.

i'm trying to figure out why i'm so disturbed by what happened tonight. i think that it could be the fact that things happened so fast. Or that i felt completely out of control. or maybe that i knew in my mind what needed to be done, but in practice i froze.

the facts:

1548. vitals: BP 171/91. HR 83. temp 98.7. resps 28. NG to LIS with bilious output. Patient previously verbally abusive, called me an "evil red-headed bitch" last time i was in his room. tech calls me to say the patient is complaining of shortness of breath.

i was busy with another patient. and frankly sick of being verbally abused and of this patient's mental issues (see yesterday's post). so i fully intended to ignore him. i can't for the life of me remember why i went to his room. maybe it was divine intervention, or maybe it was my habit of OCD checking.

1600. in to assess patient. noticed new bright red blood from NG tube in patient with recent history of GI bleed. Immediately went to RN station and got the chief resident to come to bedside. NG manipulated. bright red blood splattering in cannister. i am getting very worried.

1605. attempted to call day RN but stupid phone system will not recognize her name. attempted to call ICU RN that floated to floor to work day shift, but stupid phone system will not recognize his name. look in back room for anyone to help me, find no one. finally find ICU RN in hall and say "i think my patient is GI bleeding".

1610. ICU RN begins to tell me a bunch of things i need to do and my brain can't handle them all, much less prioritize which is most important. someone takes vital signs, i do not think it is me. BP now 81/52, a drop of 90 points systolic over about 20 minutes. this is VERY bad, and i am getting the feeling of impending doom.

1615. I tell the vitals to the chief resident, and she says that we'll get an ICU bed. i get the bag of fluids to bolus. i find the emergency monitor and bring it to the room. more people have appeared to help me, i have no idea where they came from. i can't get the IV bag in the pressure bag to bolus. the emergency monitor is missing the cord to get the patient's heart rhythm. i feel like i'm drowning.

1620. the bolus is going in, someone else is drawing labs. i run to get the connector to draw off the patient's line. we don't have an ICU bed. i don't know if anyone knows that we need one. i call the manager and she says that she'll work on it. the day RN comes in and she says she will call report. people keep asking me questions that i don't know the answer to. do we have a bed? don't know. did we get those labs? well i didn't draw them. is report called? not sure. i feel kind of useless, actually.

1625. we have a bed. report is called. patient is packed up and ready to go. i have essentially done nothing to facilitate this except call for help and then run around like a chicken. we go to the ICU.

1630. we are going very quickly to the ICU. we have to go in a side door because the attending "would rather be in the ICU than in the hall". the fact that the attending thinks my patient is going to code in the hall does nothing to comfort me. we reach the ICU and 4 nurses descend upon my patient and take off all my monitors, then put him on all of their monitors. once again, i stand there doing nothing helpful. at some point someone hands me my monitors back. i proceed to stare at what's going on until gently pried away by the ICU nurse.

1700. as i stalk my patient via the computer, his heart rate is 150 and his BP is 65/40. he is dying.

1800. apparently my patient is going to IR to get his bleed embolized.

1830. code is called to IR. i know that it's for my patient.

1900. my patient still has vitals in the computer, therefore i know he's alive

2000. someone writes a note. patient required 10 minutes of CPR. needed to be shocked 3 times.

2030. EKG comes back as acute MI. my patient has apparently had a heart attack.

2100. chief resident comes to floor, tells me all about everything that i already know. my patient is in the ICU. he is in bad shape. "good pickup" she said, followed by "there's nothing that we could have done to prevent this".

i know she's right. now i just wish that it would feel like the truth.

"those" nights

i had one of "those" nights yesterday. the kind that made me not want to go back to work ever again. the kind of shift that is only remedied by large amounts of alcohol and very good reality tv smut. the kind of night that is followed by the kind of day that requires an extra big coffee.

i have a new rule, and it is NEVER VOLUNTEER TO DO SOMETHING NICE BECAUSE IT WILL BITE YOU SO HARD YOU'LL WISH YOU WERE DEAD. i was having an ok night, so i said i'd take an ICU transfer. the patient didn't sound to bad, just maybe like he'd have some anxiety issues. i have a very good reputation for fluffing pillows and holding hands, so i thought i'd be able to handle him no problem.

well. that was presumptuous of me.

the patient came out of the ICU a hot mess. vitals all screwy, confused, trying to escape. no matter what i said, he would not calm down. no matter what i did he would not stop screaming. after he tried to kick me in the face, he needed to be restrained. this, however, only increased the incessant pleading to "call the police! call the paramedics! take me to the ER! call me a cab!" and so on. he began to tell passersby that i had abducted him. he passionately argued the fact that we were at the lake, at his house, at woodstock, anywhere but the hospital. he pulled the tube halfway out of his nose, then began pooping blood in earnest. his pressures went so high that i thought he might have a stroke, then his heart rate went so low that i was afraid to send him off the floor for fear he would code in the CT scanner. for 3 hours, i did not leave the patient's room. i had an orientee that dealt with my 3 other patients so i could stare at this guy and make sure that he didn't die. i walked off the floor bone tired and feeling like i was a horrible failure.

here are the other new rules that i'm trying to implement:

*there will be nights that you feel like you suck. do what you can and move on.

*be kind to yourself, because clearly no one else is going to.

*home is for home and work is for work. don't confuse the two.

slowly i'm learning how to cut myself some slack. i've been a nurse for years, and still feel like i'm flying by the seat of my pants most of the time. SO WHAT? the important thing is not that i feel really really smart, or look poised and in control. the important thing is that my patients are safe and well taken care of. and if that happens with me running around like a banshee and cursing the day i became a nurse, so be it. and if i have one of "those" nights? well i guess that's what wine is for.

the phrase I TOLD YOU SO comes to mind

nursing dilemma: fall into bed exhausted, or fall into bed exhausted after drinking large glass of wine?

i told the powers that be that we needed another tech, but nobody listens to me. apparently they want you to feel like you're participating in staffing choices by making you the charge nurse, but they don't actually want you to make any decisions or (heaven forbid!!) voice an opinion. so we had 1 tech tonight, 1 tech for 19 patients which i'm told is "appropriate staffing". 1 person is supposed to get vitals and fingersticks on 19 people? to take them all to the bathroom, and bring them waters, and count the intakes and outputs? to answer the call lights and clean up messes and change sheets and help turn? as fabulous as our tech is and as hard as she works, this is just not possible. but the (holy, almighty) staffing matrix says we don't get a second tech until we have 20 patients.

which is why after we got our first (of several, thank you very much) admits, i went to the powers that be and said "so we got an admission, where's my tech?"

in hindsight, that may have been inappropriate.

long story short, there was no tech. but there was another admission, then 2 more on the night shift. it was about this time that we realized that our second tech for nights never showed up to work.

then my admission rolled in at 2130 and i couldn't get anything done with her until the police finished grilling her about how she got stabbed.

so here i am, finally home after punching out almost an hour and a half late. i'd like to think of it as "revenge overtime".

should have given me that tech, hmm?

i don't think i need the wine tonight. i've got my righteous anger to keep me warm.

there are dollar signs where our hearts should be.

my heart breaks a little today, as i just found out that my favorite trauma nurse clinician's position is being eliminated in february. frankly, i'm getting more than a little bit tired of working for an organization that obviously enjoys showing nurses just how little they are valued.

it's ok with "the man" that i am verbally threatened by my patient's family. in fact, it is actually MY fault.

it's ok that i have to walk a half mile in the dark/freezing cold past the mental institution to my car at night.

it's ok that we constantly work short, with equipment that doesn't function.

it's ok to take the best resource that we have as nurses (aka our trauma nurse) away from us. It's not like she's the only one on the service that knows what's going on...oh wait, SHE IS.

i think we should change the motto of the organization to {enter greedy hospital name here}: you are replaceable.

why on earth would the hospital eliminate the person who mediates between doctors and nurses and makes us see each other as people? why would they take away the individual who can build a relationship with even most soulless of patients? why would they get rid of the nurse who has the skills to see when there is something wrong with a patient and the power to actually DO something about it. i'll tell you why

$$$

that is the only reason. and that makes me sick.

so we saved a life before 1500

nothing good starts with the sentence "I don't like the way my mom is breathing". of course i would have to be the one to answer THAT call light...so i sent the nurse down to the room to see what was going on. she came out a few minutes later reporting that the patient was breathing at 8 a minute. not good, not good at all. she grabbed a vial of narcan to reverse the narcotics the patient had gotten earlier and i went to page the doctor. i looked everywhere for the patient's chart to find what resident was taking care of her and couldn't find it, so i just sent out a general page through the operator and went in to help. the nursing student got vitals, which showed that the patient's O2 sats were 78%. my coworker started pushing the narcan and i ran to grab a face mask and put the patient on 10 liters of oxygen. less than a minute later, the patient's sats came up to 100% and she woke up, thanks to the miracle of narcan. we titrated her O2 down to 3 liters and the nursing student stayed with her to take more vitals. it wasn't until this point than the doctor called back. apparently i paged the attending.

oops.


i could tell that things weren't going too well...the nurse was having to explain herself way too much and there appeared to be some lecturing going on. the attending told her that he didn't feel comfortable telling her that it was ok to give the narcan, and he needed to look up the policy. to which i say:

SERIOUSLY?

giving narcan is within our scope of practice. and when i see a patient who is struggling to breathe, turning white, and looking like she's headed to heaven i will give my narcan and have no remorse. feel free to look up the policy, because i'm pretty sure that it won't say that we should let little old ladies die while we wait for you to return my page.

five minutes later the attending called back. he looked it up and had decided that we were indeed allowed to give the narcan. gee thanks. oh, and YOU'RE WELCOME for helping your patient live to see another day.

well THAT'S a new one.

So my patient got hit by a car. He refused medical treatment and instead went to the bar. When he was done at the bar he realized that he couldn't walk so instead crossed the street on his butt. Then he got hit by another car.

1. stop drinking
2. don't sit in the street

Make good choices, people.

entitlement

people think that they deserve special treatment all the time, and it makes me crazy.

case in point:

we get a GSW patient from the OR...should have known it was going to be a disaster when the PACU nurse said that she had 30 family members in the waiting room. (for the record, THIS IS NOT OK!! you have no business having three dozen people in your room. this is a hospital, not a club.) so the family comes up and for awhile everything was just fine. i was running back and forth through the nurses' station when i saw one of the family members barfing into our garbage can...and by that i mean on the floor, on the secretary's desk, and on the paper shredder. i actually gave this woman the benefit of the doubt...figured maybe she had gotten all emotional and got sick. so i got towels and some bleach wipes and attempted not to gag as we tried to clean up the food chunks off the floor. (ok, so when you come to the hospital, YOU ARE NOT THE PATIENT. i do not owe you buckets to barf in. i am not getting paid to clean up your puke. and i certainly do NOT think it's ok for your to throw up on our carpet and then blame it on us because "that aide didn't bring my bucket fast enough.)

we came to a consensus: sick visitor needs to go home. so our charge nurse approached her and gently suggested that she leave. the visitor was quick to say that she wasn't sick, she was have a procedure tomorrow and was taking a bowel prep that make her throw up. (oh dear, there are so many things wrong with this....first of all, WHAT ARE YOU DOING HERE? bowel preps make you poop your brains out. go home and sit in your bathroom like a normal person. who goes to the hospital swinging their bottle of golytely around? it's just freakish.) the RN still thought that she should go home, but the visitor was not receptive to this and started yelling that we would have to throw her out. (to which i say...ok!!) the charge nurse was getting nowhere with this woman so she just walked away.

i'm going about my business doing meds in the front hall when the barfy visitor and her family posse walk by. she's talking loudly about how "that nurse think she all hard" and i knew we were going to have a problem. as the family walked by, a male visitor got right up in the charge nurse's personal space as she was talking on a hall phone. he sniffed really loud like he was going to spit at her. the woman visitor took this opportunity to throw the barf bucket at the nurse's feet and says "i don't need this anymore". (oh NO YOU DID NOT JUST. first of all, intimidation and harassment, much? and don't you dare think for one minute that i'm going to put up with that just because i'm at work. you DO NOT get to treat people that way, you WILL NOT get away with that behavior, and i WILL call security and the sheriff on you and laugh gleefully as they take you away).

well the RN handled things much as i would have and, shall we say 'deflected' the bucket back at this lady. the visitor picks up the bucket and raises it above her head to throw at the nurse...and i just snapped. i charged down the hallway waving my finger at this woman and yelling "you do NOT throw things!! put that down, this is a hospital!!". the woman and family quickly began to blame things on the nurse, calling her unprofessional and going on and on about how they were going to report us. things were escalating quickly, so i called security. the woman is standing in the middle of the hall yelling "call them, i stand right here...I'LL STAND RIGHT HERE" while throwing her purse at a family member so she can "beat your MFing asses". i'm trying to hold back the nurse who's not backing down, and stepped between the visitor and the nurse, basically just waiting for someone to start ripping hair out. by this time i'm yelling "get out. go. GO!!" at these people and now more of my coworkers are coming down and trying to get both of us to walk away. security finally came up and carted the visitor away. i then had to type up a written statement of the incident. as livid as i was, i ranted for awhile and then just finally sat in the back room and cried until i felt better.

so let me recap:

this is all the hospital's fault because we didn't get the visitor her bucket in time so she had to throw up on the floor. it's her right to be here as a visitor and demand nursing care, hospital supplies, as well and gum and mints from all of us. since she didn't want to go home she can yell and scream at people so she'll get her way. When that doesn't work, she can have her family members intimidate staff and then throw things at them. When that is not well received, she can scream in the middle of the hall and disturb sick people who are trying to rest. to get her point across she can call names and threaten staff. she's not finished until she's carried away by the sheriff and given a ticket for being "disorderly" that she will probably never pay. and as the real punishment for all of this, she isn't allowed to visit for 24 hours...but don't worry, she CAN come back!! because after all, visitor's have rights.

it's apparently just the nurse's who don't.

i'm WAY over these selfish, entitled, hateful people.



*UPDATE*
the visitor in question called to lodge a complaint against us. then we had to sit through a debriefing in which this entire situation was blamed on the nursing staff. in the future, we will be looking forward to some "de-escalation training". i have the following things to say:

1. bitch please.
2. this is a hospital, not a department store. the 'customer is always right' rule does not apply here. not to mention the fact that YOU ARE NOT MY CUSTOMER. you are my customer's rude, classless family member who's barf i just had to scrape up off the floor. you're welcome for that, by the way.
3. i'm pretty sure i'm going to start strapping a shank to my ankle. can't be too careful these days.