there is multitasking and then there is nursing

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

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

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

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

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

hello and welcome to my ICU

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

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

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

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

i need a new job

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.

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

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.

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.

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.