No Hitting

Click here to credit the artist of this piece, from deviantART. (naturally)

Help me, help me. I might be socially inadequate, but I know how to do my job. Try and talk to me outside of my job and I might look like that girl in the picture.

He might have a big fist, but punching family members is not considered therapeutic, says me, the nurse.

One shift last week we were all at max ratio 6:1, which in my opinion is equivalent to a gangbang in the world of nursing. All my patients were having procedures, required extra care, and one was having a stroke.

So here walks in our newest patient care technician as they are called in my hospital. I give him report, about who can eat, who is on bed rest, who is a fall risk, blood sugar checks etc. He is going to be a nurse, and that is great, because usually nursing students working tech, seem more eager to please the nurse, learn, and be rewarded.

He worked well with us, as I frantically tried to keep up, treading water with PTTs, and heparin drips, and transfer, discharge, admit. The bleep bleep bleep of fast or slow heartbeats and ectopy. When everything is now, labs now, drugs now, must go to the bathroom now day. Everywhere I turned he was there, I was starting IVs he was watching, bed panning, can you help me turn this patient every two hours, can you take Mr. Jones to the bathroom, and please and thank you. I was stressed and he knew it and at 1800 hours, that is 11 hours into this non-stop telemetry tango, I get called to the nurse’s station to see a family member.

The family member, a daughter of my stroke patient is looking pretty pissed off. Her dad is in MRI getting an MRA of the brain, who came in for heart failure and had an in hospital acute stroke on night shift.

She says to me in a nasty tone, “Has my Fathers linens been changed today?” Now, I did not know if they were or not, I could go ask the PCT, but that would look silly, so I replied, “We do not routinely change linen in the hospital on a daily basis, unless they are soiled.” Her face became so reddened; I thought that she would hit something or me. In a social situation, I would have immediately taken a step backward, I would have blushed myself, and I would have laughed nervously or looked like an idiot.

This is not a social situation, I am good at my job, and I control it well. It is quite possible that the linens were messy and I had not realized it because I was drowning in hypotension and bleeps. I was mortified, was it possible that the sheets were dirty and I did not notice it, in the middle of untangling IV tubing like an electrician? She said the sheets were bloody.  I replied, “I will change the linens at once then.”

She stormed off in an angry manner, her ugly hair nearly whipping me in the face. I thought to myself, does she even know that her father has had a stroke, and what is going on here? Where are her priorities? I know where my priorities are, and that is anti-coagulating her Dads blood stream, and controlling the abnormal heart rhythm with intravenous calcium channel blockers, but she will not understand any of that. People cannot comprehend things like that when their loved ones are sick. They only know what they can control, when they feel that everything else is spinning out of control, and that happens to be: the linens and the nurse.

I get that, and I give them that control in a gentle professional manner. It is OK that they do not even realize it.

After she turned her back to me, I turned, looked to my PCT who watched the whole conversation, and I know that my face is a movie, regardless of what words spill out of my mouth. I said, “Let’s do it together.” Who wants to be in the room with stressed out, confused, family members alone?

We get to the linen cart, and he starts punching is fist into his hand, and says, “You want me to take care of her? Cause I will, you just don’t know me.”  I started laughing cause, I knew he would not punch any one; this is a hospital after all. It was just funny. So we went to the room smiling, and changed the bed quickly.

There was one very small spot of blood on the top sheet, and that my friends, is totally unacceptable.

On Bondage

Back when I was a teenager, I would have loved to wear these pink bondage pants. I would still rock that belt with the rings and chains. I love the color pink and most of my clothes are black. I doubt I would like those shoes though, I would be tripping all over myself in those clod-hoppers.

This post is not about my history of dressing punk rock, nor is it about sexual bondage or hidden fantasies. It is about restraints, nursing and patients. I still do want that belt though.

Lately it seems that there have been a few patients admitted to the telemetry floor where I work. They are alcoholics, withdrawing. Now, I am not a detox nurse specialist, I do not know much about rehabilitating these patients. What I do know is that they need to be sedated or they will keep climbing out of bed, all shakes and delirious, trying to leave the hospital against medical advice.

They get admitted to telemetry, because well everyone gets admitted to telemetry, but seriously, usually these people have severe electrolyte imbalances, mostly low potassium levels, which we know is not good for the heart’s rhythm. Potassium is needed for neuro-muscle cells to be able to re-polarize energy, and yes the heart is a muscle we know, and severe low potassium can cause problems with cardiac conduction. Hypokalemia may also cause respiratory problems, muscle weakness, fatigue.

We all know the alcoholic with severe liver disease, that comes in all yellow, big belly, low platelets, anemia, bleeding, low blood pressures, with metabolic encephalopathy, pooping all over the bed from the lactulose you are giving every four hours. They are so sick, it is not so difficult to give them some sedatives, get their bellies drained with paracentisis, transfuse some FFP, and maybe get them better enough to go home for a while longer.

Last week, since I am so nosey and seem to know what is going on with everyone on the floor, I hear another nurse talking about her patient that is a probably aged in the 40s, withdrawing from alcohol, with a potassium level of 1.9. Yeah that is super low, at that low-level you might see a U wave, and flattened t waves on the ECG, I imagine. The patient did not look that sick, there were tremors, but no delirium, just extreme agitation. The patient wanted to leave and it was only 0730 in the morning.

I had to intervene, I reported my 2 cents to the nurse, encouraging more sedation. The Librium 50mg every 8 hours is just not enough. This patient needed something like IV Ativan every 3 hours, that might have worked out better. Unfortunately, the nurse did not take my advice and luckily I was on the other side of the floor, so I did not have to hear, see this patient cursing and threatening to punch someone.

The shift went with the nurse trying to give IV potassium infusion plus oral replacement. Of course, the IV potassium kept burning, infiltrating etc, exacerbating the agitation. The patient kept trying to get up with an unsteady gait. The patient was orientated and kept saying: my potassium is now replaced, let me leave.

Things whirled out of control and went way over the line. A psych evaluation was ordered to evaluate competency, the psych doctor never showed up. The nurse struggled all shift.

The end of the shift came, and the patient was still trying to leave, the potassium was rechecked, it was still low and the fearful attending would not discharge the patient naturally. So what does the nurse do? She calls the doctor and gets orders to put the patient in restraints!

I am holding 1 posey soft restraint in my hand, security is there, and this yappy, dramatic nurse, who is not the patients nurse, is over zealous to get this patient into 4 point restraints. I get to the room and I am thinking to myself, something about this just does not seem legal, I mean why can’t we just give this patient some drugs and knock the patient out with chemicals and put mittens on like we usually do.  Here we are facing this 200 pound angry alcoholic, totally unsedated, who ripped out the IV access again.

Luckily, the night nurse who happens to work in a psychiatric facility was with us and I was amazed by her therapeutic communication. She came into the room with a big needle filled with Thorazine and I think Haldol too. The experienced psych nurse told the patient that she was going to help her get everything sorted out after she gives the patient an injection in the muscle with this medicine. The patient took the injection willingly, the night nurse got the patient out of her clothing, sent the valuables to security, and started IV access on the patient.

In the middle of all of this the neurotic restraint happy nurse tried to tell us: You have to restrain the patient now, the doctor’s order says so! I was like whispering shut up, because we were in the room with the patient and the order was a verbal order taken by the nurse, and we all know we do what is right, not always what is written, we clarify. I wanted to tell her to take the restraints home to her hubby if she is so desperate to use them!

I was very impressed. I was also irritated at the day nurse who failed to adequately make this patient comfortable, and I was extremely annoyed at the happy psycho nurse desperate to restrain an alert angry patient in withdrawal. Not only did it seem unethical and barbaric, we would have gotten hurt. The patient was not going to say: sure tie me to the bed you evil bitch nurses!

A few shifts later, I happened to notice that the patient was still hospitalized, happily zombified on psych medications, and transferring to a rehab facility for alcoholism. The patient was not agitated, tremors gone, and the battle was over.

Now, my potassium is not low, I am not a raging angry alcoholic in detox, but I might not mind the posey soft restraints.