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
Monday, August 30, 2010
DRAMA, life on the floor
Most weeks we have a few situations that are straight from the 10 o'clock news. This week, I could have watched most of my patients on TV. The recap:
My saddest case this week was a teenager riding in the car with his girlfriend. They got T-boned by a pickup on the drivers side. She was dead on the scene. This kid rolls up to the floor and the first thing he asks me is "have you heard what happened to my girlfriend? If you find out anything, please tell me". He didn't know. And his parent's asked me not to tell him. They wanted to do it the 'right way'. As much as I feel for them, after a few years in the trauma world you realize that the right way to tell someone that their loved one has died doesn't exist. However, the wrong way does. I was waiting for the trauma team to go in the room and for someone to offer their condolences, not realizing that this kid was still in the dark. This was such an ethical dilemma for me...on one hand, this patient is legally an adult. My obligation is to him, not his family. But who am I to decide what's right in such a complicated situation...not an easy day. For the record, the family sat down the next day and told him together before anyone accidentally let it slip.
So after all this drama, I'm feeling a little emotionally fragile. Which is why I had such clear feelings about our next trauma floor "issue". We had a prisoner patient who had been shot by the police after he open fired on 2 officers, wounding them both. He had a police guard at bedside, as is typical for anyone under arrest. After being shot a bunch of times, and only saved by his shiny gold grill that deflected the kill shot to his head, he was in pretty bad shape. Someone decided that it was a waste of time to sit by the bedside of someone trached and bedbound, so his officer was removed and we were told that someone would call daily to check on his condition. Several days later, the trach comes out, the patient stands at bedside, and we have heard nothing from the police. So we all sat around the lunch table, discussing if we should make a courtesy call to the police so they could come back. Personally, I was all for it. I don't think that people should get to shoot others and still have their annoying girlfriends sit at the bedside and feed them strawberries. So we came to an agreement: the nurse would call. And she did. A half hour later, SIX officers are on the floor. Apparently there had been a tip from a "reliable source" that someone planned on smuggling a weapon to the patient. They searched his room, placed him back in custody, and moved him. The next day, an officer came back to the floor with a fruit plate, a big tray of cookies, and a bunch of flowers for the nurse who called. Can I just say, I never realized that being a nurse carried the risk of getting shot at work? Apparently some people have no respect for the healthcare system.
So last night, after I dealt with the emotional toll of a grieving family and the anxiety of wondering if this prisoner's family was going to come back to the floor and shoot the place up, I was pretty much ready for an easy night. Not so much. I got a motorcycle accident as an admit from the ER. The guy was stable, considering that he hadn't been wearing a helmet. His wife, who was super nice, was at bedside with him. Turns out that this guy is in some sort of a motorcycle gang, complete with embroidered vest. I got report from the ER saying that his 40 motorcycle friends were down there, and everyone says that they're blood relatives, so I could expect a full house. Frankly, I wasn't looking forward to it, so was pretty relieved when the door opened and only one woman walked in. She sat herself down in the corner, and proceeded to ask the wife who she was. That was pretty awkward, so I was really surprised when, an hour later after my lunch, this woman was STILL sitting there. The wife pulled me outside and shared her concerns about this strange lady. I planned on asking her to step out for my assessment, but the wife beat me to it. I was standing outside the room doing my paperwork when the two women came out into the hallway. The wife very politely told this other woman that she wasn't comfortable with her being there, as she didn't know who she was. To which the other woman replies "I'm his baby momma". The wife clearly didn't know anything about this, and asked the lady how old her child was. "I'm pregnant" comes out of her mouth next. "With his twins". At this point, I'm realizing that I'm stuck between the wall and these women, and that I'm probably going to get hit by a person when one of these women starts swinging. I'm also calculating how long security will take to come up to the floor and how much damage these two are going to do before somebody rips them apart. But the baby momma just turned and walked away, and the wife stood there in the hall and burst into tears. So needless to say, it was a LONG night.
Yay for some time off. I'm going to need it to seek some mental help after this traumatic week.
My saddest case this week was a teenager riding in the car with his girlfriend. They got T-boned by a pickup on the drivers side. She was dead on the scene. This kid rolls up to the floor and the first thing he asks me is "have you heard what happened to my girlfriend? If you find out anything, please tell me". He didn't know. And his parent's asked me not to tell him. They wanted to do it the 'right way'. As much as I feel for them, after a few years in the trauma world you realize that the right way to tell someone that their loved one has died doesn't exist. However, the wrong way does. I was waiting for the trauma team to go in the room and for someone to offer their condolences, not realizing that this kid was still in the dark. This was such an ethical dilemma for me...on one hand, this patient is legally an adult. My obligation is to him, not his family. But who am I to decide what's right in such a complicated situation...not an easy day. For the record, the family sat down the next day and told him together before anyone accidentally let it slip.
So after all this drama, I'm feeling a little emotionally fragile. Which is why I had such clear feelings about our next trauma floor "issue". We had a prisoner patient who had been shot by the police after he open fired on 2 officers, wounding them both. He had a police guard at bedside, as is typical for anyone under arrest. After being shot a bunch of times, and only saved by his shiny gold grill that deflected the kill shot to his head, he was in pretty bad shape. Someone decided that it was a waste of time to sit by the bedside of someone trached and bedbound, so his officer was removed and we were told that someone would call daily to check on his condition. Several days later, the trach comes out, the patient stands at bedside, and we have heard nothing from the police. So we all sat around the lunch table, discussing if we should make a courtesy call to the police so they could come back. Personally, I was all for it. I don't think that people should get to shoot others and still have their annoying girlfriends sit at the bedside and feed them strawberries. So we came to an agreement: the nurse would call. And she did. A half hour later, SIX officers are on the floor. Apparently there had been a tip from a "reliable source" that someone planned on smuggling a weapon to the patient. They searched his room, placed him back in custody, and moved him. The next day, an officer came back to the floor with a fruit plate, a big tray of cookies, and a bunch of flowers for the nurse who called. Can I just say, I never realized that being a nurse carried the risk of getting shot at work? Apparently some people have no respect for the healthcare system.
So last night, after I dealt with the emotional toll of a grieving family and the anxiety of wondering if this prisoner's family was going to come back to the floor and shoot the place up, I was pretty much ready for an easy night. Not so much. I got a motorcycle accident as an admit from the ER. The guy was stable, considering that he hadn't been wearing a helmet. His wife, who was super nice, was at bedside with him. Turns out that this guy is in some sort of a motorcycle gang, complete with embroidered vest. I got report from the ER saying that his 40 motorcycle friends were down there, and everyone says that they're blood relatives, so I could expect a full house. Frankly, I wasn't looking forward to it, so was pretty relieved when the door opened and only one woman walked in. She sat herself down in the corner, and proceeded to ask the wife who she was. That was pretty awkward, so I was really surprised when, an hour later after my lunch, this woman was STILL sitting there. The wife pulled me outside and shared her concerns about this strange lady. I planned on asking her to step out for my assessment, but the wife beat me to it. I was standing outside the room doing my paperwork when the two women came out into the hallway. The wife very politely told this other woman that she wasn't comfortable with her being there, as she didn't know who she was. To which the other woman replies "I'm his baby momma". The wife clearly didn't know anything about this, and asked the lady how old her child was. "I'm pregnant" comes out of her mouth next. "With his twins". At this point, I'm realizing that I'm stuck between the wall and these women, and that I'm probably going to get hit by a person when one of these women starts swinging. I'm also calculating how long security will take to come up to the floor and how much damage these two are going to do before somebody rips them apart. But the baby momma just turned and walked away, and the wife stood there in the hall and burst into tears. So needless to say, it was a LONG night.
Yay for some time off. I'm going to need it to seek some mental help after this traumatic week.
Wednesday, July 21, 2010
baby mamas
i don't refer to my job as 'trauma drama' for nothing. we had the perfect example of baby mama drama last week. one of my coworkers was running to grab a wheelchair for a discharge when she came upon two women screaming at each other. this in itself is pretty typical. usually I say, in my firm voice "you need to take it outside, this is a hospital", then turn around before i start laughing out loud. but this time, one of the ladies in question had a baby on her hip. things were getting pretty heated, and the two women were getting closer and closer to each other. the next thing you know, the women DROPPED THE BABY ON THE FLOOR and lunged at the other lady. my coworker was horrified, and ran to grab the baby who was about a year old and now, of course, screaming at the top of her lungs. as the two women ripped each other to shreds, one of the other kids in the crowd started to narrate and explain that her mom was hitting her stepdad's sister. enter more of my coworkers, who tried to explain that "when people are sick sometimes grownups can get really upset". yeah, that's a nice way to put things. eventually security meandered in and the next thing you know, the lady took her kids and left. seriously. did i mention that she DROPPED THE BABY ON THE FLOOR?!? and she walked away with her kids. needless to say, we were not too surprised when we came back from lunch and this same lady was screaming at another, completely different, women in the hallway. people have no class. what's even weirder: we eventually figured out that this women was the girlfriend of one of our new admissions. turns out that the other lady in the fight was our patient's sister. she was convinced that this women set up the robbery that caused her brother to get shot and then jump out of a 2 story window to escape the shooter. got all that? yeah, me neither.
i couldn't make this stuff up if i tried.
i couldn't make this stuff up if i tried.
Wednesday, July 14, 2010
beware of dog
Trauma horror of the day: 81 year old vs. Casey the beagle mix. Apparently there was a slight disagreement about whether or not it was time to go inside the house. Patient pulls on the leash, dog growls. Patient pulls again, dog pulls back. Patient goes down, dog seizes the moment and takes a 4 inch chunk out of her leg. We're talking visible tendon here, people. So now this poor sweet old patient has to go in for an I+D of her leg, and Casey the beagle is headed for the big kennel in the sky. The lesson here? Not so sure. But you'd better believe I've got one eye on the cat tonight.
Friday, June 18, 2010
it is one in the morning and i am tired.
there are days when i just want to scream WHAT DO YOU WANT FROM ME?!?! at the top of my lungs and run crying to my bed. days when i really think that all my patients want for me to do is to lay down on the floor so they can repeatedly run me over with their wheelchairs. days when i literally run from one task for the next but can NOT get caught up. days when i forget whether or not i gave an antibiotic and have to dig through the trash looking for the empty syringe while giggling manically and trying not to cry. today was one of those days.
Tuesday, June 1, 2010
today
People ask me sometimes what it's like to be a nurse. I can't ever really find the words to describe the kind of stuff I deal with everyday. For example, lets take today, a very typical busy busy day on the unit.
Today, I put an elderly man on and off the commode and bedpan 5 times. Every time I took him off, his son would call back 5 minutes later and say that he had to go again. The last time I told him that he didn't have to go. That's when he pooped the bed.
Today I helped another nurse wheel a 825 pound patient out to be discharged. He was in the bariatric wheelchair that caught on every single wrinkle in the carpet and bump in the flooring. At one point, we almost tipped him out of the chair onto his head. When we finally got him to his van, he had to lay in the back seat on the floor, and we couldn't close the door because his belly was in the way. I tried to block him with my knee so he wouldn't fall out onto the pavement as he tried to hoist himself backwards into the van. While doing this, I realized that I could very likely be crushed to death.
Today I had a psychotic patient in 4-point locked restraints. He screamed at me. He said I was torturing him. He ripped off his gown and his sheets and insisted on being naked. He called me "peaches" and asked me out on a date. He finally fell asleep after I gave him many, many drugs.
Today I had an elderly woman with dementia. Her family insisted that she has to eat even though she can't swallow. She spit her pills back out at me. She grabbed my stethoscope and wouldn't let go. She tried to hit my extern. She tried to crawl out of bed. And her daughter was obsessed with her pooping. So I was supposed to give her an enema. That definitely didn't happen.
That was today. And that is nursing in a nutshell.
Today, I put an elderly man on and off the commode and bedpan 5 times. Every time I took him off, his son would call back 5 minutes later and say that he had to go again. The last time I told him that he didn't have to go. That's when he pooped the bed.
Today I helped another nurse wheel a 825 pound patient out to be discharged. He was in the bariatric wheelchair that caught on every single wrinkle in the carpet and bump in the flooring. At one point, we almost tipped him out of the chair onto his head. When we finally got him to his van, he had to lay in the back seat on the floor, and we couldn't close the door because his belly was in the way. I tried to block him with my knee so he wouldn't fall out onto the pavement as he tried to hoist himself backwards into the van. While doing this, I realized that I could very likely be crushed to death.
Today I had a psychotic patient in 4-point locked restraints. He screamed at me. He said I was torturing him. He ripped off his gown and his sheets and insisted on being naked. He called me "peaches" and asked me out on a date. He finally fell asleep after I gave him many, many drugs.
Today I had an elderly woman with dementia. Her family insisted that she has to eat even though she can't swallow. She spit her pills back out at me. She grabbed my stethoscope and wouldn't let go. She tried to hit my extern. She tried to crawl out of bed. And her daughter was obsessed with her pooping. So I was supposed to give her an enema. That definitely didn't happen.
That was today. And that is nursing in a nutshell.
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