when i write notes and have nothing to say, i usually start with "uneventful PM shift". tonight did not apply. a rundown of my special friends
1. a spanish speaking only man who got drunk and fell down. apparently sometime during the festivities, he knocked a tooth loose. i came into his room to answer a call light. he says "mi diente" and hands me his left front tooth. i tell trauma, who go put the tooth back in the socket and make a gauze dressing. when i checked on the patient 15 minutes later, the tooth was on his bedside table. he had taken it out to eat a chocolate chip cookie. needless to say, the tooth will not be getting replaced. when i tried to explain this to the patient in my minimal spanish, he was very understanding. he plans to "just get dentures".
2. a twentysomething in a car accident...not much excitement there.
3. a septic medicine patient from africa who speaks only a rare dialect that we don't have an interpreter for. temp of 103.2. heart rate 127. shaking chills. can't seem to find a source of infection. i have been watching too much House, and therefore am somewhat convinced that she has Dengue fever and so do i. but not to worry!! per the progress note "risk of morbidity: medium". lets all breathe a sigh of relief for that one.
4. and finally, a man who got his arm stuck in a grinding machine. surprise surprise, he too is a spanish speaker!! (in case anyone is keeping track, i'm at a 75% language barrier here). but as it is not enough to simply get your arm almost ripped off, he now is in uncontrolled A-fib. hopefully he doesn't need a doctor for any reason, because he's lucky enough to be a plastics patient, which means that his doctor will not call back, even after you page him 3 times to ask a question.
then on the way out of work, we had to walk through an arrest. security and the police were gathered in the middle of the hall handcuffing and frisking a man. nobody batted and eye and we walked on through. just another day on the trauma floor :)
Thursday, December 30, 2010
Saturday, November 27, 2010
pain control
pain is the sixth vital sign, or so everyone has been trained. working on a trauma floor, EVERYBODY is in pain. the narcotics are due every 1-2 hours and the reassessments of pain levels never end. most often, people are under the impression that hospitalization is supposed to be painless...right. for the record: when you are shot or stabbed or fall out of your tree stand or get hit by the city bus, you're going to have pain. my job is to give you your medicine, make the doctors order you more if it's genuinely not working, and be sympathetic. most often this involves offering to make you a heating pad. while i realize that this probably won't do much for your 4 broken ribs, it's the thought that counts. every staff meeting on the floor begins with a little blurb about how we're supposed to be doing our pain assessments, and how we score low on controlling our patient's pain. as most people would like to be medicated until they stop breathing, i honestly don't take all that too terribly seriously. bottom line: i can tell when people are truly in pain, i bring them medication as often as i can as long as it won't hurt them, and then i push tylenol and ice packs and deep breathing like it's going out of style. most of the time, this works fairly well. this week? not so much.
it always starts with an admission that i think is going to be easy. this time it was 'just abdominal pain'. unfortunately what i thought was a tummy ache turned into bounce back admission with a history of heroin and crack use and no IV access. so i picked this patient up as we were waiting for a PICC line so i could give her fluids and IV pain meds. unfortunately in the meantime, percocet wasn't working to control her pain. i'm not surprised, as NOTHING WORKS FOR PAIN AS WELL AS CRACK. i genuinely felt bad for this lady, though. she was writhing in pain and we just couldn't get the line in. each time the IV nurse repositioned the PICC, it was in the wrong place. the hours went by, the line got repositioned 4 times, and the patient still had no access for IV medications. this is where i got creative. and i'll admit, i was pretty proud of myself for being innovative. if i couldn't give the meds IV, i could give them another way!! intermuscular medication was the solution!! i could give her a little shot of fentanyl and then she would know that i was serious about controlling her pain and maybe it would even help a little. so i called up the pharmacist who told me to go ahead, and gave my lady 50 mcg of fentanyl in her bicep. then i gave myself a little pat on the back for coming up with a solution.
45 minutes later, i was in the room with the patient and a med student. the student was doing her assessment, and i couldn't help but notice that my patient was getting pretty sleepy. as she started to slur her words, i got a little concerned. the med student was kind of weirded out too, so i grabbed a set of vital signs. i was in the middle of telling the student that i was pretty sure she was fine as her oxygen levels, pulse, and respirations were all normal, when the BP recorded. 80s/60s. in a patient with previously high blood pressure. at this point, the patient was only waking up to sternal rubbing. i called the medicine resident, who said that he'd be down in 5 minutes. i called the Stat RN, grabbed some oxygen just in case, and went to get a vial of narcan.
in my head i knew that this had to all be because of the medication i had given her, but the whole situation didn't make much sense. first of all, 50 mcg of fentanyl shouldn't have had that much of an effect on someone who uses hard drugs. secondly, the intermuscular route usually isn't absorbed that fast, and i mean really, blood pressure of 80s/60s just because of narcotics? the whole thing seemed wrong. so i was running around the room getting things set up, and the commotion attracted the attention of the on call trauma resident. this guy just happened to be specializing in emergency medicine and i could tell from the gleam in his eye that he really wanted in on the action. he stood in the hallway for a few minutes watching, and then stopped trying to fight the urge to participate and came in the room. he started checking reflexes, and sternal rubbing the patient, then checked her pupils. tiny, of course, as is common when someone has gotten too much narcotic. he suggested that i "give the narcan before she codes". we gave the narcan. it took a looooong time for her to wake up, which is weird as the drug usually reverses narcotics pretty quickly. the medicine resident arrived, i bolused her with a couple liters of fluids, and her blood pressure came up. she was still really sleepy though, which made me nervous. naturally, i felt awful. even though i knew i hadn't done anything wrong by giving her the fentanyl, i felt like i caused all this drama. so as i usually do when i don't feel right about something, i held a little vigil. i ran around to all my other patients, and in between grabbing meds and changing dressings, i would pop in her room to count her respirations and take a blood pressure. when it came time to do report sheets, i sat in her room to write them. my computer charting got finished from the chair that i pulled up to her bedside. her blood pressure was stable, she was still really sleepy, but everything else was ok, so i felt a little better. when she woke up to me yelling her name or shaking her arm, the patient said she had no pain. well, at least i accomplished something.
it was finally time to punch out and go home, and i should have left well enough alone. but nooooo, i had to get just one more blood pressure so i could sleep that night. i snuck into her room, blew the cuff up, and wasn't too terribly surprised when the result came back at 70s/50s. and so we started the whole process over again: bolus, Stat RN, medicine resident, narcan...deja vu. then i pushed her upstairs to the medical ICU for a possible narcan drip. then i punched out, an hour and a half after my shift ended. i checked up on her the next day: completely fine. awake. stable BP. go figure.
pain control is officially dead to me.
it always starts with an admission that i think is going to be easy. this time it was 'just abdominal pain'. unfortunately what i thought was a tummy ache turned into bounce back admission with a history of heroin and crack use and no IV access. so i picked this patient up as we were waiting for a PICC line so i could give her fluids and IV pain meds. unfortunately in the meantime, percocet wasn't working to control her pain. i'm not surprised, as NOTHING WORKS FOR PAIN AS WELL AS CRACK. i genuinely felt bad for this lady, though. she was writhing in pain and we just couldn't get the line in. each time the IV nurse repositioned the PICC, it was in the wrong place. the hours went by, the line got repositioned 4 times, and the patient still had no access for IV medications. this is where i got creative. and i'll admit, i was pretty proud of myself for being innovative. if i couldn't give the meds IV, i could give them another way!! intermuscular medication was the solution!! i could give her a little shot of fentanyl and then she would know that i was serious about controlling her pain and maybe it would even help a little. so i called up the pharmacist who told me to go ahead, and gave my lady 50 mcg of fentanyl in her bicep. then i gave myself a little pat on the back for coming up with a solution.
45 minutes later, i was in the room with the patient and a med student. the student was doing her assessment, and i couldn't help but notice that my patient was getting pretty sleepy. as she started to slur her words, i got a little concerned. the med student was kind of weirded out too, so i grabbed a set of vital signs. i was in the middle of telling the student that i was pretty sure she was fine as her oxygen levels, pulse, and respirations were all normal, when the BP recorded. 80s/60s. in a patient with previously high blood pressure. at this point, the patient was only waking up to sternal rubbing. i called the medicine resident, who said that he'd be down in 5 minutes. i called the Stat RN, grabbed some oxygen just in case, and went to get a vial of narcan.
in my head i knew that this had to all be because of the medication i had given her, but the whole situation didn't make much sense. first of all, 50 mcg of fentanyl shouldn't have had that much of an effect on someone who uses hard drugs. secondly, the intermuscular route usually isn't absorbed that fast, and i mean really, blood pressure of 80s/60s just because of narcotics? the whole thing seemed wrong. so i was running around the room getting things set up, and the commotion attracted the attention of the on call trauma resident. this guy just happened to be specializing in emergency medicine and i could tell from the gleam in his eye that he really wanted in on the action. he stood in the hallway for a few minutes watching, and then stopped trying to fight the urge to participate and came in the room. he started checking reflexes, and sternal rubbing the patient, then checked her pupils. tiny, of course, as is common when someone has gotten too much narcotic. he suggested that i "give the narcan before she codes". we gave the narcan. it took a looooong time for her to wake up, which is weird as the drug usually reverses narcotics pretty quickly. the medicine resident arrived, i bolused her with a couple liters of fluids, and her blood pressure came up. she was still really sleepy though, which made me nervous. naturally, i felt awful. even though i knew i hadn't done anything wrong by giving her the fentanyl, i felt like i caused all this drama. so as i usually do when i don't feel right about something, i held a little vigil. i ran around to all my other patients, and in between grabbing meds and changing dressings, i would pop in her room to count her respirations and take a blood pressure. when it came time to do report sheets, i sat in her room to write them. my computer charting got finished from the chair that i pulled up to her bedside. her blood pressure was stable, she was still really sleepy, but everything else was ok, so i felt a little better. when she woke up to me yelling her name or shaking her arm, the patient said she had no pain. well, at least i accomplished something.
it was finally time to punch out and go home, and i should have left well enough alone. but nooooo, i had to get just one more blood pressure so i could sleep that night. i snuck into her room, blew the cuff up, and wasn't too terribly surprised when the result came back at 70s/50s. and so we started the whole process over again: bolus, Stat RN, medicine resident, narcan...deja vu. then i pushed her upstairs to the medical ICU for a possible narcan drip. then i punched out, an hour and a half after my shift ended. i checked up on her the next day: completely fine. awake. stable BP. go figure.
pain control is officially dead to me.
Tuesday, November 16, 2010
cupcakes
when i got to work today, there was a box of beautiful cupcakes in the fridge from a patient that i had a year ago. the note on top thanked us for all of our care and went on to say that we are responsible for this patient's new outlook on life. "it has been one year to the day, and thanks to you all, i have many more to enjoy". needless to say, at this point there were tears. there are lots of thing that i'm accustomed to hearing on the floor, such as "you're overstaffed" or "you need to be doing your hourly rounding" or countless demands for pain meds and bedpans and water. but thank you? thank you is something that is rare. a kind word spoken about a job well done? an acknowledgement of the fact that i pour my heart and soul into this job? that was startlingly unexpected. it was a good start to a week that i was praying would go well.
1800: lasix and metoprolol were due for a lady in a-fib. since both the drugs lower blood pressure, i got a bp. 80s/40s. not good, not good. maybe the other arm? 60s/30s. very very very bad. manual BP? 70s/50s. three strikes for me. now this patient is (of course) sick and complicated. she was up in the icu for a long time on pressors to increase her BP and has been having an irregular heart rate with 3 second pauses. naturally, she is the one that i am scared of. so i paged the doctor, who told me that she hadn't gotten sign out from the primary team. she suggested that i page the chief resident, which i did.
then i waited.
and waited.
then after 10 minutes, i paged again.
and waited.
and waited.
then i paged the chief resident who was covering.
and waited.
and waited.
by this time it had been over a half hour and my patient is still sitting in the 70s/40s. low blood pressure means not enough blood to the brain, not enough blood to the kidneys, and passing out and coding and dying.
so i thought about calling the attending, but quickly changed my mind when i saw that the attending on call tonight is seriously one of the most frightening people i have ever met.
by this time i was obviously in distress. i was mad because no one was calling me back. i was mad because well-meaning people kept telling me that "she's fine" as if that's some sort of excuse to ignore unstable vital signs. i was mad at my coworkers who were telling me "don't get so worked up". this situation was no longer about the patient's blood pressure. this situation was now about the negligence of the trauma team and brought to mind all the other times that i have felt abandoned and been forced to fend for myself because the doctors were "too busy" to help me. so i turned redder and redder as i do when i'm upset, and one of the trauma nurses went upstairs to the icu to find me a doctor. she came down with the icu resident who knew my patient and thought that she just needed some fluids because of the all diarrhea she was having. i was still mad, but at least a little pacified by the fact that someone was giving me an order.
and then of course, 45 minutes later, the chief resident saw fit to call back. i politely told him what was going on, and asked if he was at home. yes, he said "you know that" (no i didn't). he then barked some questions at me about admission weight and how many liters of fluid she is 'up' for this admission. when i told him that i thought the patient was dehydrated, he told me that she wasn't. i argued my case for dehydration respectfully, bringing up the fact that she was nothing by mouth for 14 hours and having lots of diarrhea. he didn't seem to agree, and told me that she was up 25 liters since admission, and therefore wasn't dry. so i brought up her edema and suggested that her fluid might be in her tissues instead of in her vessels. he didn't seem to agree. i suggested a catheter so we could monitor her urine output. no. i suggested some fluids so we could increase the volume in her blood vessels. no. then came the most horrifying part of the conversation:
he told me to give the lasix.
with a blood pressure of 78/44.
lasix is a diuretic. lasix makes you pee out all your fluid. fluid comes out, blood pressure goes down. blood pressure much lower than 70s/40s is not compatible with life.
i told him that i didn't feel comfortable giving the lasix. he told me it wouldn't drop her blood pressure. i said it would. he said "i've been around for a little while, you know". i said "i've been around just as long as you have". the whole conversation went nowhere, and at this point i just said "ok" to everything that he said until he finally stopped talking.
i didn't give the lasix.
the patient is still sitting at a BP of 84/44. and we are just going to 'watch her' for awhile. because when she starts to have altered mental status we will know for sure that her brain isn't getting enough blood and then maybe we can do something to treat her. until then, it is apparently my job to keep my mouth shut and follow orders. psssh.
so my day started with a thank you and ended with a screw you.
but at least i got cupcakes.
1800: lasix and metoprolol were due for a lady in a-fib. since both the drugs lower blood pressure, i got a bp. 80s/40s. not good, not good. maybe the other arm? 60s/30s. very very very bad. manual BP? 70s/50s. three strikes for me. now this patient is (of course) sick and complicated. she was up in the icu for a long time on pressors to increase her BP and has been having an irregular heart rate with 3 second pauses. naturally, she is the one that i am scared of. so i paged the doctor, who told me that she hadn't gotten sign out from the primary team. she suggested that i page the chief resident, which i did.
then i waited.
and waited.
then after 10 minutes, i paged again.
and waited.
and waited.
then i paged the chief resident who was covering.
and waited.
and waited.
by this time it had been over a half hour and my patient is still sitting in the 70s/40s. low blood pressure means not enough blood to the brain, not enough blood to the kidneys, and passing out and coding and dying.
so i thought about calling the attending, but quickly changed my mind when i saw that the attending on call tonight is seriously one of the most frightening people i have ever met.
by this time i was obviously in distress. i was mad because no one was calling me back. i was mad because well-meaning people kept telling me that "she's fine" as if that's some sort of excuse to ignore unstable vital signs. i was mad at my coworkers who were telling me "don't get so worked up". this situation was no longer about the patient's blood pressure. this situation was now about the negligence of the trauma team and brought to mind all the other times that i have felt abandoned and been forced to fend for myself because the doctors were "too busy" to help me. so i turned redder and redder as i do when i'm upset, and one of the trauma nurses went upstairs to the icu to find me a doctor. she came down with the icu resident who knew my patient and thought that she just needed some fluids because of the all diarrhea she was having. i was still mad, but at least a little pacified by the fact that someone was giving me an order.
and then of course, 45 minutes later, the chief resident saw fit to call back. i politely told him what was going on, and asked if he was at home. yes, he said "you know that" (no i didn't). he then barked some questions at me about admission weight and how many liters of fluid she is 'up' for this admission. when i told him that i thought the patient was dehydrated, he told me that she wasn't. i argued my case for dehydration respectfully, bringing up the fact that she was nothing by mouth for 14 hours and having lots of diarrhea. he didn't seem to agree, and told me that she was up 25 liters since admission, and therefore wasn't dry. so i brought up her edema and suggested that her fluid might be in her tissues instead of in her vessels. he didn't seem to agree. i suggested a catheter so we could monitor her urine output. no. i suggested some fluids so we could increase the volume in her blood vessels. no. then came the most horrifying part of the conversation:
he told me to give the lasix.
with a blood pressure of 78/44.
lasix is a diuretic. lasix makes you pee out all your fluid. fluid comes out, blood pressure goes down. blood pressure much lower than 70s/40s is not compatible with life.
i told him that i didn't feel comfortable giving the lasix. he told me it wouldn't drop her blood pressure. i said it would. he said "i've been around for a little while, you know". i said "i've been around just as long as you have". the whole conversation went nowhere, and at this point i just said "ok" to everything that he said until he finally stopped talking.
i didn't give the lasix.
the patient is still sitting at a BP of 84/44. and we are just going to 'watch her' for awhile. because when she starts to have altered mental status we will know for sure that her brain isn't getting enough blood and then maybe we can do something to treat her. until then, it is apparently my job to keep my mouth shut and follow orders. psssh.
so my day started with a thank you and ended with a screw you.
but at least i got cupcakes.
Sunday, October 24, 2010
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.
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.
Tuesday, October 12, 2010
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.
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.
Friday, September 17, 2010
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.
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.
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
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