I work in an Animal House

Do not worry. That is not a picture of me after working three shifts in a row. This is a piece of art work found on deviantArt by Sabi-Krabi found here http://fav.me/d1ty67k   The sheets look comfortable though and maybe I would not mind being swaddled like that for a while.

Everyone knows that working on telemetry floors can be a little chaotic sometimes. Part of my personality is drawn to the bedlam like the moons pull on the ocean. [or something like that] .

On the third day of my work week, a few weeks ago, the associate of  my Fave Pulmonary MD summed it up best when responding to a question: Where are you? via the telephone, he answers: I am here, down here in this hell hole.

I started my work with a 6:1 ratio where 1 of the 6 was to transfer to medical. On the next door medical floor it was heard: a patient screaming with post operative psychosis that was to transfer to telemetry for…the administration of intravenous haldol. Now we all have learned that intravenous haldol has the potential to prolong the q-t interval that could lead to torsades. It must be expressed about that medical floor, sometimes while dripping full of sweat and stress: I look over and see those nurses lounging around reading fashion magazines and wonder about what the hell really is going on around here.

I have the inclination that since I am the only nurse with a transfer to medical patient, that I will be the nurse to receive the psychotic patient. So I run out of report and try to assess my patients as quickly as possible: not starting off with a good face to my patients as I seem hurried. We all learn with speed: patients often do not care, what their blood pressure is, what pills you are encouraging them to swallow or what drugs you are pushing into their veins: if they do not feel that you have time for them, the rest is meaningless.  Quick assessing like: blood pressure cuff on, listen to lung bases only, ascultate the anterior chest speedy like and check legs for edema, light touch on the belly; forget about 0800 coreg administration, they will not get it till 1000.  That is it folks, no turning, no ordering their breakfasts, no chatting, no untangling messy IV tubing. The OCD in me gets  highly annoyed as my inner self panics about that unlabeled, tangled IV tubing.  I get the phone call: It is the clinical coordinator with the news I had guessed: Give report on your transfer [wait I have not even seen that patient yet as she is the most stable] and I have assessed only one patient! The clinical says: Give report and get report on your transfer.

I walk back to the nurses station. The nursing supervisor is there! Great! I take her to the side and tell her: There is a grave unsafe situation going on here and feel terribly worried. The staffing on this floor is at an all time low, every nurse is at maxed ratio and there are only 2 nurse aides for allll of these patients. That means, in my humble opinion: no patient will be turned properly, no patient will be bathed, no patient will be fed, and some patients will fall out of the bed today.

When the monitor is alarming on the confused patient: sinus tachycardia, that was in normal sinus rhythm, that patient might be on the floor.

During this conversation with the supervisor, the chief of medicals partner was eavesdropping. He erupted in a rage and threatened action and demanded to know why from the vice president of nursing: Why do you tell me in the meetings that hospital staffing is adequate when clearly it is not?

Who shows up to the floor within one hour? The director of my floor and the vice president of nursing and they want to know why I went to the cheif medical to complain about “nursing” issues. <curstey> Excuse me but I did not do that, is it my fault that he was listening in to my concerns?

Needless to say his rage was worth naught [he is well-known for a good rage, always directed towards nursing], it did not miraculously bring more staff to the floor STAT. It did however, put me on a list I am sure: the list of whiney nurses for administration.

All of this stress worsens my confidence in the clinical coordinator, the one I need to trust to control this place.

The worst vision came true! The supervisor moved my medical off and moved in the psychotic post operative patient. The nursing supervisor gives the IV Haldol, IV Valium, takes a blood pressure for me and walks away. Yes she left me and so did the clinical. I find the patient: in four point restraints in a room farthest away from the nurses station. The patient is thrashing around even in restraints. The NGT so pertinent to healing a perforated ulcer has been dislogded and I am maxed out on sedation drugs. The patient then rips out of the restraints. Someone did not do a good job with those posies.

I am weakened: at 1000. I start assessing and taking blood pressures and passing medications all together now. The psychotic patient goes to ICU, apparently for deep sedation with intubation for: safety? I had no idea that psychotic patients could be intubated and sedated for the pure reason of psychotic-ness? Someone fill me in because I am still very new at this and I never heard of that before. I thought patients were sedated /intubated for: ventilation needs.

And what happens a week later?

I get called into my directors office to “chat” about concerns that she was probing for. After wasting 45 minutes of my time that I needed for end of shift wrap up she pulls out a paper. It says on the top: Corrective Action. Apparently my contract states that I can only call out sick twice in a six month period and if I defy that contract rule: grounds for termination are clear. I have been out four times in the last six months. Basically it felt like: You tell me about these nurses; since I did not stab anyone in the back, or feed into this probing: I get reprimanded? Now? After excellent work ethics for three years?

Where will I go now?

That was me after experiencing a real GI bleed for the first time.

 

I will never forget the first patient I cared for with an acute GI bleed. It was insane and bloody smelly. The patient came to telemetry after having blood in the stool and feeling weak and chest pain. The hemoglobin on admission was around 10 [not so bad right?]. The patient gets to the tele floor and tells me he has to poop. He looks pastey white and I give him the bedpan. I stay in the room and the smell really surprised me: I had always heard that GI bleeds were smelly. I turn the patient over to take him off the bedpan and find the bed pan full of frank red blood [and I did not see any hemmroids]. No urine in that bed pan, the patient had a catheter. The bed pan was literally filled. I called the GI MD and revealed this information and naturally the MD requested the patient to be transfered to ICU: there were 2 units ready in the blood bank [thanks to the ER type and screen]. The patient did not need to be packed up because the patient just arrived, we are leaving to roll the big bed to ICU and the patient tells me: I have to poop again. We are half out the door and I roll him back a few feet, shut the door, put him on the bed pan: he fills it with blood again. I sent the tech to the blood bank with the request slip and ask her to meet us in ICU and we go. This has nothing to do with this post, but the artwork above reminded me of that first GI bleeder. While late entry charting I could not resist checking the hemoglobin that was drawn 8 hours after the first hemogram done in the ER: it was 6. <gasps> the patient was not actively bleeding in the ER.

The place I work has bad reputation, some of which might be  blamed on the nurses bitchy attitudes, but not entirely, there are some great nurses there. A lot of it has to do with the atmosphere, there is no space, it is loud and it is messy. Mostly I have felt that it has to do with the lack of leadership and control. There is no control. We are the red-headed step children of the hospital.

Is that why I stay there? Inherently drawn to chaos and instability by nature?

Why do I stay there? I like the fast turn over of spinning tele packs. I like skating on IV poles down the halls. There are some really cool nurses there to off-set those who are less-than-cool.  I like learning about all kinds of arrhythmias and the electrical conduction system of the heart and the effects of medications on that system. I am still missing retired Fave Cardio and still see him standing at our watch station saying to me: Holy long QT interval  bat girl, no wonder her family history includes early deaths. Just as I will never forget the first time I pushed Lasix 80mg on the heart failure patient filled with rales, I nearly peed my own pants looking at that big vial.  I get a huge thrill watching the heart rhythm in atrial fibrillation, pausing, pausing, then converting to sinus rhythm. [the artist in me feels that hearts struggle]  Nothing tops the code in ventricular fibrillation run by Zorro MD, blasting the patient with 360 joules over and over again: the patient lived with enough strength to try to pull out the ETT while en route to ICU after being stabilized on the floor. Everything I ever hated about Amiodarone was suddenly made up for on that day. [I still do not like Amio, but I now appreciate its usefulness much more]

I now have three years running on telemetry. I do get tired. The shift, the house census, the acuity, the assignment/floor all contributes to the stress level. There are many stable shifts, followed by: wow, some of these patients would probably be better off in ICU if there were beds available.  I mean it  is difficult to assess these patients every four hours or more often actually to do it right [and check the outcomes]  when there could potentially be six patients to care for. Even if only two are really sick requiring all of your attention, the other four still need you; and the ruled out MI is patiently waiting for the discharge instructions. [lifestyle changes +cake walk= i love my job] 

Tele nursing has been a  huge lesson in: prioritizing. Those questions from nursing school of: which patient will you go to first?  Is reality especially when the night nurse gives you  a patient having a systolic pressure <70 and you are thinking the MAP is greatly <65 [also thinking of hypo perfusion to the vital organs, did the patient even make urine?] and that nurse is acting clueless and you know where you will be for the first half of the shift.  It has been a chaotic dance where just when you think the routine is on task: you stop everything you are doing for the chest pain in room four. Or you go into the room where the DNR is dying with no family member in sight and hold her hand, watch the irregular resps, agonal, wonder about her life and why there is no family around, and throw another blanket on top instead of watching the monitor brady-ing down.

I plan on attempting to transfer to ICU nursing when a place becomes available. I like to assess patients, that is why I want to go there. I am obsessed with hemodynamics: If I had time I would be in my patients room measuring the JVP with a centimeter ruler.  Here is the thing though: I secretly harbor social angst inside. Fear of rejection: what if they will not have me?  I still feel like a new nurse after 3 years, although I do not deny the skills, knowledge and experienced gained quickly on telemetry. I almost rolled on the floor laughing last week when a so called experienced nurse, even with ICU experience was telling a new nurse [trying to interpret a rhythm strip] that she was looking at a burst of a fib: I almost died telling her: No what you see is a burst of  PSVT, paroxysmal atrial tachycardia to be more specific, just go ask Fave Cardio sitting over there.  Isn’t it easier to stay in an atmosphere of knows something, than to switch to knows much less. Starting over? Will they nurture me? Feed me to the wolves?  Should I take into consideration my personality? In the tele whirlwind of where I now stand, all the nurses think nothing of my high energy caffeine fueled mania. They are used to me, used to my chronic blush [idiopathic cranio-facial erythema], and my talking out loud, to myself or anyone who will listen. My co-workers love me! [most of them]. In my inner world of fragile security that means lots to me. transferring would mean no more skating on IV poles because then they would all know I am goofy!

The truth is I am a sucker for forever learning so the end result of this self debating of where do I want to go and who will have me?  I will be so afraid actually, but I will never know that I can do it [or can not do it] unless I make an attempt.

i hate asystole

epi epi epi

It is official, I have decided that I hate asystole or PEA codes.  Since my new nursling days that is almost 3 years ago today (I am still a nursling <3), I have been directly involved in a total of 4  code blues. I am not including respiratory distress with intubation etc because luckily in those situations intervention preceded cardiac arrest.

3 out of the 4 pulseless codes have been aystole or PEA and those 3 patients died. The only 1 that lived was the shockable ventricular fibrillation: so that is the kind of code I liked best, if “liking” a code were possible.

I am still feeling yucky about the last asystole code. The whole thing keeps playing over in my mind and I keep thinking of how it could have been better. I also can not stop thinking about: this code blue seemed different, maybe because it did not happen on my floor where I work. I was going over to a medical floor to pick the patient up to transfer to telemetry. I  had the feeling that something was not right because the nurse called me in a panic, requesting me to hurry and pick up the patient. While I was en-route 3/4 of the way there I heard the code blue announced to the very place I moving towards and I guessed that it was the patient I was supposed to be picking up.

I walked into the room and the medical nurses were doing chest compressions and nothing else. I am not trying to describe anything negative about the medical floor, I am just trying to express that the other code blues that I have been around on the telemetry floor where I work: the nurses just start working as if being moved by some invisible robotic arm. In fact the other codes on the tele floor that I have seen looks more like:  the defibrillator is hooked up, someone is ventilating till the RT gets there, CPR is performed, someone is checking the line, someone is getting the chart, someone is getting the doppler, someone is calling for an IV pump just in case, someone is recording, someone is printing out the morning labs. It helps that I work on a pretty big floor so there are lots of “someones” around to help. <giggle> And all these someones seem to just announce what they are doing without anyone asking or telling them what to do.  The nurse is telling everyone what is going on and then he/she repeats it all again when the doctor and the ICU nurse arrives.

All I can say is that I would rather see v fib on the monitor than asystole any day. This code was just lifeless, and actually I wonder how long the patient was dead before CPR was started. The latter part depresses me too.

So it makes me think about: I like to bitch and complain about the circus arena that I work in on telemetry. But here is an example of: I wished that patient was coding in my own area called telemetry. I am not intending to claim that the outcome would have been different for the patient, that patient was dead. I am just forming an early opinion that there might be a difference in atmosphere. The outcome for my emotions would be different. I bet I would of felt less hopeless afterwards.

And for me, for my sake who is going to lick my wounds and give me some understanding?

I started this blog in the summer of 2007 when my first patient died in a code 2 weeks off of my orientation. I was sad. It helped me to write my experiences and it still serves the purpose. I feel comforted reading medical and nurse blogs because it helps me to feel not so alone in this thing that we love to do: healthcare.

Nurse Me

I got really sick to my belly

Well what happens when the nurse is sick? Oh what a terrible dilemma had washed over my bowels rendering me a weak attenuated thing. The awfulness can not be underestimated. So how did it start?

Pre viral load day, I felt an aching chill that spread through my body. I sat in the neighbors car for an hour on her heated seat for comfort, it relieved the pain in my ass that I thought was secondary to sitting for a long period studying for PCCN. I never was a good sitter and school used to drive me insane, sitting for lectures equated to one big ouch as I shifted my weight every minute and pumped my calves continuously to the annoyance for sure of all around me.

That night, to weak to cook a meal I consumed pizza and salad from a take out Italian place not to far from my housing. Afterwards I slept without to much of a hitch.

The next morning at 0600 I awoke and groomed myself diligently for the start of a 3 day work spree. I sat on my lowly toilet to pass urine and what came out was diarrhea! I had not felt sick and anyway it was too late to actually call out of work at this point so I trucked into work.

Then at 0800, my first patient, while being assessed by the nice belly doctor asked me about my patient. So I told him the news of liquid stool to which he then asked me: “Will you get me a gown and assist me whilst I perform a rectal exam?” I replied, “Naturally, of course I will assist you dear doctor.” I then proceeded to tie his gown in the back for him nicely and then I moved to opposite side of the bed, leaving the backside for him to assess. What happened next was the good doctor placed his two fingers inside my patients rectum and removed some poop and said, “Nurse the patient is filled with stool and I will have to remove it, can you squeeze some surgical lubrication on my gloved poopy hand.” I said, “Surely anything to make this easier for the patient.” As I thought of what was to come. My imagination behooved me as I stood at the head of the patients bed, gently stroking the hair repeating, “The doctor has to remove the poop that is stuck in your colon and it will be uncomfortable but you will feel better when it is done.”  I felt myself turning green.

My chronic flush fading as I felt the precious warm blood drain from my facial capillaries. I watched the doctor remove pile after pile four fingers wide of poop like bricks that I never thought possible to be stored in one persons colon.

 

I almost passed out, feeling very syncopal as I discarded the large pile of poop down the toilet in increments of quarter loads to not break the toilet. And then I found myself in the bathroom, somewhat of a wretch with my own gastrointestinal problems in the form of nausea, vomit, and diarrhea. Every patient smell made me want to hurl out the contents of my stomach which was filled at this point with nothing and I felt myself become depleted.

 

Fluid volume deficit is an understatement as I secretly guess-timated how much volume was lost with each episode. When I finally got home I bet my blood pressure was in the 70s, but I would not dare attempt to measure my pressure, it is bad enough I was mentally mathematically calculating my intake and output.

 

I crawled into bed with my Gatorade bottles and Tylenol, I was febrile and hurting.

 

I did not dare take the Immodium because I know whatever was cooking in my intestines did not want to stay there to grow and multiply like some sick fermentation pressure container.

I stayed home from work on day 2 and felt weak but on the road to getting better. I ate toast: the first solid in 40 hours. It did not stay down, it came out the back door. By the evening I tolerated vegetable soup and crackers without immediate expulsion. I went to work for day 3, still feeling weak.

I found myself in charge again and the monitor tech without patients, which was good because I doubt if I could have spinned on telemetry like my usual self. It was still a rough shift and my body was still hurting, it still hurts. My emotions hurt too, but I will save that for another helpless self esteem bashing post another time.

Whatever decided to invade my body achieved its intended effect: to make me cry. Now I feel better enough to seek revenge: I have a big bottle of bleach and a bucket, and I know how to use it. Seek and destroy you nasty poop virus.

forever student

I am not gonna try this!

We never stop learning around here in this business we call healthcare, I guess that is why I like it so much. I get to be a forever student and I do not have to rationalize it to anyone! A few months ago this blogger told me about a procedure demonstrated in the above picture: the precordial thump! At first I hardly believed it although it kinda makes sense I mean a fist can pack some energy. So I looked it up and found some articles and I guess it is used if there is no defibrillator in sight and you witness a cardiac arrest. I doubt that I would ever try it: unless I am in the middle of the desert, or the jungle, or lost in the mountains, and sure that EMS is not going to roll up and rescue and take over; I suppose in those situations I would give it a good whack, I mean thump and hope that I could end a lethal arrhythmia with my fist.   In my pursuit of finding out about this method I also found some other outdated medical procedures such as inserting mercury to break down a bowel obstruction! Read it all here. if you feel like it.  

Anyway it is good to have an open mind and be flexible, or “teachable”. I happen to fit into that teachable flexible type. I want to know if there is a better way, I want to know why we do the things we do as nurses. Things will just get into my mind and I have to know the answer. For example now I find that I am still perplexed over the purpose of infusing half normal saline. I just do not get it and as soon as I finish this post I am going to seek and destroy all useful materials till I find the answer. I guess it is something I should know the rationale for already right? Maybe I just like normal saline because it helps to raise the blood pressure in the sinking, dehydrated, patient. I get jollies from that cause I am a nerd. And because of my fondness for normal saline all other salines can hit the road.

Seriously though, some nurses tend to get stuck in their ways of doing things that they just can not get past any other way. I was told by one experienced nurse who noticed that every week I handling report with one particular night nurse more often than with other night nurses, that it was not healthy because a relationship develops, or you might trust her too much, or things might get missed. This had been planned by me and this night nurse because we worked the same days and it became extremely convenient. Well, I found out that it was true and this nurse has become a nightmare for me, an unhealthy work relationship; I tend to take things personally.  Her anxiety level is so high I am not sure how she handles her job the way she gets so worked up over everything. I try to placate her, but her negativity has striked an all time low lately and I have decided to sever this relationship with her for both of our sakes.  And she also suffers from nurse who thinks she is a doctor and I think that is where all of her angst comes from, that and working on night shift she does not realize that all the physicians have assessed the patient, looked at their labs, adjusted medications, and so on, she just does not see the picture. She starts out every night with negative verbiage like: Am I transfusing blood again? And I respond like, no but if the patient needs a blood transfusion that is your job. And she will greet me in the morning with some negative crap like: Your patients were pooping all night, why did you give this to me? And I respond like, they are “our” patients not “my” patients and sometimes people are sick and poop a lot. Her last meltdown was over the usage of a flat sheet versus a fitted sheet over an air mattress on a patient that has skin breakdown on the back already. Now I am not sure where I learned that a flat sheet is better, I just knew that probably from orientation but it does not really matter in the end really. I advised her if she did not like the sheet that I used she was free to change it. She did not like my response very much and flipped out and even cursed at me telling me to show her the policy and evidence of utilizing a flat sheet. Of course I could come up with no such piece of paper to please her outraged mentation so I just ended the conversation and made sure that every single patient that we had on an air mattress had a flat sheet over it so she could become enraged after I was out the door and in my warm car, to safety.  I did not  flip out on her when she handed me a patient that had an occluded lumen on the PICC line that she was infusing antibiotics via the other lumen when the hospital policy clearly states that the lumen should be cleared before infusing anything. I mentioned it to her briefly that we should tPA the line, and that is what I did after she was gone, spoke with the physician about the occluded lumen and tPAd the line. I do not want to drag this out anymore, I really did get it out of my system last week ranting and raving about her unprofessional behaviour and luckily I obtained the support of colleagues. I just do not want end up like her one day: negative all the time.

I am back to studying for PCCN certification and I applied to a university to start the work for a BSN, I hope to start this semester one class at a time and I have no excuse not to. I am secretly contemplating writing a novel, but this is not the time to show my hidden talents.

Happy late New Year! Maybe some time I will have the time to fix this blog up, it looks kinda plain to me lately.

In the holding tank

A few weeks back I was pulled to work in the emergency department to care for the patients that have been admitted to the hospital but have not been assigned to a unit or bed related to the fact that there were no beds available. This is not uncommon when the hospital fills up to maximum capacity and yet there are still more sick people who require hospital admission. I have mulled over this debacle many times, have been pulled to emergency for “tele holds” many a dreary occasion.

When I arrived to the department I found the place to be busy and chaotic, the nurse coordinator exclaimed with excitement, “Are you here for the critical care holding?” I replied with a quick no, no way, I am here for the telemetry holding, boarding patients. She seemed exasperated. Not only do I not have critical care experience, but even if I did, the emergency room setting is the last place I would want to be trying to maintain safety on sick patients.

I know there is research out there on the outcomes of patients holding in the emergency department waiting for admission beds, but it escapes me right now where I have read such research. It does not take a researcher in a white lab coat to figure out that: patients holding in the tank (while safety may be maintained) are not receiving the most optimal care. The emergency department is just not equipped, not set up, for routine nursing care as it is on the floor. Emergency rooms are set up for *gasps* emergencies.  Here is a little article found in haste about this holding issue.

On this particular day, the coordinator for some strange reason pulled me to the middle of the department and all my holding patients were surrounded by patients in respiratory failure to my left and right. I must have seen at least 3 people roll in via EMS to be immediately intubated and 1 rolled in needing full ACLS. In the midst of all of this, I was giving report slowly and painfully to the floors on each patient that was lucky enough to receive bed assignments.

Jane in true narcissistic fashion wondered what it would have been like for my holding patients had I not been there to nurse these holdings, lost in the limbo patients. I mean certainly the emergency nurses were busy caring for the never-ending stream of emergent patients that were scurried in via medics. 

The bottom line is this: A few hours of holding might not be a problem, but when the patient is holding for a shift or more, routine care is compromised. For example patients needing routine medications, or say: a bowel prep for surgery in the morning, the emergency dept is not the best place to provide this care. During my last 12 hour stint caring for the holding: I bowel prepped a patient for surgery and there was not toilet in the room to rinse the dirty bedpan after the patient downed the mg citrate! This means walking around the emergency dept to the nearest toilet that everyone uses to rinse a poopy bedpan! Can we hold off on surgery that the patient needs because there is no bed available? The surgeon wants to operate, the patient needs it, and yet where is the patients bed? Surely the patient will get a bed before the morning so there is no stopping this essential bowel prep just because the patient is sitting in the holding tank with no toilet nearby!

These patients are sick and they need to get to the floor, and in my opinion: the quicker the better for the patient. (Unless the patient can not breath, has no pulse, or has no blood pressure duh)

I used to rant and rave over the emergency dept sending patients to the floor without “doing” anything, but my opinion has been changing lately. Sure the ED should be screening the patient for sepsis  when they present that way and yada yada yada, but my experience is the place is chaotic and the emergency department needs to tend to emergencies so if the ED calls me to give report on a stable patient that does not have a complete admission order set written, I take report and say: red rover red rover send my patient on over. I would rather assess the patient myself  and then call the doctor for everything I need at one time anyway. This is not to say that I do not get miffed when my patient arrives from the 5 minute transport to the floor in respiratory distress and the patient presented that way, and ABGs have not been done and the patient needs BiPAP like right now and I end up rapidly responding the patient: that irritates me.

I am just sayin: there has to be a happy medium right? Getting these holding patients to a room was not easy, admissions appeared to like to give the bed assignment then page it away to someone else rather quickly and as soon as one patient left, another patient was added to my assignment. It was impossible to actually chart my assessments on all of these patients: probably 12 throughout the shift. I could only document the vital signs and the medications on the more stable range and type in only essential notes on the more critical side and only charting interventions performed because I spent the rest of my time trying to give report to the floor.

I hang on the receiving line and hear: the bed has not been assigned, the room is not ready, the curtain needs to be changed, can I call you right back?, this patient is to sick for telemetry call the doctor for ICU (nursing the numbers), the nurse is on lunch, etc, etc, etc.

Now I have been on the other end of this line and I have to say that I always take report immediately because I know that what my patient needs, they are probably not getting right now, not because of incompetence but because half the stuff they need is not even there! Hello Nurse world: The ED medication dispenser does not have coumadin loaded into it(as well as many other drugs)! You can wait and beg the pharmacy to send it to you via the awesome bullet system, but in a hospital built in utopia like the one that lives in my mind: admitted patients will not be holding that long in the emergency department!

I am not taking an “us versus them” attitude. I am taking a “let us be a functional family” attitude.  We are all in this to care for the patient: that is the job at hand, the task, the mission, it is what we do this for. I can say that having seen how crazy the emergency room is: when filled with emergencies, there is no reason for the floor nurse to not take report and receive the patient as soon as possible. On the other hand: I understand the telemetry nurses complaints about patients that are sent to telemetry that are on the cusp of critical care and we tele nurses tend to blame it all on the ED nurses! Like: they sent this critically ill patient to me, and wasted time that could have been spent on resuscitating the patient! Of course the patients are sick! If we all wanted stable we would work in the doctor’s office!

Let us all just be friends and trust each other! Tele nurses: take report on the patient right away unless you feel that the admission to telemetry is totally inappropriate and the need to advocate for a critical care admit is completely obvious via report (do not nurse the computer).  Emerg nurses: screen tele admits ie: if the patient has a respiratory rate greater than 30 and need 100% oxygen on a non rebreather please get the ABG and triage the patient for appropriate bed assignment especially when the admitting MD has not assessed the patient yet. It does not have to be a battle, we can all get along in my Utopian Hospital.

I know I have made this lengthy, trying to put words to my experiences from nursing the holds in the setting of the emergency department. I may not have summed it all up accurately, so here is how I felt: I just felt that sooner the patients could get to a more controlled environment with one primary nurse the quicker the patient could get appropriate treatments. Everyone should be where they belong and that goes for nurses and patients! The thing is I am not sure where I belong yet, but I still like my job! <3

Oh and Merry Christmas and Merry Holidays to everyone! I tend to cry lots around this time but heh, I am just a sack of emotions. ewww.

Rage against the ME

The start of this blog the tone is one of an insecure new nursling taking bits of learned information, inherited through repetition of the same diagnosis and the treatments that follow them around like a broken record.  What have I become? A bitchling nurse? I will fix me.

I will never forget as I doubt any nurse can forget the first patient that arrested cardio-pulmonary fashion. I was on the telephone, receiving report for an ICU transfer to telemetry when my patient coded and as the code blue was announced on over the intercom, I was like: I better call you back, I think that is my patient coding. I did not know what was going on with the patient. No: I do not know what the K+ level is today, No: I do not know if the INR is therapeutic yet for the DVT treatment, No: I do not know shit: except I do know that the patient is sick and just had a TEE done at the bedside and I think they said that the central line was found to be inside the left atria somehow and that they found vegetative growths on the heart explaining the blood stream infection that never went away.

What about all those transfers to ICU especially during my first year as a fledgling nurse, on my patients that I had no idea what was going on or wrong with them. My report sounded something like this: Fave ICU nurse much like: (a cynical nurse): Why is the patient coming up here? Me: I dunno, the patient is sick. #FAIL.  Or the end stage cancer patient: dehydrated to the bone, with no blood pressure palpable: I started the dopamine gtt as per the internal medicine MD (like a good little monkey nurse) never bothered to ask the MD for some IV fluid resuscitation first, not knowing that the dopamine will do jack crap if there is not any fluid volume to work with. Fave ICU nurse: Did you try and get the pressure via doppler? Me: how do you even do that? #FAIL.  What about the patient, lethargic, pasty, pale and waxy looking:  septic soaked from head to toe in urine, hypotensive, hypothermic and limp by the time that patient gets upstairs. Fave ICU nurse: This patient is soaked with urine. Me: Yeap, I guess I did not realize how sick this patient really was till I got no blood pressure during 1200 assessment and vitals, while I was running around tele all morning doing tasks of a lesser priority. #FAIL.  What about the patient in status epilepticus transferred to ICU. Fave ICU nurse: Did you give the patient the seizure medications? Me: No the patient has been either having a seizure or appearing post ictal, so I could not give any medications by mouth, so every time the patient has a seizure, I  just give the IV ativan. Fave ICU nurse: Did you call the neurologist to change the oral meds to IV to prevent future seizures? Me: No, I just keep giving the ativan, but the blood sugar is ok. #FAIL.

With the above paragraph in mind it should be noted that this ICU nurse in description never really made me feel inadequate or embarrassed about my knowledge deficits, instead of that: each experience was a learning experience that I put in my pocket for the next time. If this nurse never asked me the questions to which I had no answers, I would have never even thought about it for the next patient that needed it. When I can not get the blood pressure with a manual cuff: I just get the doppler! When a doctor asks me to infuse dopamine on a patient that is dehydrated: I stop and ask for IV fluids too.

And that being said: I would like to rant on ME because of my inappropriate behaviour the last few times I received transfers from a medical floor where I acted like I was all knowing and the nurse was all not knowing. A few examples: Post-operative patient has a fast heart rate, they do not know the rhythm on medical they just tell me the heart rate is 130-150 and that the MD wants the patient transferred to telemetry and a STAT cardiology consult. Me: Does the patient have a fever and what is the hemoglobin? Medical floor: No fever, the hemoglobin was 12 before the surgery, not sure what it is today. Me: *sighs* I go pick up the patient in sinus tachycardia white as a sheet. I give the patient the lopressor 5mg and do a STAT cbc, the lopressor does nothing and the cbc comes back with a hemoglobin of 6. I transfuse a few units PRBCs and the tachycardia goes away and the patient turns from white to pink and I rant off in the nurses station about the medical floor nurse being an idiot. Another one. Me: Why is this patient coming to tele? Medical floor: I dunno, the doctor said so. Me: What doctor? Medical floor: I dunno. Me: What is the problem? Medical floor: Change in mental status. Me: Did you do anything for the patient. Medical floor: Like what? And then I rant off the whole time under my breath as I push the bed with a co-worker all the way from the medical floor to the CT room for the STAT CT of the head and then all the way to tele after that, all irritated and sweaty.

Then I get home and think about it with guilt. I took an irritated tone plenty of those times while receiving medical transfers to telemetry, mostly cause I was probably busy in my own chaotic world of spinning tele packs, and now I have to figure out what is going on with the new patient to my group and half the time worrying that if they want the patient transferred to tele, the patient might be even to sick for tele and might really need to go upstairs to critical care: but instead of the nurse calling in the whole picture to the MD they just call for one thing: like the tachycardia,  and the patient gets sent to telemetry to get sent to ICU a few hours later like a roller coaster ride or lets play musical beds and waste resources. So I am guilty of the rant factor, and now I can stop to think about all of my transfers to ICU when I did not know what was wrong with my patient, just like the medical floor not knowing what was wrong either. And I stopped to think how lucky I really am to be able to learn something every time I transfer a patient to ICU, and next time I will not be so condescending to the medical floor nurse.

I mean what I am trying to say is that we are all working for the patient, right? And some of us are in this to keep learning too, right? I might have the care for: chf, afib, sepsis, copd, pneumonia, stroke, and NSTEMI down to a theatrical performance after 2 1/2 years post orientation on telemetry but I am still lost with those basic concepts like just how does the fluid dwell in the abdomen of this ETOHer all yellow in liver failure as my brain tries to figure it all out as I clean up the poop that fills the bed from the lactulose for the 12th time this shift.

After all: we are all special in our own ways: I have seen ICU nurses pulled to telemetry freaking out as to how they will assess 5 patients in the same fashion they assess their 2 in ICU.  I have been pulled to medical and freaked out over how can I assess, medicate, manage tube feedings, change all those dressings, on 7 patients like I do 4 or 5 on telemetry. I have seen the surgical nurse pulled to telemetry and fearfully asks Fave Cardio about a patient he just wrote discharge orders for: “Are you sure I can give all these cardiac medications at one time?” and Fave Cardio tells her, “Sure give the patient all the meds, if the patient does not pass out, discharge to home.”

With all that being said: I need to take out the professional whip on myself because I have been freaking out way to often at work. Some nurses act crazy and inappropriate on my floor and I do not want to be like them. Just last week I freaked out on a lazy nurse as she tried to move around the patient assignment and break up my group at shift change while she was not in charge AND I was bedpanning 2 of her patients all day because I had the neighbors of her patients and could not walk away from their toileting requests. Little See Jane Nurse went ballistic till she put everything back the way it was on the board. I got what I wanted at the expense of looking like those who I have the often occasion to laugh at: laughing my panties wet at nut job nurses having meltdowns and temper tantrums over stupid stuff and lately I just did the same exact thing. oh noes.

So part of this fixing me at work is just knowing what I do not want to be: that mean nurse that feels superior to other nurses, or that nut job nurse that freaks out and throws a rage over minor details, or the nurse that nurses numbers and computers. I want to be the nurse that keeps on learning via cool ICU nurses and continuing education, I want to get what I want at work via professional verbiage and I want to share what I do know with others instead of hording it to myself and making someone else feel inadequate. I want my attitude to the medical floor nurse to be like: hey, I know you are busy over there with 7 or maybe 8 patients! and we can figure it out together, and I am coming over to pick your patient up, okies?  Cause hell, I know well how good it feels to drop a sick patient off to ICU and feel relieved because the patient is sick and things are spiralling out of control and I have 4 other patients to care for, knowing that the sick patient is now in a more appropriate place to get the care they need.

Since this post is longer than I originally intended I will go study the cardio portion of the PCCN prep course that I have involved myself in. Cardiovascular is 36% of the exam, I finished studying: pulmonary, neuro, nehpro and even professional caring and ethical practice as outlined by AACNs synergy model for patient care. After cardio I have left to study: heme, endocrine, multisystem and behavioral. Okies I am rambling now but imagine if I pulled this off to my charge nurse: According to the AACNs synergy model for patient care, the acuity of my patient assignment is complex according to the patients characteristics of: read them here.  Rambling, I think I will go pen some cardiac haiku or something that will surely lead to my fame and fortune as a writer, nurse, fake poet.

More on Sepsis

Here is one awful situation that will surely make your hair stand up.

Patient comes in I think from the nursing home, foley is inserted in the ED, out comes chunky soup into the foley bag. Blood pressures in the 80s, change of mental status. Diagnosis is urosepsis. ED does blood cultures, gives one dose of antibiotics, hangs up some normal saline and gives report to night shift tele RN. ED RN tells tele RN: pt on room air, NSS infusing at 100ml hour,NSR, pt given Tylenol for rectal temp of 102F, blood cultures sent, SBP  now in the 90s, WBC count elevated. The tele RN stops and says, “This patient sounds to be septic, did you get a lactate level according to sepsis screening?” The ED RN flips out becomes verbally defensive and tells the tele RN: “Not every patient needs a lactate level drawn.” Well, after that the teleRN calls the nursing supervisor and voices her concerns, she is shut down by the nursing supervisor who verbalized, “I have worked with that ED RN, she is a good nurse, do not worry about it.”

Patient gets to the tele floor, tele RN assesses: NSS bone dry to the line (not a drop left, and wonders for how long? certainly not for the quick transport), pt is tachypnic >30 resps per minute on 5 liters of oxygen (she said room air), pt is febrile rectal temp 101, pt SBP via doppler is 70 (she said in the 90s), pt is sinus tachycardia 130s (she said NSR), peripheral pulses NOT palpable, pulse ox: unattainable.

Wow. what a big change in condition from the ED holding room to the telemetry floor in less than ten minutes, this patient appears to be crashing. I am not saying it is NOT possible, but the attitude delivered from the ED RN when questioned about sepsis screening put the tele RN on edge to start with.

Immediate interventions by telemetry RN: Fluid resuscitation with NSS started, ABG obtained now, lactate now, rapid response called now.

The outcome: Pt was found to be hypoxic and in severe metabolic acidosis followed by a lactate level >5. The patient was immediately transferred from telemetry to ICU, where the patient then arrested cardio-pulmonary style and died exactly one hour from leaving the emergency department.

I am not writing this post about the ED nurse not screening for sepsis, I know that acute care patients are not stable, hell if we only wanted to deal with stable we would be working in doctors offices or something like that. The point is that sepsis screening was missed, the patient sat in the ED holding tank for 8 hours post triage and admit orders and interventions were missed, delayed by exactly that much time. If the patient were to have been screened prior to crashing upon arrival to telemetry the patient would of been admitted to critical care and would of received aggressive antibiotics and fluid resusc and hemodynamic monitoring as per severe sepsis standards.

The response: “She is a good nurse, do not worry.” is a highly inappropriate response from the supervisor. It is not about being a good nurse or a bad nurse (we are not label givers), it is about following the hospital policy and providing standards of care. The attitude of the ED nurse just made the whole situation less tolerable.

We are all in this together and that is for the patient, our job would be so much easier if we would all just work together. And on that note: my next blog post is going to be rant about myself and how awful I have been lately. Coming soon.

Alive after the code

I am being a lazy nurse blogger again. What can I say for myself? I have no legitimate excuses, I miss my blog so here I am with not much to say. I was going to write about my latest experience in a code blue situation, I was going to give everyone the step by step run down of ACLS initiated at the bedside on a telemetry floor and the awesome outcome, but I lost my drive as each day passed by after the event, till it seemed like routine. It was pretty darn amazing though: the teamwork, Fave Cardio, the RT, the nurses, the whine of the defibrillator charging.

Here is the scene without a minute by minute detail: I was just back from lunch, and the patient was being diaylized, I am walking down the hall and I hear the dialysis RN yelling we need help in here. She was talking to the patient when all of a sudden: nothing, no pulse, no response. At the same time at the monitor station the tech was saying: Ventricular Fibrillation in room # 13. By the time I get into the room I see the dialysis nurse un-hooking the permacath from her machine, there is water all over the floor, 2 nurses are already at the bedside, 1 calling for the backboard and 1 lowering the head of the bed and raising the bed at the same time.  It seemed like it took forever to hear the “code blue room telemetry room # 13″, in fact by the time I heard the announcement the patient was already being ventilated via ambu, the backboard was under and the patient was being compressed and had already been defibrillated with 200 joules and the first epinephrine was already prepared waiting to go in. Ten minutes in the patient was intubated, the House MD was there and one Fave Cardio showed up to collaborate with the House MD. Fave Cardio did a superb job demanding full charge on the defibrillator and he seemed to like to press the charge and shock button, he made everyone nervous charging that machine but kept saying every time, “Do not worry keep compressing, it is just charging.”  I took the position as recorder which I am comfortable doing and helped to keep everyone organized and aware of: how many shocks have been delivered, how much time has passed, reminding everyone to stop after the shock to check the rhythm and for pulse (it seems that it is natural and easy for everyone to get back on the chest quickly, forgetting to check pulse/rhythm) how many epinephrine have gone in, how many amiodarones have gone in, how many bicarbs have gone in etc. It was kinda amazing and long: over one hour this patient was being resuscitated related to the fact that the patient did get a pulse, rhythm, response several times but then kept losing it and we would start all over, and kept going till after about an hour and fifteen minutes the patient maintained pulse and rhythm to the point of moving the lower extremities, by the time we rolled the patient up to the unit the patient was trying to pull out the ET tube! It was neat to see not only ACLS but the differential being worked up at the same time to try and reverse the causation of the problem. ABG revealed severe acidosis and that being said it did seem that after dumping in amp after amp of HCO3 and running in the amiodarone gtt the whole intervention started to turn for the better, with maintenance of pulse and rhythm for longer periods. It was strange to watch the patient get defibrillated, hear the pulse via doppler, see a sinus rhythm on the monitor and then watch it go back to v fib again and then the scenario repeat time and again. The bottom line: the patient lived, early defibrillation improves the outcomes, and it does not always end badly. This was a patient on the younger side and we did not give up. Not to say that we would give up on the elderly patient though, it is just that in my 2 years and 10 months of being a registered nurse witnessing several code blues in the hospital setting, this is the only one that I actually witnessed a living outcome. All the rest died.

On a another note I have experienced many more rapid responses that prevent code situations before they develop, so I encourage the use of the rapid response system even if you are not sure what is going on with the patient, the point is to get help for the patient.

Other news: I am still spinning on telemetry. I am in a perpetual debate with myself over where I want to be in my career, so I just keep turning the telemetry packs. I kind of like tele nursing, the turnover rate is fast, the patient acuity has a huge range but at the same time I feel like I am doing the same thing everyday. Hmm, still thinking about  it.  The contest is between emerg vs critical care, we will see who the winner will be one day. <3

lazy nurse go learn something

I am lazy and neglectful around my brain. It was several months ago that my beloved hospitals education department tempted all the nurses on the telemetry floors to study for PCCN certification and I was super motivated. I showed up for the classes, did all the homework , and took home the ten audio lectures on my flash drive and the worksheets and said to myself I can do it.

What happened? The first section is Pulmonary which comprises 14% of the test, second to Cardiac which is 36% of the test (thankfully). So here I am still studying Pulmonary, I keep dwelling there, not because I am not comfortable there but because the next lecture, the next section is Neurology. It is not that I do not like the neuro, hell I know I have a whacked out limbic system, but it is just that it just does not excite me that much. I have one fave neuro MD, but only because he likes to chew pink bubble gum and blow bubbles in the halls like me when no one else is looking (busted); I like to slip him some gum when he is unaware to be accused later when he finds it, “How did you get that gum in my pocket?” and I reply, “While you were assessing my patient of course.”   I might be neurotic, he might know that. That is about the only thing I like about neurology so far. I feel terrible caring for the stroke patient that comes in rapid atrial fibrillation and find a history of atrial fibrillation and blood work that reveals a sub-therapeutic INR.  I just do not have the answers to: when is this going to get better? to the families of patients who are presenting with stroke. I am not saying that I always have to know the outcome, I can deal with the un-predictable factor, but maybe I just need some more education and here I am delaying the studying by writing this in the first place; procrastinate I do. I should get into it, after all I am caring for stroke patients, especially the ones with arrhythmias. I know what I have to know at the minimum. Yes I certified to score the NIH on admission, but I just do not like it, and still have to get out that little assessment book to score the patient appropriately. I am being pessimistic but I should reveal that I have seen patients actually have an acute stroke after admission to the hospital that received tPA and have had good outcomes. I should lighten up about this predicament I find myself in.

I could happily skip from Pulmonary to Cardiac and then on to the Nephro because there is something I like about the way the dialysis machine spins and smells. I know it is strange loving, but I get a thrill out of chemistry and Renal is filled with it.  I loved chemistry in school and I still rock (like some other person I know) like a tetrahedrally bonded carbon atom with a strong covalent bond, adamas: a diamond.  The first thing I really noticed about ABGs was if all the values went up or down in the same direction you see a metabolic disorder, sick way of learning, I know.  I will think about nephro when I get tired of spinning on IV poles in the halls, and that is going to be a good long while I am sure.

After that I will study the rest, or maybe I will just go take the test because after all this might just be one more way of being lazy. I did not do horrid on the pre-test. I do not know what I am really waiting for. Maybe because I know that I am a good test taker but if I pass does not mean I really know anything!  This way I just keep on learning; sick way of learning, I know.