lady was not my patient, but i pushed for her to be in the ICU because she was way too sick for the floor and her nurse was too new to realize it. this little old man wasn't my patient either, but he went to the ICU after i stumbled upon his nurse telling him to take deep breaths with sats in the 70s. and i've "helped" my coworkers this way more than even that.
because it's all about the patients, right?
or is it all about me? me being right, me liking to save the day, me wanting to be in charge?
things have gone the other way too. once i paged a bunch of doctors about a patient that wasn't mine who looked HORRIBLE, like he was about to code. turns out he looks like that quite regularly and they weren't impressed. and then there was tonight. i paged the chief resident, they were in a trauma, and he couldn't come up.
the patient took his papers and left AMA.
i overstepped my boundaries, made my coworker mad, and the whole thing came back to bite me.
and i'm thinking about it, and i really don't like myself for being this way. and just because people don't always do things the way that i would doesn't mean that their way is wrong. and it doesn't give me the right to take over every time i feel the urge to be in charge.
maybe i was right, and maybe i wasn't. i hold myself to a high standard, but maybe it's time to take some of my own advice and just focus on myself. would i let a brand-new post-op leave AMA without a fight? no. but he wasn't mine, and the responsibility for him does not fall on me.
when everyone on the floor was brand new, all the patients were essentially mine. but around here, in the land of turnover, "veterans" are two years out of school. so now that these girls have been here over a year, i guess it's time to let go.
and i guess that instead of overstepping, i need to just step away.
the patient was a man stabbed in the neck by his wife. he was immediately post op. he found out that his underaged child couldn't stay overnight, so he decided to leave AMA.
time to worry? for me, definitely. the guy just got out of surgery. the anesthesia is still hanging around, and lord knows it makes some people crazy. he shouldn't leave, or at least he shouldn't leave until the doctor could try to talk him out of it.
but his nurse saw it differently. she tried to talk him into staying and he wouldn't. she paged the doctor and he didn't call back. the patient was stable, he signed the AMA papers, she did all she could.
except call the chief resident. if one doctor isn't paying attention to you, you go above him. but when i suggested that she try that, she told me that she "wasn't really concerned about it".
well that made my blood boil. how could you not be concerned about a person who literally just got out of surgery with a stab wound to the neck up and leaving? she was WRONG.
so i paged the chief resident.
and the other nurse found out, and she was mad.
maybe it's because management is trying to push this idea of "all of our patients are all of our patients". they take that to mean that people can't walk past beeping IV pumps or bathroom call lights because "it's not my patient". but i take it a little differently. to me, it means that as a nurse on the floor, i have the responsibility to intervene in situations where i feel that a patient is not being provided with the care that they need. for example, if a patient looks sick and the primary nurse isn't doing anything about it, you jump in and start doing stuff, basically whether she likes it or not.
but it's a fine line to walk. and it's gone my way more than once. this lady was not my patient, but i pushed for her to be in the ICU because she was way too sick for the floor and her nurse was too new to realize it. this little old man wasn't my patient either, but he went to the ICU after i stumbled upon his nurse telling him to take deep breaths with sats in the 70s. and i've "helped" my coworkers this way more than even that.
because it's all about the patients, right?
or is it all about me? me being right, me liking to save the day, me wanting to be in charge?
things have gone the other way too. once i paged a bunch of doctors about a patient that wasn't mine who looked HORRIBLE, like he was about to code. turns out he looks like that quite regularly and they weren't impressed. and then there was tonight. i paged the chief resident, they were in a trauma, and he couldn't come up.
the patient took his papers and left AMA.
i overstepped my boundaries, made my coworker mad, and the whole thing came back to bite me.
and i'm thinking about it, and i really don't like myself for being this way. and just because people don't always do things the way that i would doesn't mean that their way is wrong. and it doesn't give me the right to take over every time i feel the urge to be in charge.
maybe i was right, and maybe i wasn't. i hold myself to a high standard, but maybe it's time to take some of my own advice and just focus on myself. would i let a brand-new post-op leave AMA without a fight? no. but he wasn't mine, and the responsibility for him does not fall on me.
when everyone on the floor was brand new, all the patients were essentially mine. but around here, in the land of turnover, "veterans" are two years out of school. so now that these girls have been here over a year, i guess it's time to let go.
and i guess that instead of overstepping, i need to just step away.
and the best excuse of the week goes to...
...the patient who was found shot in a crack house telling us that he was "just there to play dominos".
um no, you weren't. ok.
um no, you weren't. ok.
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