A day at the Spa

Well I did it. I nurse Jane had a pedicure, and I must say that I am proud of myself! I went in and had my eyebrows waxed (ouch), my nails painted and my feet pedicured.

The nail part was no problem.

 The eyebrows unfortunately got waxed to thin for my taste and now I keep looking at myself in the mirror as if I do not recognize myself~ Is that me? I look like an alien!!!  AHHHHHHHHHHH!! NEVER going to do to that again. Just not worth it.

The feet part was a big anxiety attack as to, “Are those tools clean?” “Who sank their feet into this tub water before me?”  Fortunately for me the salon did not offer Carp cleaning fish pedicures.  

Can you imagine that? Wow…not for me. I am way to ticklish for that kind of treatment.

On a more serious note~ A pedicure can be dangerous as outlined in the book Death by Pedicure, written by a podiatrist, Robert Spalding.

Well I took a risk and in the end it did feel pretty neat in just took me 99% of the time to get used to it, and then it was over.

So much for a relaxing day at the Spa.

This Pharmicist hates Nurse

Most of the pharmacists where I work are great and are super smart~ They can be super helpful and reassuring such as dealing with the multiple calls from nurses about dosage, compatibility, missing medications, administration timing etc…I mean I am not sure how many times I have called  the pharmacy to confirm gtt rates for certain medications, or to check the compatibility of antibiotics with say…heparin infusions (saving me from putting in additional lines in the patient.)

There is however this one  pharmacist who always likes to as nurse K would put it “jack my sh**t”.     I am serious! Here is my latest scenario with Pharmacist who hates Nurse: I have a patient circling the drain and a rapid response is called: Amongst the rapid response team is a Pharmacist who should always respond as well.  After 15 minutes it is determined that The patient is going to be transferred to ICU  –but the problem is that no beds are available. The situation during those first 15 minutes is deemed stable so the the pharmacist leaves, and the ICU nurse continues to treat the patient with assistance from myself and my charge nurse and the attending MD. Hours go by, and the patient still does not have a bed yet because ICU is full. This is all taking place in a telemetry floor. Well…the situation is deteriorating quickly and the patient needs to beintubated.  Medication orders were faxed to the pharmacy for diprovan needed for the impending intubation. So I ask one of the other nurses on the floor to walk down to the pharmacy and get the diprovan gtt for me because I knew that the ICU nurse was going to get the bolus out of the pyxis or that she was going to get it out of the code cart. Well…The pharmacist who is known for hating nurses gives her a hard time telling her to call some other pharmacist etc…The nurse leaves without the diprovan. So I call the pharmacist who hates nurses and ask why are you giving us a hard time, and he states something about a label printing out etc…I tell him…My patient is being intubated, we had to tether the patient to the bed, the patient keeps waking up, and we need the diprovan NOW, I ask the pharmacist who hates nurses if he will bring us the drip now. He then proceeds to tell me that it will take longer then.   WHAT?   I mean the orders for the diprovan were faxed to the pharmacist  at least 30 minutes prior to the intubation, at that point intubation could not be put off any longer and the MD and the RT had to proceed with tubing this patient. I mean we could not just wait around all day for the pharmacist to “get around” to dispensing the diprovan. This pharmacist who hates nurses should team up with the Angry Pharmacist (I love reading the Angry Pharmacist!!) , they would make a great duo and we would end up in tears when looking for STAT medications.  It is like  a big huge lack of communication~ Doesn’t the pharm remember that this patient was rapidly responded, is now in critical condition and near code status and we need the drugs NOW?

Ahhh….This Pharmacist HATES us!!!!!!

Alcoholism-The Game

See Alcoholism The Game  By 3amArt on deviantArt site.

It is pretty self explanatory and explains complications of Alcoholism including: frequent falls, blaming others, jail, DUI, fines, legal problems, binge drinking,  yelling, crying, ending up with liver failure and death and that is the “You Win” aspect at the end. I thought this was creative.

Alcoholics

So I get the phone call to go and check on my relative who suffers from alcoholism, who verbalizes a wish to go to a detox center (again).  Me Nurse Jane with my never ending inkling of optimism and hope drive on over to pick up my relative with the intent of going to a detox center self paid.  I was not ready to detox my relative on my “couch” with a bottle of librium, folic acid, thiamine, multivitamin, bananas, and Gatorade like I just did last month. 

I get there, the place is a mess and there has to be at least 25 gallon or half gallon sized empty rum bottles, my relative can not talk, looks as though a stroke is taking place, and is covered in urine from head to toe.  My relative looks like an insane person.

If anyone ever doubts that alcoholismis not a disease, than they have never experienced it close at hand.  It is easy for those in the health care profession to become jaded, to give up, but it is easy to see the insanity, hard to feel compassion and hope. It is insanity. No one would “want” to keep doing the same thing over and over again. The sickness, the detox, the losing your wife, your car, your job, your mind, your family.

For the people caring for alcoholics the emotional drain can be great and is not to be underestimated. I include in this family members as well as those in the health care profession. The ED techs who keep these patients from falling, the nurses and doctors who “sober” them up before sending them out the door (if they are stable) and the EMTs who usually pick them up off the streets or out of their homes.

The bottom line is that drunks have to want to get sober. They have to get of the self pity train and on to the I am responsible train, and that is not easy for them. They have to relearn how to be a human again. One method that really seems to work is Alcoholics Annonymous.   I have not done the research as to why it works the best for alcoholics but it does. It is working through 12 steps, finding a sponsor, and helping other drunks get sober that helps others find and keep sobriety. Without this support it just does not work.

Unfortunately it was another trip to the ED because I could not possible get my relative to detox in that condition, and 18 hours later with a blood alcohol level back to acceptable levels my relative was released with some librium and we went straight to the detox center. Unfortunately it is only jails, institutions or death as the end point for alcoholics.

Anyway I will not give up hope!  There is always hope. People can get sober if they want to and when my relative is ready I will be there to help. There is always hope.

Intuition *blink*

The power of thinking without thinking.

 

So I have always wondered how some people just “know”~ You know you walk into a room, you see your patient, perform a quick assessement and you just *know* something is not right.  It is times like this you feel your heart beat faster, you palms start to sweat and before you think about the facts you already know that something is not right. You might feel that you want to call in another nurse, or call the physician and say, “something is not right” with this patient, but you can not do that so you have to stop and think and use your concious, logical process of decision making. This is not to minimize that “thin-slice” of information.

Ok here is the deal…I have always thought that the intuition that we feel is not worthy because it is not objective. There is no objective information to that *gut* feeling of “something is not right, or sense of impending doom for the patient. Well…fool me once! I am reading  a book called blink, by Malcom Gladwell and it this book (I have not finished yet) there is scientific data that proves that that feeling, or split decision making within minutes actually comes from the unconcious mind sometimes.  It is rapid cognition.  It is about immediate automatic associations before logical objective thinking can take place.

It is an interesting read with many explanations to behaviour and decision making that is really hard to imagine, or rationalize. At any rate I am absorbing it in and going back to reading about the power of thinking without thinking!

The Sepsis Cloud is following me.

I can not escape the sepsis cloud lately. Here I am Nurse Jane, a new nurse on a telemetry floor for about one and a half years. The one thing that I see over and over again is patients swirling into septic shock right in front of my eyes. It took a few patients before I realized the pattern, the scenario was repeated many times in the form of this: A patient on a medical floor developes hypotension, the MDs and Admins in Charge decide the patient is appropriate for telemetry (alot of times it is true). The patient arrives to the telemetry, receives some fluids, sepsis workup is done including: Lactate level, cbc, bmp, urine cultures, blood cultures, ABG, chest x ray etc. 2 hours later the verdict is in: Lactace levels greater than 5, WBC doubled in a day etc..patient is hypothermic, with a systolic blood pressure in the 80s, increasing lethargy, tachypnea, metabolic acidosis and you as the nurse now need a rapid response to handle this rapidly deteriorating patient and the rest of your patients get nothing! http://emedicine.medscape.com/article/167027-overview

I mean this happens alot. These patients need aggressive resuscitation with fluids and they need an intensive critical care nurse at the bedside!

Now I am not saying that every patient with an elevated lactate level needs intensive care. I have had patients with moderate lactic acidosis, that were septic from a known source, treated appropriately with antibiotics and fluids who within 24 hours have mean arterial blood pressures greater than 60, wbc decreased in half in one day, and lactate levels return to normal with no hypothermia or hyperthermia and seemed to progress towards positive outcomes. I am not going to freak out at every abnormal lab value…

On the other hand…these patients need to be monitored so closely that the nurse on the floor has to be on guard. I had a patient with a lactate level 3.9–the patient remained on telemetry because of 1. orientated mentation 2. systolic blood pressure greater than 100. So the patient was not transferred to ICU–Sepsis workup was not done–and within 12 hours the patient had severe tachypnea, severe metabolic acidosis–and a lactate level greater than 9, WBC tripled– the patient was falling apart in front of my eyes and of course a rapid response was initiated.

We all need to know that just because the patients pressure is not low or that the mental status is orientated for now, does not mean that the patient is “ok” –they can decline rapidly. Sometimes the support is there from supervisors and charge nurses~ sometimes it is not! So till then I will keep shouting out loud about suspicion for sepsis in rapidly (or even not rapidly) declining patients and what to do when it happens to you!

Symptomatic Severe Hyponatremia

I had a patient today with symptomatic hyponatremia.  I am still not sure why this patient had such an awful lyte imbalance.  I only had a few hours with the patient and he was newly admitted to our floor. It could of been anything: depending on fluid status it could of been hypervolemic, euvolemic, or hypovolemic hyponatremia; it could of been cirrhosis, heart failure, or nephrotic syndrome; it could of been SIADH, polydipsia, adrenal insufficiency or hypothhroidism: it could of been from renal loss versus extra renal losses.  At any rate it is loss of salt or a gain of water. Whew! I was confused to say the least.  Anyway the treatment was fluid restriction of 800 ml for 24 hours and infusion of 3%  Saline times 2 four hour periods at 40ml/hour with chemisty checks every 2 hours to reach a goal of Na+ equal to 120. I was pretty perturbed by this treatment to day the least.  The patient was mildy confused but easily reorientated, had vomited times 1 and had other electrolyte imbalances as well. Symptomatic Severe Hyponatremia when the serum Na+ is less than 110 really should be admitted to ICU care because replacing the sodium and potassium in that manner with hypertonic saline and blood draws every 2 hours as well as assessing the patient every hour for increased mental status changes while caring for 5 other patients is just not realistic. It is not real fair to the patient or the nurse! Well… here I am ranting and raving. I do not like to be a complainer! The outcome was good for the patient but I was lucky enough to tell a senior nurse on the floor the situation. The senior nurse told me that hypertonic solutions are risky and that the patient needs to be monitored closely in which I complied of course, but I did not really know how serious sodium replacement could be. Little nurse Jane did call up the MD and asked if this patient should be in ICU or if it was safe and appropriate to be admitted to telemetry with a nurse patient ratio of 1:6. The patient stayed on telemetry and did get better after lyte replacement therapy. It is a serious matter though. Here is a tutorial for hyponatremia that I found useful in answering my questions, after I got home and started studying of course.  We have to love those Renal MDs I mean check out the math for electrolyte and fluid replacement calculations. I mean my brain hurts just thinking about it!

Clinical judgement and experience

There is a great article over at White Coats Call room it also links back to another article with dialogue between White Coat and Maxwell S Kennerly and attorney apparently based in Philadelphia.  It is an interesting read on the view of defensive medicine and whether or not it even exists.  I can agree with White Coat in that it does exist, and there is a fine line, and the fine line is called clinical judgement.  I see it happen all the time, the patient is admitted gets a consult for every specialist there is, prior to discharge the patient has gone through, heart Doppler, eendoscopy, colonoscopy, heart cath, vein mapping, CT of chest, MRIs, MRAs etc…during the “prep” for the colonoscopy the patient falls,  the list and scenarios are endless. The bottom line is if you keep searching for the possible things that could be wrong with someone you will find it, even if that wrong thing is a result of the hospital stay or just found incidentally, even if was not part of the original complaint, or diagnosis. I will not even mention the “hits” the kidneys will take from some of these tests.

The whole conversation seems to imply that physicians should be the do all, be all, know all, for the patient and in reality phycisians are human. It seems that society and the school of law are trying somehow to dehumanize the whole process of caring for people.  If you asked me if I wanted a bizillion specialists, ten diagnostic tests to rule out the most serious, but most improbable of all illness relating to a specific symptom I would surely say no! I want a physician who uses clinical judgement and experience, expertise not a computer who orders a zillion tests for the “could be” rare diagnosis. I see the harm done, the emotions spent, on defensive medicine.

It happens in nursing as well. Spend more time charting in front of the computer, document everything, just in case a bad outcome happens and you did not document every interaction, intervention, education provided. My time would be better spent in the rooms, with the patients and families  providing the care they need, assessing,  and teaching; it has turned into quick assessments, quick turning, quick teaching, and back to the computer to chart it all.

Well this is my rant about defensive medicine. I am sick of it! I am tired of these workups that can mostly be done as outpatients anyway. It is insanity.

Annoying + Extra Work

One of the most annoying things that happens at shift change is the nurse who looks at the patients lab values and declare that the patient should be in ICU without even looking at the patient themselves, without even assessing the patient for themselves. Sometimes the numbers really look bad and yet the patient is appropriate. Sometimes the numbers look good on paper and yet something is really wrong with the patient. It can be frightening to receive a patient with awful electrolyte imbalances, especially when we anticipate aggressive replacement and retesting etc…but that is our job. I just do not understand if the patients were to be “well” they would not be in our hospital bed!

ETOH

When the sick person in the ED is your relative, you just feel like sick because you know the implications and complications of the situation. Alcoholism just sucks.  This particular ED has a crisis center and this particular hospital has a detox center, but you just can not “force” someone into detox.

The discharge instructions read as follows: You have a serious drinking/alcohol problem. Continued consumption of alcohol will have serious effects on your health such as liver damage and heart problems. You are refered to AA and should get a sponsor immediately.